Breaking Bad News

Breaking Bad News

Questions for discussion

• What is bad news?

• Give examples of bad news?

• Why breaking bad news is difficult?

• What are the benefits when effectively breaking bad news?

• What S.P.I.K.E.S (6 Steps Protocol stand for)?

• What are the causes of fear in bad news?

• If a patient with lung cancer asked you “patient like me survive for how long” what is your reply?

• What not to do in BBNs?

1. What is Bad News?

BBN: a definition

• Bad news is any news that seriously and adversely affects the patient’s view of his or her future.

Buckman 1992

What is bad news?

• Bad news can mean different things to different people
• “any information, which adversely and seriously affects an individual’s view of his or her future”
• A message which conveys to an individual fewer choices in his or her life.

Situations of Concern

• situations where there is either

  • a feeling of no hope,
  • a threat to a person’s mental or physical well-being
  • a risk of upsetting an established lifestyle

• The common denominator is that bad news is a message, which has the potential to shatter hopes and dreams leading to very different lifestyles and futures.

Examples

• A patient who is told he / she is HIV positive.
• The man who is told his partner has Alzheimer’s disease.
• The patient who is told the lump has been diagnosed as cancer.
• The couple who are told they cannot have children.

S.P.I.K.E.S (6 Steps Protocol)Z

Breaking Bad News

• S - SETTING

• Anticipate the possibility of bad news, and arrange a follow-up visit after significant scans, biopsies etc.

  • Avoid telephone
  • Private setting, sitting down
  • Turn off beeper, no interruptions
  • Ensure adequate time

• S – SETTING (cont)

  • Lab reports, X-rays present
  • Support person present, if desired
  • Review the condition, basic prognosis and treatments before the visit
  • HOPEFUL TONE

• P - Finding out what the patient knows or PERCEIVES

  • Before you tell, ask ……
    • What do they Know?
      • e.g. “what have you been told so far?”
    • How much do you understand about your illness? How do you feel?
    • What is troubling you the most?
  • Note denial (if present) or misinformation

• I - INVITATION by the patient to share the information

  • From the patient to give the information. Would you like me to explain ………? Are you the sort of person who wants to know what’s happening?
  • Different ways of asking
    • e.g. “Are you the sort of person who…”
      • Accept their right not to know
      • Aim to get clear invitation

• K - Giving the KNOWLEDGE and medical facts

  • Giving information
  • Warning shots
  • Small chunks
  • Check understanding

➢ Emotions

• Observe for and allow emotional reactions
• Kleenex handy, use of touch (NURS)
  • Naming the feeling “I know this is upsetting”
  • Understanding “It would be for anyone”
  • Respecting “You’re asking all the right questions”
  • Supporting “I’ll do everything I can to help you through this.”

➢ Summarise & Strategy

• Have a plan

Kaye’s Model

Breaking Bad News

1 - Preparation

• Know all the facts.
• Ensure privacy.
• Find out who the patient wants present.
• Introduce yourself.

2 - What Does the Patient Know?

• Open ended questions.
• Statements may make the best questions.
• “How did it all start?”

3 - Is More Information Wanted?

• Not forced on them.
• “Would you like me to explain a bit more?”

4 - Give a Warning Shot

• Not straight out with it!
• “I’m afraid it looks rather serious”

6 - Explain If Requested

• Step by step.
• Detail will not be remembered but the way you explain it will be.

7 - Listen to Concerns

• “What are your concerns at the moment?”
• Allow time and space for answers.

8 - Encourage Ventilation of Feelings

• Acknowledge the feelings.
• Non-judgmental.
• Vital step for patient satisfaction.

9 - Summarise

• Concerns.
• Plans for treatment.
• Foster hope.
• ? Written information.

10 - Offer Further

• Availability.
• Information.
• Future needs will change.

4- Why is Breaking Bad News Difficult?

What are your thoughts?

• Concern for how the news will affect client
• Client’s fears of social stigma and impact of disability and illness
• Fear of client’s reaction to the news
• Uncertainty in dealing with intense emotional response
• Fear of being blamed
• Fear of how this affects your emotion
• Challenge of delivering the news appropriately and sensitively for this client
• Not wanting to take away hope

BBN: Why is it important?

Relatively common in clinical practice; includes:

• Diagnosis of life limiting illness
• Disease recurrence
• Spread of disease
• Irreversible side effects
• Positive results of genetic tests
• Discussing palliative and end of life care

• Majority of patients want the truth How bad news is discussed can affect important outcomes, including:

• Comprehension of information

• Satisfaction with medical care

• Level of hopefulness

• Subsequent psychological adjustment

• Comfort with breaking bad news may be associated with less stress and burnout in physicians

The interviews

• The interviews

Reactions

• Fear
• Anger
• Despair
• Isolation
• Disappointment
• Depression
• Relief ?
• Disbelief/Denial

BBN: Is there a need for training?

