Bad news is any news that adversely affects the patient’s views of the future. There is a misguided belief that bad news always has to involve a cancer diagnosis, but any condition that may have personal implications is a bad news event for that patient.
Breaking bad news is one of the most challenging yet, when done effectively, one of the most rewarding communication issues that you will face as a doctor.
Preparation
Try to avoid being caught unawares by ‘bad news’. If you are doing tests for a patient, anticipate how you will give the results. Check the results before seeing the patient for follow-up and anticipate the possible reaction from that particular patient. If you expect to be delivering bad news you might ask the patient to come with a friend or relative. Be aware of the setting where you will be delivering bad news and make sure that you will not be disturbed.
Listen to the patient
At the start of the consultation encourage the patient to express their thoughts and concerns about their medical condition and be aware of cues about worries or fears.
If possible use those thoughts and concerns to express in clear, non-medical language the bad news that you have to share with the patient.
Make sure that the patient understands what you have said and allow time for the information to sink in — this means being quiet and allowing the patient to express themselves in their own time.
Answering questions
Encourage questions and keep your explanations to answering the patient’s questions at this stage.
Maintain eye contact and make your non-verbal communication receptive of the emotions being expressed.
You might not know the answer to some of the questions that the patient might ask you, but it is much better to be honest about the things that you are unsure and say that you do not know. If there is a need to apologise do not be afraid of saying sorry. This can often lead to an opportunity to help the patient by finding out the answer or preparing the patient to ask questions of a specialist.
If there are grounds for being optimistic share those thoughts with the patient.
Support and planning
There is often a lot that the doctor can do after imparting bad news to make the patient feel better. Many patients will feel relief at knowing that their doctor understands their distress.
Drawing up a plan with the patient of what will happen next can be very reassuring.
Try to involve the patient’s relatives if possible. Sometimes the patient is going to have to pass on the news to a partner or to their family. It is helpful for you to assist them with this by asking the patient to tell you what they are going to say. This also helps to clear up any misunderstandings.
If possible arrange a follow-up appointment. This will allow the patient to mull over the news and come and ask more questions and receive further help.
These consultations are often emotionally difficult for the doctor — a discussion with a colleague or a moment to collect your emotions and prepare yourself for the next patient is of great importance.
Dr Havelock is a GP trainer in Wooburn Green, Buckinghamshire
Learning points
A supportive attitude goes a long way to help your patient
- Bad news is any news that adversely affects the patient’s views of the future.
- Breaking bad news situations need preparation and planning.
- Try and establish the patient’s understanding before giving bad news.
- Be clear and unambiguous in giving bad news, using plain non-medical language, and be honest in answering questions.
- Be prepared for the patient to express emotion and leave space for it.
- Arrange support and a follow-up appointment.
Case study Miscarriage
Mrs X, who was 12 weeks pregnant, came to see me urgently one morning to say that she had lower abdominal pain and a bloody discharge; she was concerned that she was having a miscarriage. An examination showed that she was slightly tender in her lower abdomen with a bright red vaginal loss.
I agreed that she could be having a miscarriage then told her that an ultrasound scan would be needed. I explained the incidence of miscarriage in first pregnancies to her and I allowed her a moment of reflection.
She then asked questions about future and I was able to reassure her about subsequent pregnancies.
We discussed what would happen with the scan and what might happen concerning the vaginal blood loss.
I shared best and worst scenarios and appropriate actions. We arranged an appointment after the scan and emphasised that she should contact me if she was concerned.
