Breaking bad news can feature in different ways within primary care setting - ranging from telling a patient they have been diagnosed with a life changing chronic disease through to a terminal condition.
Our perception of bad news may be very different to a patient’s and what we may consider ‘normal’, for example hypertension, may have profound implications for a patient.
- Diagnosis of a chronic condition, for example diabetes, COPD, asthma, hypertension.
- Suggesting that there is a high probability of a terminal condition based on test results, such as an abnormal lesion on CT scan.
- Suggesting a likely diagnosis of a cognitive disorder.
- Diagnosing a mental health problem such as depression or anxiety.
It is unlikely that you will have to deliver the news of a terminal diagnosis with prognosis, as this should have been covered in the hospital setting, but it is possible.
Preparing to deliver the news
You will probably be the aware the patient is coming in to discuss the result of a test, so make sure you have reviewed the record thoroughly. If you are able, ensure appropriate time is allocated to this appointment - this may involve a double or triple appointment.
You may know the patient and organised the investigation yourself, but increasingly we see patients to discuss results of tests ordered by healthcare professionals in other settings. Further data gathering may be required before you speak to the patient.
Important things to consider include:
- Do you have the correct notes and are you happy that the result is for the correct patient?
- Who arranged the test, when was it performed and why was it performed?
- Are there any recent discharge letters, relevant clinic letters or consultations within the practice?
- Does the patient have any co-morbidities/relevant medical history, or taking any medications that may have an impact on further investigations?
- Is the patient fit enough to undergo further investigations?
- Do they have capacity to make decisions?
- Are there any barriers to communication, such as language or any disabilities?
- Are there are any patient information leaflets or local support groups that would be useful for the patient to take away with them following the appointment?
Before the appointment ensure your room is set up appropriately and free from distractions, including computer pop-up messages and mobile phone interruptions.
Delivering the news
Be flexible in your approach to delivering the news. If you do not know the patient, establish rapport. Key non-verbal skills to consider include:
- Eye contact
- Active listening
- Empathy and sensitivity to the situation, including empathic statements where appropriate
- Soft tone
- Avoid any judgment
- Avoid making any assumptions
Data gathering may be required. How much you do at this stage will depend on whether you know the patient and their case and whether you were the doctor who arranged the test.
However, the following are useful points to consider:
- Establish what the patient already knows. Explore their thoughts and concerns around their symptoms and the test or tests performed.
- Do they know which test they had and, if so, do they know why? It is not uncommon to see patients who have undergone tests in hospital not knowing what was done, why it was done or even that it was done at all.
- Recap the original symptoms reported if appropriate.
- Summarise information back to the patient to show you have listened and have established the correct sequence of events.
- Find out how much the patient actually wants to know - this will vary from patient to patient.
- Provide a warning shot, for example: ‘we have the results of X, what did you feel this may show?’
- When explaining any results, establish the patient’s baseline knowledge of the suspected condition and tailor your language accordingly.
The rest of the consultation
What subsequently happens during the consultation will depend on the type of news, how the patient responds and their personal background, culture and health beliefs.
Have a flexible approach and find out at this point how the patient wishes to progress.
If the news is a complete shock, it may be that nothing further can be absorbed and they will require further review to make any plans. This will need to be done in a timely manner and you may wish to advise them to bring a friend or relative with them when they next attend.
If the consultation continues, provide time at this point for the patient to ask questions and for you to clarify things.
It is worth exploring the patient’s social situation, including home and work life, as these may be impacted by the news and the patient may have questions about this. Again, this may require the patient to come back in a couple of days if they need time to digest the news.
Summarise the information provided so far and explore what they have understood, providing more opportunities for questions. If hospital appointments are needed, ensure these are sorted and the patient understands what they have to do and what will happen at the appointment.
If you plan on managing the condition yourself, ensure the patient has appropriate follow up with yourself or a colleague.
Make sure you provide any useful leaflets or information and stress that they can come back to see you if they have any more questions or want to discuss future treatment plans.
Recognise the impact this has on you
Breaking bad news can be emotionally difficult for the GP involved and on occasions it can be a stressful experience. If you find that a consultation has been especially difficult you could benefit from discussing it with a trusted colleague – especially if you are in the first five years of your career.
Common pitfalls in breaking bad news
- Not having full knowledge of facts.
- False reassurance
- Too much information
Dr Singh is a GP trainer in Northumberland