ABSTRACT
Breaking bad news is never easy for anyone, especially those who worked in the healthcare field. Often the healthcare personnel find themselves in extremely stressful situations, whether to tell their patients the truth and risking unpredictable negative responses, or just telling them the superficial diagnosis without going deep into the facts. In assessing the best way to break a bad news, excellent verbal and non-verbal skills are required, because breaking bad news is a complex communication task. If the news is poorly delivered, misunderstanding can arise and patient can be hard to cooperate with.
Breaking bad news comes in various forms. It is a regrettable but important duty that must be done very carefully, yet it tends to receive a little attention in medical training. This assignment will discuss a hypothetical situation of breaking a bad news in different level of patient’s awareness, typical responses from patient, how to approach the situation, and the next steps that need to be taken after the news has been delivered. The case involves Mr. X, a 35-year-old man who has just been diagnosed as having a terminally ill disease. The doctor who did the diagnosis is assigned to break the news to him.
BEFORE BREAKING THE NEWS
In breaking a bad news, strategy must be planned in order for the news to be conveyed effectively and to avoid unnecessary negative circumstances. First of all, the doctor must familiarize himself with the patient’s background, medical history, and test results. Next, set up a consultation session with the patient. This is important because a bad news must be transmitted in person and not over the telephone. Arrange some privacy to the patient, such as in a consultation room.
When conveying the message, the doctor must not do it while standing up. The appropriate way is for him to sit down and talk calmly, as this is less intimidating and shows that it is not done in rush. If it is possible, provide a written report to support the verbal news. This is to provide a mean of repeating the information later at home. Recording the consultation is also one of the ways to provide later review of information.
CHECKING PATIENT’S AWARENESS
As the consultation took place, the doctor needs to assess Mr. X’s awareness regarding his condition, whether he is unaware, aware but do not want any information, or unaware and do not want any information.
Situation 1: When Mr. X is unaware
In this situation, it is more difficult to break the news. For example, Mr. X feels healthy, suspects nothing about his illness and lived a normal life before. Suddenly the doctor told him that he has a terminally ill disease. It is more likely that Mr. X will not believe the news. Consider the following conversation.
Doctor: Mr. X, I hope you can be calm, be patient and remember God. I’ve just got your test result…I’m so sorry to tell you that you have lung cancer.
Mr. X: Lung cancer? No, doc. You must be wrong. I never feel anything abnormal before. You must be wrong!
At this point, the doctor must change Mr. X’s perception regarding his health. He must tell him that cancer can affect anyone without their knowing. He also must not push him into the state of denial by stating the facts about his medical history and background.
Doctor: No, actually this can affect anyone; even the healthy person can get cancer. First of all, do you smoke or live near to those who smoke?
Mr. X: (Pause momentarily)…but I have quit it a month before…
Doctor: That’s the problem. You have been smoking for years, and that means the risk of getting cancer is elevated. It takes time for cancer to manifest its effect. But don’t worry, we will try our best to treat you.
Give some time to Mr. X to think about what the doctor has just said, and look if he is interested in knowing more about the disease and the treatment plan. If Mr. X is ready to cooperate with the doctor, offer him the plan of treatment in the simplest terminology, as to avoid Mr. X to think that it is too complicated.
Situation 2: Mr. X is aware but doesn’t want more information
Consider the following conversation:
Doctor: Mr. X, we have just got your test results. I want to ask you a few questions; do you notice some changes, like fever or anything abnormal?
Mr. X: Wait a minute. What are you trying to suggest here, doc?
Doctor: Well, we have noticed the lump on your lymph nodes has enlarged and…
Mr. X: So it has gotten serious? I knew the treatment is useless!
Doctor: I hope you don’t panic, please be patient, and don’t worry because we still can…
Mr. X: Look, doctor. Just predict how month I have left, spare your medical jargon and let me out of here. Ok? Just a waste of money and time, that’s what you are.
In this situation, the doctor must respect Mr. X’s wish and let him out. Don’t try to force him to hear the explanation as he is already blocked his mind. What the doctor can do is to get the closest relative and explain to them about the seriousness of his disease. Get them to talk to him about the possible treatment and consequences. If then Mr. X has come to his reasons and want the information, explain it to him patiently.
Situation 3: Mr. X is unaware and doesn’t want more information
10% of patients will deny the seriousness of their illness and don’t want to hear the rest of the diagnosis. It is as the first situation, but has gone all wrong. Consider the continuation from the first conversation:
Doctor: No, actually this can affect anyone; even the healthy person can get cancer.
