Session 10

Question 1

What is bad news?

Answer 1

[*] What is bad news? Range of things, not just giving a terminal illness diagnosis

• Any information that drastically alters a patient’s view of their future for the worse (Kaye 1996)
• Situations where there is either a feeling of no hope, a threat to a person’s mental or physical well-being, a risk of upsetting an established life-style or where a message is given which conveys to an individual fewer choices in his or her life (Buckman 1984)
• E.g. terminal prognosis, disabling condition, traumatic/sudden death (breaking the news to relatives), infertility, antenatal testing, intra-uterine death

Question 2

Is bad news always bad?

Answer 2

[*] we cannot make assumptions that the news is always entirely bad – what you see as bad news may not always be seen in the same way by the patient.

• Patient may feel relief at finally having a diagnosis
• Able to be treated / out of pain
• Carer may feel burden lifted
• News that end of life may bring relief – patient and carer may look forward to end of suffering.
• What you may think is trivial e.g. loss of power in a hand can be devastating to someone such as a professional musician, artist etc.

[*] Determination that the news is entirely ‘bad’ is in the mind of the perceiver and may vary according to personal circumstances

• Age
• Familial obligations

Question 3

Describe the GMC guidelines on bad news

Answer 3

How much information you share with patients will vary, depending on their individual circumstances. You should tailor you approach to discussions with patients according to

• Their needs, wishes and priorities
• Their level of knowledge about, and understanding of, their condition, prognosis and treatment options
• The nature of their condition
• The complexity of the treatment
• The nature and level of risk associated with the investigation or treatment

You must answer patients’ questions honestly, and as far as practical, answer as fully as they wish.
You need to respect patients’ wishes for information - must give patients the information they want or need about:

• The diagnosis and prognosis
• Any uncertainties about the diagnosis or prognosis including options for further investigations
• Options for treating or managing the condition, including the option not to treat
• The purpose of any proposed investigation or treatment and what it will involve
• The potential benefits, risks and burdens, and the likelihood of success for each option; this should include information, if available, about whether the benefits or risks are affected by which organisation or doctor is chosen to provide care.

Question 4

Why is it important to tell patients bad news?

Answer 4

[*] Dislosure

It is important to inform the patient when the diagnosis is confirmed – move towards greater openness.

[*] Why is it important to tell patients when there is bad news?

• To maintain trust
• To reduce uncertainty, worry and stress by reducing ambiguity
• To prevent unrealistic expectations about the future
• To allow appropriate adjustment and allow patients to come to terms
• To promote open communication – easier for doctors to know openly if patients are fully-informed.

[*] Most patients wish to know their diagnosis and be informed about the progress of the treatment and disease e.g. 96% of cancer patients wanted to know diagnosis; 91% wanted to know chances of a cure; 79% wanted as much information as possible (Meredith et al 1996)

[*] Doctors find it easier to treat and care for patients if they know their diagnosis (Seale 1991)

Question 5

Explain the implications for patients if bad news is not delivered well

Answer 5

[*] Lack of information can increase patient uncertainty, anxiety, distress and dissatisfaction (Audit Commission 1993)

[*] Disclosure of terminal illness seen by some cultures as harmful, cruel or dangerous

• Codes of medial ethics in “Islamic” countries.
• In some countries, medical ethics allows concealment of information when there is bad news and some cultures promote informing family members and allowing them to handle the bad news with the patients. There may be some difficult situations e.g. family members wanting to withhold the information from the patient.

[*] If bad news is not delivered well, this can have an impact on

• Doctor-patient relationship
• Emotional wellbeing e.g. distress and depression (Kings Fund 1996, Mager & Andrykowski 2002)
• Adjustment to and ability to cope with the illness, for patients and their relatives (Woolley et al 1989; Fallowfield 1993; Kruijver et al 2000)

Question 6

Describe ‘blocking behaviours’ in breaking bad news

Answer 6

[*] Doctors sometimes use ‘blocking behaviours” in order to protect themselves from the emotions in the consultation

[*] Telling patients’ distress is normal

[*] Changing the subject

[*] Giving information/advice before concerns have been elicited – moving on quickly to the next step rather than giving patient time to express their emotions

[*] Focusing only on physical aspects

[*] Asking leading/closed/multiple questions – not giving patients the chance to open up/break down.