Less than 10% report any formal BBN training

• Ability to break bad news rated by:
  • ➢ 53% as good to very good
  • ➢ 39% as fair
  • ➢ 8% as poor

Causes of Fear in People with a Life Threatening Illness

• Fear of separation from a loved one, home, jobs.
• Fear of becoming a burden to others.
• Fear of losing control.
• Fear for dependents.
• Fear of pain.

Causes of Fear in people with a life threatening illness

• Fear of dying
• Fear of not being able to complete their role
• Fear of being dead
• Fear of the fear of others

Parkes 1998

Take home message

• 7 - Areas

Interview Preparation Steps

1. Prepare yourself
2. Prepare your setting
3. Prepare your patient
4. Providing information
5. Providing support
6. Providing a plan
7. After the interview

1- Prepare yourself

• Have your facts right first
• Familiarised yourself with the Patient’s background, medical history, test results & possible future management
• Mentally rehearse the interview including likely questions & potential responses
• Relatives can be in attendance, however you should be guided by the wishes of the patient.

2- Prepare your setting

• Meet in a quiet room
• Arrange some privacy & ensure you are not going to be disturbed
• If you have recently examined the patient, allow him to dress before the interview

3- Prepare your patient

• Assess the patient understanding of their condition
• What do they know already?
• What have they been led to expect?
• Never impose information, respect patient wishes
• Build up gradually.

4- Providing information

• Use basic communication skills: use simple language, listen, follow up verbal & non-verbal cues
• Start at the level of comprehension & vocabulary of the patient
• Avoid excessive bluntness; as it is likely to leave the patient isolated & later angry
• Set the tone. “I am afraid, I have some bad news.”

Guidelines for Communication

• Give the information in small chunks
• Avoid using terms e.g. “there is nothing more we can do for you”
• Be truthful, gentle & courteous
• Offer hope
• Emphasize the positive
• Allow questions.

5- Providing support

• Acknowledge & identify emotions; when a patient is silent, use open Q. “How are you feeling now?”
• Do not say “I know how you feel”
• Allow the patient time to express their emotions
• Unless the patient’s emotions are adequately addressed, it is difficult to move on to discuss other issues, remember it is the patient crises, is not your crises; listen.

6- Providing a plan

• Provide a clear plan for the future, with treatment options & management plan discussed
• Identify support systems; involve relatives & friends
• Offer to meet & talk to the family if not present
• Make written materials available
• Summarized.

7- After the interview

• Make a clear record of the interview, the terms used, the options discussed & the future plan.
• Inform other people looking after the patient what you have done.
• May need to have a number of meetings.
• Follow up the patient.

What not to do

• BBNs over the phone
• Avoid the patient
• Leave patient in suspense
• Lie to the patient
• Tell patient if he or she doesn’t want to know
• Interrupt excessively
• Use jargon

What not to do

• Give excessive information as this causes confusion
• Collude
• Be judgmental
• Give a definite time span (as days to Weeks) or (months to Years) etc.
• Pretend treatment is working if it isn’t
• Say “Nothing can be done.”

One of the famous strategies for breaking bad news is the S1PIKES2 Protocol:

• Explain briefly what SPIKES stand for?
  1. S1 -------------------------------------------------
  2. P --------------------------------------------------
  3. I --------------------------------------------------
  4. K --------------------------------------------------
  5. E --------------------------------------------------
  6. S2 -------------------------------------------------

Match the following phrases in their appropriate place of THE S1-P-I-K-E-S2 Protocol of RBN

1. “What are your concerns at the moment?”
2. Support person present, if desired
3. Offer to meet & talk to the family if not present
4. It is more serious than infection.
5. “What have you been told so far?”
6. Accept the patient right not to know

In SPIKES Protocol, which of the following statement is best describe the Perception?

• a) Making sure that the patient will receive the best possible treatment.
• b) “Before you tell, ask.” What is your understanding?
• c) Mental rehearsal is a useful way for preparing for stressful tasks.
• d) Respect patient wishes not to know.

In preparing the setting for effective breaking bad news before you prepare the physical setting and prepare your patient.

• What you need to do first?
  • a) Know all the facts.
  • b) Ensure privacy.
  • c) Find out who the patient wants present.
  • d) Call the reception not interrupt you.