Dr Kirti Bushan
“Bad news” has been defined as any information which adversely and seriously affects an individual’s view of his or her future. Breaking bad news to cancer patients is inherently aversive , described as “hitting the patient over the head” or “dropping a bomb”. It is really challenging to break bad news about spread of disease, recurrence, failure of treatment to affect disease progression, the presence of irreversible side effects, revealing positive results of genetic tests, and raising the issue of hospice care and resuscitation when no further treatment options exist. It can be particularly stressful when the clinician is inexperienced, the patient is young, or there are limited prospects for successful treatment. How bad news is discussed can affect the patient’s comprehension of information , satisfaction with medical care , level of hopefulness , and subsequent psychological adjustment.
Breaking bad news : why is it important ?
Historically it was given scant attention in medical practice . This is, however, changing and acquiring consultation skills for breaking bad news especially cancer are now a core part of management . Surveys conducted from 1950 to 1970s, when treatment prospects for cancer were bleak, revealed that most physicians considered it inhumane and damaging to the patient to disclose the bad news about the diagnosis. Ironically, at present when treatment advances have changed the course of cancer so that it is much easier now to offer patients hope at the time of diagnosis. Patients wants to know the truth and the chances of cure for their cancer and the side effects of therapy. There are clear ethical and legal obligations to provide patients with as much information as they desire about their illness and its treatment . Physicians may not withhold medical information even if they suspect it will have a negative effect on the patient.
Barriers to breaking bad news
“Breaking bad news” consulttions don’t happen often and studies suggest that a number of factors affect a doctor’s ability to impart bad news sensitively. These include deficient knowledge about subject, burnout and fatigue, personal difficulties, behavioural beliefs and subjective attitudes. Psychological analysis have shown that shown that the bearer of bad news often experiences strong emotions such as anxiety, a burden of responsibility for the news, and fear of negative evaluation. This stress creates a reluctance to deliver bad news, and has been named the “MUM” effect. The MUM effect is particularly strong when the recipient of the bad news is already perceived as being distressed by family members and physician. Poor communication, particularly with cancer patients, has been shown to be associated with worse clinical and psychosocial outcomes, including worse adherence to treatment, confusion over prognosis and dissatisfaction at not being involved in decision making.
Breaking bad news- spikes protocol
Breaking bad news is a complex communication task. In addition to the verbal component of actually giving the bad news, it also requires other skills. These include responding to patients’ emotional reactions, involving the patient in decision-making, dealing with the stress created by patients expectations for cure, the involvement of multiple family members, and the dilemma of how to give hope when the situation is bleak.
The process of disclosing bad news can be viewed as an attempt to achieve four essential goals. The first is gathering information from the patient. This allows the physician to determine the patient’s knowledge and expectations and readiness to hear the bad news. The second goal is to provide intelligible information in accordance with the patient’s needs and desires. The third goal is to support the patient by employing skills to reduce the emotional impact and isolation experienced by the recipient of bad news. The final goal is to develop a strategy in the form of a treatment plan with the input and cooperation of the patient. Meeting these goals is accomplished by a six-step SPIKES protocol and has been shown to improve the confidence of clinicians while breaking bad news to cancer patients
The sex steps of spikes Setting up the interview
The casual physical setting causes interviews about sensitive topics to flounder. Unless there is a semblance of privacy and the setting is conducive to undistracted and focused discussion, the goals of the interview may not be met. Some helpful guidelines: Ideally, bad news should be given in person and not over the telephone. For doctors this may be just another day at work but to the patient and the family it is a pivotal day of their lives. The patient should be allowed to be accompanied by family members or close ones. A doctor must arrange for some privacy, making patient sit down and relax, connect with patient, comfort the patient, provide enough time for patient satisfaction and avoiding interruptions in conversations. Mental rehearsal is a useful way for preparing for stressful tasks. A physician must have full knowledge of patients status and ready with a treatment plan.
Asssessing the Patient’s perception
Before disclosing bad news , the clinician must use open-ended questions to create a reasonably accurate picture of how the patient perceives the medical situation. Based on this information clinician can correct misinformation and tailor the bad news to what the patient understands. It can also accomplish the important task of determining if the patient is engaging in any variation of illness denial: wishful thinking, omission of essential but unfavorable medical details of the illness, or unrealistic expectations of treatment .
Obtaining the Patient’s invitation
While a majority of patients express a desire for full information about their diagnosis, prognosis, and details of their illness, some patients do not. When a clinician hears a patient express explicitly a desire for information, it may lessen the anxiety associated with divulging the bad news
Giving Knowledge and Information to the patient
Sharing medical facts with the patients may be improved by a few simple guidelines. First, start at the level of comprehension and vocabulary of the patient. Second, try to use nontechnical words. Third, avoid excessive bluntness as it is likely to leave the patient isolated and later angry, with a tendency to blame the messenger of the bad news. Fourth, give information in small chunks and check periodically as to the patient’s understanding. Fifth, when the prognosis is poor, avoid using phrases such as “There is nothing more we can do for you.” This attitude is inconsistent with the fact that patients often have other important therapeutic goals such as good pain control and symptom relief.
One must use language that the patient will understand and give plenty of opportunity to interrupt if they want something elucidated. It is a common complaint from patients that medical staff spoke to them in language that they did not understand. Consider how much detail the patient may want to know . Observe the patient and see how they are coping. Talking directly is perceived by patients to represent honesty and trustworthiness. Be honest about what you don’t know. As a doctor you may not be able to give exact figures for survival rates but the patient may return to you after a specialist appointment asking about them. Make sure that they understand the nature of risk and probability and what these figures mean.
Addressing the Patient’s Emotions with Empathic responses
Responding to the patient’s emotions is one of the most difficult challenges of breaking bad news. Patients’ emotional reactions may vary from silence to shock, isolation, disbelief, grief, crying, denial, or anger. In this situation the physician can offer support and solidarity to the patient by making an empathic response. Patients regard their oncologist as one of their most important sources of psychological support , and combining empathic, exploratory, and validating statements is one of the most powerful ways of providing that support .It reduces the patient’s isolation, expresses solidarity, and validates the patient’s feelings or thoughts as normal and to be expected.
S-Strategy and Summary
Patients who have a clear plan for the future are less likely to feel anxious and uncertain. Before discussing a treatment plan, it is important to ask patients if they are ready at that time for such a discussion. Presenting treatment options to patients when they are available is not only a legal mandate in some cases but it will establish the perception that the physician regards their wishes as important. Sharing responsibility for decision-making with the patient may also reduce any sense of failure on the part of the physician when treatment is not successful. Checking the patient’s misunderstanding of the discussion can prevent the documented tendency of patients to overestimate the efficacy or misunderstand the purpose of treatment.
(The author is Consultant Surgical oncologist, Asian Institute of Oncology, Raheja (fortis) hospital, Lilawati hospital Mumbai. kirtibushan@gmail.com)
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