[*] These behaviours are not experienced positively by patients.

Question 7

What is the Spikes Model?

Answer 7

[*] No universally agreed guidelines on how to break bad news although there is a general consensus (Ptacek 1996)

[*] Most patients except full disclosure delivered with empathy, kindness and clarity (Buckman 2005)

[*] Key Guidelines: SPIKES (Buckman) and 10-step approach (Kaye)

Question 8

Define the S in the Spikes Model

Answer 8

[*] S – Setting & Listening skills

• Break the bad news face-to-face, not over the telephone / in a letter. Avoid informing relatives first.
• Ensure privacy and no interruptions (let other staff know), allow enough time.
• Find out who the patient wants present – give the patient the option but acknowledge they may not want anyone else online.
• Introduce yourself and any colleagues (ideally no more than 3 staff)
• Sit down, eyes on the same level – eye contact, calm. No physical barriers – computer etc. Tissues available. Being able to offer tissues can be a signal to patients that it’s ok to cry and break down.
• Listening mode – silent and repetition – to show you emphasise, allow patient to open up.

Question 9

Describe the P in the Spikes Model

Answer 9

[*] P – Patient’s Perception

• What does the patient know already? Consider expectations such as patient might already be expecting cancer.
• ‘Before you tell, ask’
• Start consultation with general question e.g. “What have you been told about all this so far? What do you know about this already?”
• Provides entry point for the best way to break bad news

Question 10

Describe the I in the Spikes Model

Answer 10

[*] I – Invitation from patient to give information

• Don’t assume patient will want to know everything – ask patient how much or what information they want to know
• “How much information would you like me to give about your diagnosis and treatment?” Do you prefer to know everything going on or the bare minimum?
• If the patient declines information at any point, respect this. Allow for denial and offer opportunity for further discussion – denial can be a healthy coping mechanism so they might not want to know everything at this time but give them opportunities in the future.

Question 11

Describe the K in the Spikes Model

Answer 11

[*] K – Knowledge

• Give a warning shot: “I’m very sorry to have to tell you this”
• Direct patient to diagnosis:

Give information in small chunks – as patient might be in shock
Give patient time to consider and ask questions before continuing
Check understanding – if in doubt, ask patient to recap

• Avoid jargon, align language with patient
• Use clear and simple explanations – avoid medical language and euphemisms (‘cancer’, not just ‘tumour’ or ‘growth’)

Incorporate key terms used by patients e.g. ‘spread’

Question 12

Describe the E in the Spikes Model

Answer 12

[*] E - Empathy:

Empathetic response

• How are you feeling? (Give patients opportunity to express their emotions)
• Acknowledge connection between news and emotion – “this information has obviously come as quite as a shock”, “I can see this news is very upsetting for you”
• Validate / normalise emotion “It’s not surprising you feel angry” “I can understand how you can feel that way”

Listen to patient’s concerns – “What is concerning you the most?” If you could address patient’s biggest concerns, patient may go away feeling a lot better.

Question 13

Describe the second S in the Spikes Model

Answer 13

[*] S – Strategy and Summary

• Summary: summarise the main discussion topics and check understanding again
• Strategy:

Discuss strategy – be clear what the next step is going to be, agree on next step
Be optimistic, but avoid inappropriate / premature reassurance.

• Closure:

Signal closure, give opportunity to ask questions (written information?)
Offer future availability
If the patient is still distressed ask if they would like: a member of the healthcare team to remain, someone contacted or to be left alone.

[*] It is very important to document the consultation in the patient notes – make all doctors and staff are on the same page and knows what the patient has been told. Aids coordination between different healthcare professionals.

[*] Doctors need to apply good practice guidelines but remember to treat patients as individuals