Mr. X: I have a grandfather who smokes all his life. He never got any cancer. How come that I got that? You must have the test conducted wrongly!
Doctor: Mr. X, please understand. As I said, cancer can affect anyone...
When this happens, what the doctor can do is to challenge Mr. X by stating his medical history. If there is medical jargon, explain the meaning by the simplest term a layman can understand.
Although Mr. X is reluctant to hear the rest of the diagnosis, in this situation, he will usually ask about possible treatment. The fact that Mr. X doesn’t want any information might be due to the frightening that he might get if he knew the details. If he asks about the possible treatment, explain it to him. Respect his wish not to go deep into the facts. But if Mr. X is ready at a later time and wanted to know the details, always provide it to him.
By analyzing these situations, sometimes it is the healthcare personnel that need to be patient more than the patients themselves. Because healthcare field deals with a wide range of people, patience is an essential skill that personnel must acquire. A doctor who suddenly gets mad and throw a patient out from his room just because the patient asks too many question is a situation most undesirable.
AFTER BREAKING THE NEWS
The bad news would somehow have an impact on the patient, whether noticeable or not. At this time, healthcare professionals must provide the emotional support to the patient. As in case of Mr. X, the doctor must first observe for his emotion; such as shock, anger, or silence. Give him some time to vent his emotion, expressing his concerns and what he thinks. If Mr. X is just being silent, the doctor must ask open questions, asking him how he feels and what he’s thinking. Don’t immediately offer more information or reassurance to him. This will help him to articulate his emotion and concerns better.
It is important that the doctor elicit all Mr. X’s concerns and emotion as to assist the effectiveness of the treatment. When he hides anything from the doctor what might have been an important fact, then it is difficult to move on to discuss other relevant issues. Conduct this in negotiating manner, not by force or rush.
After the concerns and emotions have been expressed, the doctor must acknowledge the emotions and show empathy. Avoid saying ‘I know how you feel’ because no one ever know what the other person feels, even if he had the same experience before. Instead, he can say, ‘I think I understand how you feel.’
Sometimes a doctor is unable to be with a patient for a long time. When this happens, the doctor must stress on what he judged as the major concern of the patient. Advise Mr. X the conditions of his disease and recommendations (based on his major concern) as preliminary information before he can set up a later meeting. In this situation, Mr. X needs to feel that his concerns are being identified and understood by the doctor. In that sense, explain to him that the other concerns are not being ignored; it will be dealt at a later time.
DIFFICULTIES AFTERWARDS
Sometimes, in an overwhelmingly emotional situation, Mr. X can asks, ‘am I going to die?’ This is indeed a difficult question to answer as the matter of life and death is only in God’s absolute knowledge. What the doctor can do is acknowledge the question and try to understand why Mr. X asks that question. Sometimes it is due lack of knowledge regarding the disease. If that’s what it is, the doctor can explain again the possible treatment and state that within the extent of power given to human and by God’s will, the disease can be cured or at least managed.
If it is because the seriousness of the disease that has reached the grave danger, the doctor must reflect the question back to Mr. X and ask if he really want to know the truth. Acknowledge his distress and try to comfort him by religious means. Ask if Mr. X wants to share his concerns, such as what will happen to his children and family. This might not help much, but at least the burden is lighten by sharing it.
Often doctors can’t give a certain answer to patients. This might due to the advancement of the treatment, lack of knowledge or unavailability of the treatment in the country. In this situation, the doctor must acknowledge the uncertainty. Don’t risk the pride for a price of life. If it is due to unavailability of the technology, inform Mr. X that he might need to go to other hospital where the technology is more advanced. If it is due to lack of knowledge, inform him that the doctor needs to do more research regarding his disease before a firm decision can be made.
CONCLUSION
No matter how bad the news is, or how negative the response is, the task still needs to be done. It is a matter of ethics. By developing excellent communicating skill, showing empathy, and understanding how patient feels, the task can be eased. These skills, however, require experiences and guide. Thus, all staff, especially the senior ones, needs to share experience and guide the new member of the healthcare team. Communicating bad news to patients well is not an optional skill; it is an essential part of professional practice (Breaking Bad News – Regional Guidelines, 2003).
