“Don’t shoot the messenger!” they say, but many people do. Especially when the message is badly delivered, the emotional reaction to the messenger, but also to the information, creates problems damaging the quality of care received. Fortunately there is ample research about the best ways of delivering bad news to patients. In this article we summarize some of the core ideas.
The delivery of bad news has always been a sensitive topic to discuss, but it has not always been approached in the same way throughout the years. In the late 1970’s and 1980’s, many characteristics related to the doctor’s profession were assumed to be innate, such as communication skills and the ability to feel or sense what the patient is experiencing (Buckman 2002). However, these beliefs were erroneous. All medical education now also focusses and soft skills, empathy and communication skills. Delivering bad news is taught and learnt. Let us explore how.
Why is delivering bad news so difficult?
What is “bad news” in healthcare? Bad news is “any news that drastically and negatively alters the patient’s view of her or his future” (Buckman, 1984). Delivering bad news is such a difficult mission for one obvious reason: it is two-sided. It is indeed hard for the doctor to deliver bad news due to many reasons that are discussed below, and it is unarguably hard for the patient to receive a message that will have a dramatic impact on the person’s future life. On the one hand, there are many problems that doctors are facing when the need for breaking bad news arises. Some of these fears include:
- The fear of being blamed: doctors often fear that the patient will tend to blame the person delivering the bad news. At the heart of this fear is the identification of the target for the blame. The level of simplicity in identifying the authority delivering the bad news is high when a doctor breaks bad news, it is… the doctor itself. (Buckman, 1984).
- The fear of the unknown and untaught: in the past, doctors weren’t trained enough in communication skills, nor in discussing a patient’s fatal disease with the patient itself. This lack of training and experience leads doctors to feel awkward in delicate situations such as breaking bad news, further encouraging them to avoid this type of situation. (Buckman, 1984)
- Fear of expressing emotions: doctors have often been taught to suppress any panic in emergencies and to remain calm and composed. This has become part of the standard in many situations, leading to a need to relearn, as a deliberate effort, the manifestation of human empathy and sympathy. (Buckman, 1984)
- Fear of not knowing all the answers: usually, the more senior a doctor is, the more comfortable he will be and the lesser self-confidence he will lose by saying “I don’t know”. And it might be the same for the listener; it is almost a universal law that one person must seem to have a big quantity of knowledge before being “allowed” to confess to not knowing it at all. However, when it comes to breaking bad news, knowing The Answer may not be as important as it seem to be. What the patient is really looking for is a doctor that can genuinely listen and is attentive. (Buckman, 1984)
On the other side of the bad news, we find the patient, whose reaction to the news can be difficult to predict. Because such an announcement will affect the patient adversely, back in the old days doctors may have withheld the news. Hippocrates advised “concealing most things from the patient while you are attending to him. Give necessary orders with cheerfulness and serenity…revealing nothing of the patient’s future or present condition. For many patients…have taken a turn for the worse…by forecast of what is to come” (Hippocrates, 1923). Nowadays the ethical consensus is that the patient has a right to know, and the doctor and obligation to inform. Numerous studies have shown that patients usually want honest and empathetic disclosure of a terminal diagnosis or other bad news. (Buckman, 1984). The results of this study leads us to the next point, which highlights breaking bad news as being an important skill rather than an innate quality. A skill that can be learnt.
Learning to Deliver Bad News
In the past, the focus in medical training placed more value on technical proficiency than on communication skills. Therefore, due to the lack of training in these skills, many physicians felt unprepared for the difficulty of breaking bad news. Consequently, this feeling of unpreparedness leads the physicians to be increasingly uncertain and uncomfortable. The observed consequence is a disengagement of physicians from situations in which they have to deliver bad news. Moreover, like Dr. Vandekieft, assistant director of the Palliative Care Education and Research Program at Michigan State University, said: “A physician’s attitude and communication skills play a crucial role in how well patients cope when they receive bad news” (Vandekieft, 1976).
These cumulative effects bring us to one obvious conclusion: breaking bad news is an important skill to have and it needs to be trained. Learning and developing this specific communication skills will make the physician less uncomfortable when announcing bad news, which in turn increases the satisfaction of the patient and his or her family (Ellis & Tattershal, 1999). Without much surprise, multiple studies have demonstrated that focused educational initiatives ameliorate student skills in delivering bad news (Cushing et Al. 1995, Garg et Al., 1997 and Vetto et Al., 1999).
How to Deliver Bad News?
Different models for delivering bad news have been created over time and three major models are discussed in this section.
How to use Fine’s Model to Deliver Bad News:
Fine’s model: Fine elaborated a protocol with five different phases.
