BREAKING BAD NEWS

«  Bad news is any information that drastically alters a patient's view of his future. It may include information about symptoms (“Your breathing will not get completely better.”) or prognosis (“This disease will shorten your life.”)

«  Adjustment to bad news, to a different future, takes time and is similar to a process of grief. The person is shocked and needs support.

«  The way the diagnosis of life-threatening illness is first impared can affect the family’s ability to cope.

Comments from a patient on how not to do it:

(Mrs. S.C. is 35. Advanced cancer of the ovary was diagnosed at laparotomy 2 days after delivery of her first child.) “The way I was told the diagnosis is still a very painful memory. It still hurts very much. It was not my own gynecologist, it was a doctor I had never seen before. He didn’t wait for my husband or even ask if I wanted him there. He started right away telling me about the chemotherapy and said ‘Yes, you may lose your hair, but don’t be vain.’ You can’t remember the details of the information. It needs to be repeated again and again. People are shocked when they are told something is wrong with them. It takes time to adjust."

 Comments from a relative on how not to do it:

“I found out one evening after visiting Fred. My son and I were walking down the corridor and a medical resident stopped us and said ‘I’m afraid I think this effusion is serious’ I asked him what he meant and he said ‘Can’t you guess?’ I asked if he meant cancer. Just then his beeper went off and we had to wait in the corridor for him to come back. My son looked gray. When he came back my son suddenly fainted and we spent the rest of the evening in the emergency ward. The resident came down there later and said he was sorry, and told the emergency doctor that he had just given us some bad news. It was a nightmare. Then we had to decide how to tell Fred.”

These doctors broke most of the rules of common sense and common courtesy. Breaking bad news is never easy (and never should be easy). It does not necessarily need to be time-consuming to be done satisfactorily.

Basic principles:

•  Set aside time (give your beeper to someone else!)
•  Arrange for privacy and quiet
•  Convey empathy (“You must be worried.”)
•  Ask questions first and listen
•  Explain using kind words
•  Give information in a graded way
•  Avoid jargon (it confuses)
•  Arrange emotional support (“Who will be at home?”)
•  Offer to meet with family members (a disaster happens to a whole family)
•  Offer availability (“Let’s meet again next week.”)

The person must be ready to hear the information. The person may react with anger or may deny having heard the information and yet become very anxious. Telling people something unpleasant that they do not want to hear can be a risky business (the ancient Greeks used to kill the bearers of bad news).

It is often possible to gauge the information a person needs and wants. On walking into an out-patient clinic for the first time, one lady with cancer said “Now don’t go telling me anything I don’t want to hear.” This is a clear message which should be honored. Most patients are less forthright but the signs are there to be read nevertheless. Changing the subject, looking out of the window, a slight widening of the eyes – all say “this conversation is becoming increasingly frightening” – and are messages to be noted.

Avoid making assumptions. Even if a patient asks a direct question, (“What do you think is wrong with me?”) it is important not to start giving information based on assumptions about what data is wanted and needed. Reflect the question back (“What have you been thinking is wrong with you?”) and ask questions until the person has expressed his knowledge and some of his feelings. In this way you can develop an intuitive feel for the right approach and for what to say or not to say.

A common dilemma is sensing that more knowledge would reduce a patient’s uncertainty yet sensing also his fear of hearing bad news. It is possible to test feelings with questions like “Are you a worrier?” or “Have you been worrying about yourself?” The initial answer is usually “No”, but if a friendly silence is allowed to linger, the patient may say something relevant, making it clear whether more information would be helpful. Information must be clear and simple and free of jargon. A person receiving bad news is shocked and often remembers virtually nothing of facts and figures.

Use kind words. It is tempting for professionals to hide behind technical explanations and jargon to spare themselves emotional distress. But detailed explanations (or discussion of treatment options) should usually take place later. Patients often comment “Once he told me I didn’t hear anything else.”

The words do make a difference. One couple whose child had cancer asked for a second opinion. Afterwards, they said “He only said what the other doctor said, but somehow it didn’t seem so bad.” A “hierarchy of euphemisms” can be helpful to test how much the person can take at that time (“problems, illness, lump, tumor, cancer”).

Be as optimistic as possible. “No one knows enough to make a pronouncement of doom upon another human being.” (Norman Cousins)

The purpose of breaking bad news is to reduce uncertainty about the future and enable appropriate adjustments to occur. Uncertainty is the hardest of all emotions to bear. A common reaction to bad news is “It’s a relief now that I know.” Reducing uncertainty enables a person to make sensible decisions about the future.

A common myth about bad news is “Don’t tell him, it will destroy all his hope.” Inappropriate hope can be an exhausting and depressing business. Watching someone spending his last weeks hoping for an operation to cure him, or hoping to wake up feeling well again, as he gets weaker day by day is a sad sight. It usually causes the patient anxiety (“What is happening to me?”) and guilt (“Am I doing something wrong?”). It cheats him of the opportunity to use his remaining time for things that are important.

Bad news obviously affects the whole family. It often helps to have family members present. On-going support from family and friends is very important in the patient’s process of adjusting to bad news. It is essential that all family members be given similar information to enable and encourage mutual support. (see Communication Problems, Talking with Families, Telling the Truth)

«  The breaker of bad news may also need support (time to share his own feelings with colleagues or friends).

«  If bad news is explained completely and compassionately, anxiolytics are rarely needed.

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.