Breaking bad news

Breaking Bad News

You cannot soften the impact of bad news. However, delivering this news will not only ensure the message is clear and understood but also helps the person adjust to the consequences of the news. PREPARE

• Find out what the patient already knows and find out how much the patient wants to know. Give a warning signal. Break the news using simple but clear language. PAUSE

• Wait for a response. ASSESS

• Focus on the patient’s feelings. Encourage the patient to express their concerns. Check the patient understands. Make a plan of action with the person, including positive practical support but not false reassurance. • Ensure a follow-up appointment is available. Give written information as appropriate. Check your own state of mind before seeing the next patient.

A model to support you in Breaking Bad News

Setting up the conversation:

Gather relevant information and think about the terminology you will be using (it must be understandable by all involved), privacy and who needs to be there (staff, significant others). Consider how to open this conversation.

Perception:

Find out what the patient knows and how serious they think it is. Use open ended questions to ensure you get the information needed.

- What is your understanding of your illness? - What did Dr X tell you when they sent you here?

Invitation:

Patients have the right to hear every detail but they also have a right not to hear or want to know every detail. Unless you ask, you will never know how much information they need. - Offer to answer any questions they may have.

Knowledge:

Having found out what the patient already understands – clarify this and use this as your starting point. Build the conversation. Give information in small chunks and check that it has been understood. Simplify if needed. Listen to the person’s agenda, not just your own!

Emotions:

Respond to the person’s emotions – people react in different ways. Acknowledge what you see and ask about it – ‘what are you thinking’ – explore further if you need to. Empathy will offer support and allow the person to express their feelings and worries.

Summary and Strategy:

People will look to health professionals for help in making sense of confusion and offering plans for the future. Make a plan or strategy and explain it, for example preparing for the worst and hoping for the best. Help identify their coping strategies, other sources of support and incorporate them.

DOCUMENT the conversation clearly in the notes!

Talking to relatives

A guide to compassionate phone communication during COVID-19

Introduce SPEAK SLOWLY OPEN WITH A QUESTION ESTABLISH WHAT THEY KNOW

GRACE

WARD SISTER I’m calling to give you an update on your brother, Frank. Are you OK to talk right now? Can you tell me what you know about his condition?

Share info in small chunks

Helpful concepts

Honesty with uncertainty PAUSES SIMPLE LANGUAGE EUPHEMISMS JARGON

There are treatments that might help Frank get better, such as giving him oxygen to help with his breathing. But if his heart stopped, we wouldn’t try to restart it, as this wouldn’t work.

We hope Frank improves with these treatments, Hope for the best, plan for the worst but we’re worried he may not recover.

Sick enough to die

Comfort and reassure

Frank is very sick and his body is getting tired. Unfortunately he’s now so unwell that he could die in the next hours to days. I’m so sorry to tell you this over the phone, but sadly Frank died a few minutes ago.

Is there anything you can tell me about Frank to help us look after him? What matters to him? We’ve been looking after him and making sure he’s comfortable.

Allow silence LISTEN EMPATHISE ACKNOWLEDGE

I am so sorry. Please, take your time. It must be very hard to take this in, especially over the phone. I can hear how upset you are. This is an awful situation.

Ending the call DON’T RUSH NEXT STEPS

Before I say goodbye, do you have any other questions about Frank? Do you need any further information or support?

Afterwards

Chat with a colleague. These conversations are hard.

#weareallhuman

Developed by Dr Antonia Field-Smith and Dr Louise Robinson, Palliative Care Team, West Middlesex Hospital