Step 1: The first phase is called preparation and involves all the activities surrounding the delivering of bad news: establishing appropriate space, being sensitive to the patient’s needs, cultural and religious values and being goal-specific.
Step 2: The information acquisition stage consists of asking the patient what he or she already knows, what he or she believes and is willing to know.
Step 3: Is the information sharing phase and it includes agenda re-evaluation and teaching.
Step 4: The penultimate stage is the information reception and allows for the clarification of any miscommunication, misunderstanding and the careful handling of disagreements.
Step 5: Finally, the last phase entails identifying and acknowledging the patient’s response to the news and closing the interaction (Fine, 1991).
How to use SPIKES model to deliver bad news:
SPIKES: Baile et al proposed a comprehensive model called SPIKES. This protocol is divided into six different steps to follow (Baile et al, 2000).
Step 1: Setting up the interview. In order for the interview to be successful and have a chance to meet its goals, the doctor must arrange for privacy, involve of a significant other (like a family member for instance), sit down and make connection with the patient, as well as manage time constraints and interruptions.
Step 2: Involves assessing the patient’s Perception. It is very important to ask open-ended questions before touching on medical findings to have a clear grasp of how the patient perceives the medical situation and consequently adapt the bad news announcement to the patient’s understanding.
Step 3: Third, the bad news deliverer needs to obtain the patient’s Invitation. Every patient is different in his or her desire for information disclosure, and a clear expression of such a desire will reduce the doctor’s anxiety.
Step 4: The actual Knowledge and information sharing to the patient. It is important to warn the patient that bad news is coming in order to lessen the shock as much as possible and to ease information processing. Moreover, there are some main points to be careful about: use of understandable non-technical vocabulary, avoidance of excessive bluntness, and the sharing of information in small chunks.
Step 5: Addressing the patient’s Emotions with empathetic responses. As the patient’s response varies from patient to patient, this step is the most complicated one. To address the emotion, empathetic statements can be brought forward. If the emotion is not clear, exploratory questions can be used, and finally, the use of validating responses are important to express solidarity and diminish the patient’s isolation.
Step 6: The ultimate steps consists of formulating a Strategy and making a Summary. In this part, it is important that the patient feels involved into the decision making process involving the treatment(s). It is also crucial to understand the patient’s goals (eg.: symptom control) and to ensure and communicate to the patient that the best possible treatment and continuity of care will be given. This allows hope to be framed in terms of what is feasible to achieve.
How to Deliver Bad News using the ABCDE model:
Another comprehensive model that can be used to deliver bad news more compassionately and effectively was developed by Rabow and McPhee under the name ABCDE (VandeKieft 1975-8). This model includes five steps.
Step 1: Advance preparation, includes learning about what the patient already knows, arrange for a good time and setting, prepare a possible script and prepare for emotions.
Step 2: Build a therapeutic environment and relationship. In other words, the place should be quiet and private and the doctor should sit close enough to touch if appropriate.
Step 3: Communicate well. This means being direct, not using medical jargon, allowing for silence, etc.
Step 4: Deal with the patient and family reactions. Listening actively, exploring and having empathy are crucial tasks during this phase.
Step 5: Encouraging and validating emotions. During this step, future patient’s needs should be addressed based on the exploration of what the news means to the patient (Rabow, 1999)
What Methods to Use to Learn to Break Bad News?
It should now be clear that through the learning of general communication skills and through the use of models such as the ones described above, the delivering of bad news could be fulfilled in a less uncomfortable way for the physician, and received in a more appropriate way by the patient and their relatives. Moreover, there have been numerous investigations that revealed the benefits of focused educational interventions in improving student and resident skills in such a domain.
In order to develop such skills, Videolab is a very powerful tool used in medical schools (as well as many other faculties requiring this type of soft skill). At leading universities and medical centres across Europe Videolab is used as the central platform for students to share their videos of interactions with patients or simulation patients. In many institutions, the training and the recording of delivering bad news is a common practice, like at the “Royal College of Surgeons of Edinburgh”, where there exists communication skills competition, focused on the delivery of bad news. The training of bad news can be enhanced through Videolab in the following way: once the videos are recorded by the trainees and uploaded on Videolab, trainees can examine their performance and self-reflect on it by adding fragment comments, symbols or general remarks. Because the way bad news is delivered and received is highly dependent on the person, feedback from peers and professors is a highly valuable instrument to consider different perspectives and be open-minded to be better prepared for future real situations. Moreover, professors are also able to upload specific videos related to breaking bad news for teaching purposes, and students are able to assess what to do and what not to do.
Everything is in place for the current and future healthcare professionals to be trained in the deliverance of bad news. Codific is here to help with the practical implementations. Let’s build a simple and safe digital future together.