Communicating bad news to patient and family

When you are the first person to know that a patient has a terminally ill disease and is likely to die soon, how do you communicate this to the patient or his/her family members? This is one daunting task which many doctors face on a very frequent basis. This is not just a piece of information, but an information that is going to severely affect the emotions of receiver and can have an adverse effect on their psychological status if not given with due care. And yet, there is hardly any formal training that doctors receive on how to break a bad news. 

My post on ‘Dealingwith relatives in case of patient’s death’, identifies the need of communicating the bad news in a proper way with patient and family members. Here I going to write about what should be the proper way, which is based upon an article published in ‘The Oncologist’ on ‘A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer’. Although the article is specially for dealing with unfavourable news in case of cancer patient, the protocol it outlines is relevant for any other bad situation. 

Before this I suggest you to read the post on ‘Dealing with relatives in case of patient’s death’, to appreciate why is this issue so important.

The six step protocol for breaking bad news is

Step 1: Setting up the interview

The messenger of the news (often the doctor in-charge) must do a mental rehearsal of the information to be shared and words/statements to be used for communicating it. He/she should be mentally prepared for the likely emotional reactions and the questions that will follow. The news should be communicated in semblance of privacy and the setting should be conducive to an un-distracted and focused discussion.  To whom the information to be shared is very important and depending upon patient’s choice, the guardian family member should be involved.

Step 2: Assessing patient’s perception

Before discussing the medical findings, the doctor must ask open ended question to patient/family to assess how they perceive or feel about their medical condition. Questions like ‘What have you been told about your medical situation so far?’ or ‘What do you feel about how worse your disease is?’. Based on the replies, the doctor can correct misinformation if any or tailor the bad news to what patient understand

Step 3: Obtaining patient’s invitation

Each patient is different. Some may want to know full information about their condition, while for some it could be difficult to hear the details. Doctors must either directly ask how much information they would like to know. Alternatively, the doctor can judge this from the assessment described in step 2

Step 4: Giving knowledge and information to patient

Start by giving a hint or warning. This may lessen the shock that follow disclosure of bad news. For example, start with a statement like ‘Unfortunately, the findings we have is not great’

The actual sharing of information should be kept very simple and correct. The language should be easily understandable by patient. Avoid using technical terms. Give information in chunks. Lastly do not end in a manner that sounds hopelessness.

Step 5: Addressing patient’s emotions with empathetic responses

Observe for emotional signs. Modulate your communication accordingly. Give time to patient to adjust to his/her emotional status. Reflect empathy through expression and non-verbal behaviours.

Step 6: Strategy and summary

Wait for patient to get cleared from his/her emotional state before sharing further details or any other useful piece of information. Once the patient is emotionally stable, inform about further treatment plan and prognosis. At the end, summarise the entire discussion to make sure the communication is complete.

Full article can be accessed here - SPIKES—A Six-StepProtocol for Delivering Bad News: Application to the Patient with Cancer

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