REFERENCES
1. www.depts.washington.edu/bioethx/topics/badnws.html (8/10/2009)
2. www.dhsspsni.gov.uk/breaking_bad_news.pdf (8/10/2009)
3. http://www.patient.co.uk/doctor/Breaking-Bad-News.htm (8/10/2009)
Breaking bad news is never easy for anyone, especially those who worked in the healthcare field. Often the healthcare personnel find themselves in extremely stressful situations, whether to tell their patients the truth and risking unpredictable negative responses, or just telling them the superficial diagnosis without going deep into the facts. In assessing the best way to break a bad news, excellent verbal and non-verbal skills are required, because breaking bad news is a complex communication task. If the news is poorly delivered, misunderstanding can arise and patient can be hard to cooperate with.
Breaking bad news comes in various forms. It is a regrettable but important duty that must be done very carefully, yet it tends to receive a little attention in medical training. This assignment will discuss a hypothetical situation of breaking a bad news in different level of patient’s awareness, typical responses from patient, how to approach the situation, and the next steps that need to be taken after the news has been delivered. The case involves Mr. X, a 35-year-old man who has just been diagnosed as having a terminally ill disease. The doctor who did the diagnosis is assigned to break the news to him.
BEFORE BREAKING THE NEWS
In breaking a bad news, strategy must be planned in order for the news to be conveyed effectively and to avoid unnecessary negative circumstances. First of all, the doctor must familiarize himself with the patient’s background, medical history, and test results. Next, set up a consultation session with the patient. This is important because a bad news must be transmitted in person and not over the telephone. Arrange some privacy to the patient, such as in a consultation room.
When conveying the message, the doctor must not do it while standing up. The appropriate way is for him to sit down and talk calmly, as this is less intimidating and shows that it is not done in rush. If it is possible, provide a written report to support the verbal news. This is to provide a mean of repeating the information later at home. Recording the consultation is also one of the ways to provide later review of information.
CHECKING PATIENT’S AWARENESS
As the consultation took place, the doctor needs to assess Mr. X’s awareness regarding his condition, whether he is unaware, aware but do not want any information, or unaware and do not want any information.
Situation 1: When Mr. X is unaware
In this situation, it is more difficult to break the news. For example, Mr. X feels healthy, suspects nothing about his illness and lived a normal life before. Suddenly the doctor told him that he has a terminally ill disease. It is more likely that Mr. X will not believe the news. Consider the following conversation.
Doctor: Mr. X, I hope you can be calm, be patient and remember God. I’ve just got your test result…I’m so sorry to tell you that you have lung cancer.
Mr. X: Lung cancer? No, doc. You must be wrong. I never feel anything abnormal before. You must be wrong!
At this point, the doctor must change Mr. X’s perception regarding his health. He must tell him that cancer can affect anyone without their knowing. He also must not push him into the state of denial by stating the facts about his medical history and background.
Doctor: No, actually this can affect anyone; even the healthy person can get cancer. First of all, do you smoke or live near to those who smoke?
Mr. X: (Pause momentarily)…but I have quit it a month before…
Doctor: That’s the problem. You have been smoking for years, and that means the risk of getting cancer is elevated. It takes time for cancer to manifest its effect. But don’t worry, we will try our best to treat you.
Give some time to Mr. X to think about what the doctor has just said, and look if he is interested in knowing more about the disease and the treatment plan. If Mr. X is ready to cooperate with the doctor, offer him the plan of treatment in the simplest terminology, as to avoid Mr. X to think that it is too complicated.
Situation 2: Mr. X is aware but doesn’t want more information
Consider the following conversation:
Doctor: Mr. X, we have just got your test results. I want to ask you a few questions; do you notice some changes, like fever or anything abnormal?
Mr. X: Wait a minute. What are you trying to suggest here, doc?
Doctor: Well, we have noticed the lump on your lymph nodes has enlarged and…
Mr. X: So it has gotten serious? I knew the treatment is useless!
Doctor: I hope you don’t panic, please be patient, and don’t worry because we still can…
Mr. X: Look, doctor. Just predict how month I have left, spare your medical jargon and let me out of here. Ok? Just a waste of money and time, that’s what you are.
In this situation, the doctor must respect Mr. X’s wish and let him out. Don’t try to force him to hear the explanation as he is already blocked his mind. What the doctor can do is to get the closest relative and explain to them about the seriousness of his disease. Get them to talk to him about the possible treatment and consequences. If then Mr. X has come to his reasons and want the information, explain it to him patiently.
Situation 3: Mr. X is unaware and doesn’t want more information
10% of patients will deny the seriousness of their illness and don’t want to hear the rest of the diagnosis. It is as the first situation, but has gone all wrong. Consider the continuation from the first conversation:
Doctor: No, actually this can affect anyone; even the healthy person can get cancer.
