Consultation skills - The best way to break bad news

Employing a step-by-step protocol can make delivering bad news much easier, says Dr Mona Kular.

Breaking bad news to patients can be highly stressful and is not something for which we feel adequately trained. Yet getting it wrong can be extremely detrimental not only to the patients' psychological wellbeing, but also the doctor-patient relationship and our own personal self-esteem and confidence.

What is bad news?
Bad news can be different things to individual patients - being given a diagnosis of cancer; finding out they are infertile; receiving a positive HIV test result; learning that they have a chronic disease such as diabetes, liver disease or chronic kidney disease; or discovering that their partner has dementia are all examples.

A useful definition of bad news is 'information that adversely and seriously affects an individual's view of his or her future'.

The GP's role
There are times when patients have been told bad news by clinical specialists within secondary care, but have not fully absorbed or understood the information. In these cases, our role is to go through this information with them again.

In some situations, preliminary investigations reveal a high index of suspicion for certain diseases or malignancies, and it is our role to go through the information with these patients prior to referring them for a definitive diagnosis.

Useful pointers
Breaking bad news requires great sensitivity and good communication skills. It is important to address possible barriers to the consultation, such as language or disability, prior to starting the process. The 'connecting' and 'summarising' stages of Professor Roger Neighbour's consultation model may be especially relevant in this context.

Confidentiality is as important when breaking bad news as in other situations: for example, relatives should not be told about the patient's condition without their consent. Conversely, information about the diagnosis should not be withheld from patients.

The SPIKES approach
The SPIKES approach, which was developed in 2000, is a six-step protocol for delivering bad news. Although initially designed for patients with cancer, it can be adapted for any situation in which bad news needs to be delivered. The SPIKES approach is as follows:

- Setting up: Ensure that the setting has enough privacy. Involve one or two relatives or friends of the patient's choice. Sit down to help the patient relax and to show you have time for them. Establish a rapport with the patient through eye contact or touch. Minimise interruptions from other people, pagers or phones, and set aside adequate time for the consultation.

- Perception: Find out how the patient perceives the situation using questions like, 'What have you been told about ... so far?' or 'What is your understanding of why we arranged ... investigations?'

- Invitation: Establish that the patient wants to hear the news, and find out whether they would like brief details or an in-depth explanation. Asking about this directly may be the best way of doing this.

- Knowledge: Give the patient the relevant information in a language they understand. It might be helpful to begin with a statement such as 'I'm afraid I have some bad news' or 'I'm sorry to tell you that ...'. Give information in small chunks and stop periodically to check that the patient understands. Avoid overly negative statements such as 'There is nothing more that can be done'. Patients might be more concerned with quality of life.

- Emotions - An empathic response to the patient's emotional reaction is important. Start by observing their emotional response and try to identify the emotion being displayed, such as sadness or anger. You might want to ask the patient how they are feeling if it's not clear. Identify the reason for this particular emotion. Again you may want to ask the patient if you are not sure.
Give the patient some time to express their feelings and then show them that you have acknowledged their response, for example by saying 'I know this isn't what you wanted to hear ...'

- Strategy and summary - Finally, summarise the discussion and check that the patient has understood the areas covered. Formulate a strategy with the patient based on their own hopes and expectations, and specific concerns or goals they might have. Arrange follow-up.

Other useful resources
A useful website, sponsored by Pfizer, is www.breakingbadnews.co.uk. It provides guidelines on how to go about breaking bad news as well as strategies on how to deal with difficult situations such as denial; family members asking you to withhold information from the patient; handling anger, guilt and blame; answering difficult questions; grief; and encouraging hope.

Dr Kular is a GP registrar in Gamston, Nottingham

Contact Sharon Pickett at GP Education at (020) 8267 4512 or email GPregistrar@haymarket.com

Learning points
Pointers for handling a difficult consultation

1. Breaking bad news can be stressful but needs to be done effectively in primary care.

2. Bad news can be anything from a diagnosis of diabetes or infertility to cancer.

3. Communication skills are important and Professor Roger Neighbour's consultation model may be useful.

4. The SPIKES approach provides a framework to use when breaking bad news.

Resources

  • Buckman R. Breaking Bad News: A Guide for Healthcare Professionals. Johns Hopkins University Press.
  • Neighbour R. The Inner Consultation. Radcliffe Publishing, 2005.
  • Breaking bad news: www.breakingbadnews.co.uk.

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