Mr. X: I have a grandfather who smokes all his life. He never got any cancer. How come that I got that? You must have the test conducted wrongly!
Doctor: Mr. X, please understand. As I said, cancer can affect anyone...
When this happens, what the doctor can do is to challenge Mr. X by stating his medical history. If there is medical jargon, explain the meaning by the simplest term a layman can understand.
Although Mr. X is reluctant to hear the rest of the diagnosis, in this situation, he will usually ask about possible treatment. The fact that Mr. X doesn’t want any information might be due to the frightening that he might get if he knew the details. If he asks about the possible treatment, explain it to him. Respect his wish not to go deep into the facts. But if Mr. X is ready at a later time and wanted to know the details, always provide it to him.
By analyzing these situations, sometimes it is the healthcare personnel that need to be patient more than the patients themselves. Because healthcare field deals with a wide range of people, patience is an essential skill that personnel must acquire. A doctor who suddenly gets mad and throw a patient out from his room just because the patient asks too many question is a situation most undesirable.
AFTER BREAKING THE NEWS
The bad news would somehow have an impact on the patient, whether noticeable or not. At this time, healthcare professionals must provide the emotional support to the patient. As in case of Mr. X, the doctor must first observe for his emotion; such as shock, anger, or silence. Give him some time to vent his emotion, expressing his concerns and what he thinks. If Mr. X is just being silent, the doctor must ask open questions, asking him how he feels and what he’s thinking. Don’t immediately offer more information or reassurance to him. This will help him to articulate his emotion and concerns better.
It is important that the doctor elicit all Mr. X’s concerns and emotion as to assist the effectiveness of the treatment. When he hides anything from the doctor what might have been an important fact, then it is difficult to move on to discuss other relevant issues. Conduct this in negotiating manner, not by force or rush.
After the concerns and emotions have been expressed, the doctor must acknowledge the emotions and show empathy. Avoid saying ‘I know how you feel’ because no one ever know what the other person feels, even if he had the same experience before. Instead, he can say, ‘I think I understand how you feel.’
Sometimes a doctor is unable to be with a patient for a long time. When this happens, the doctor must stress on what he judged as the major concern of the patient. Advise Mr. X the conditions of his disease and recommendations (based on his major concern) as preliminary information before he can set up a later meeting. In this situation, Mr. X needs to feel that his concerns are being identified and understood by the doctor. In that sense, explain to him that the other concerns are not being ignored; it will be dealt at a later time.
DIFFICULTIES AFTERWARDS
Sometimes, in an overwhelmingly emotional situation, Mr. X can asks, ‘am I going to die?’ This is indeed a difficult question to answer as the matter of life and death is only in God’s absolute knowledge. What the doctor can do is acknowledge the question and try to understand why Mr. X asks that question. Sometimes it is due lack of knowledge regarding the disease. If that’s what it is, the doctor can explain again the possible treatment and state that within the extent of power given to human and by God’s will, the disease can be cured or at least managed.
If it is because the seriousness of the disease that has reached the grave danger, the doctor must reflect the question back to Mr. X and ask if he really want to know the truth. Acknowledge his distress and try to comfort him by religious means. Ask if Mr. X wants to share his concerns, such as what will happen to his children and family. This might not help much, but at least the burden is lighten by sharing it.
Often doctors can’t give a certain answer to patients. This might due to the advancement of the treatment, lack of knowledge or unavailability of the treatment in the country. In this situation, the doctor must acknowledge the uncertainty. Don’t risk the pride for a price of life. If it is due to unavailability of the technology, inform Mr. X that he might need to go to other hospital where the technology is more advanced. If it is due to lack of knowledge, inform him that the doctor needs to do more research regarding his disease before a firm decision can be made.
CONCLUSION
No matter how bad the news is, or how negative the response is, the task still needs to be done. It is a matter of ethics. By developing excellent communicating skill, showing empathy, and understanding how patient feels, the task can be eased. These skills, however, require experiences and guide. Thus, all staff, especially the senior ones, needs to share experience and guide the new member of the healthcare team. Communicating bad news to patients well is not an optional skill; it is an essential part of professional practice (Breaking Bad News – Regional Guidelines, 2003).
REFERENCES
1. www.depts.washington.edu/bioethx/topics/badnws.html (8/10/2009)
2. www.dhsspsni.gov.uk/breaking_bad_news.pdf (8/10/2009)
3. http://www.patient.co.uk/doctor/Breaking-Bad-News.htm (8/10/2009)
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