Bad News

1. When giving bad news, ensure that the setting is appropriate, and ensure patient’s confidentiality
2. Give bad news:
   • in an empathic, compassionate manner
   • allowing enough time
   • providing translation, as necessary
3. Obtain patient consent before involving the family.
4. After giving bad news, arrange definitive follow-up opportunities to assess impact and understanding.

Approach to breaking bad (or serious) news

• STEP 1: S—SETTING UP the Interview
  • Gather information, test results, treatment options (consider speaking to patient's other doctors).
  • Identify if patient has decisional capacity, and if surrogate decision maker has been identified
  • Translator if needed.
  • Arrange for some privacy.
  • Involve significant others (obtain patient consent).
  • Sit down, make connection with the patient (eye contact or touch).
  • Manage time constraints and interruptions.
• STEP 2: P—Assessing the Patient's PERCEPTION
  • What have you been told about your medical situation so far?
  • What is your understanding of the reasons we did the TEST?
• STEP 3: I—Obtaining the Patient's INVITATION
  • How would you like me to give the information about the test results?
  • Would you like me to tell you the details of the diagnosis?
  • Would you like me to give you all the information or sketch out the results and spend more time discussing the treatment plan?
• STEP 4: K—Giving KNOWLEDGE and Information to the Patient
  • Warning Shot
    • I'm afraid I have some bad news
    • I wish things were different, I wish I could say that
    • I'm sorry to tell you that…
  • Give information in small chunks, check understanding, use nontechnical words
  • Generally would like to cover Diagnosis, Treatment Plan, Prognosis and Support
• STEP 5: E—Addressing the Patient's EMOTIONS with Empathic Responses
  • Observe for any emotion on the part of the patient.
    • Allow silence, do not argue.
  • Identify the emotion experienced by the patient by naming it to oneself.
    • If unclear, open questions to query the patient as to what they are thinking or feeling.
  • Identify the reason for the emotion if not clear.
  • After you have given the patient a brief period of time to express his or her feelings, let the patient know that you have connected the emotion with the reason for the emotion by making a connecting statement.
    • I know that this isn't what you wanted to hear. I wish the news were better.
• STEP 6: S—STRATEGY and SUMMARY
  • Identify other sources of support for the patient and incorporate them
  • Invite questions
  • Learn about patient/family goals given new reality
    • Knowing that time is short, what's most important to you?
  • Tell them what happens next, make recommendation to the patient/family about the most appropriate medical plan
    • There's so much more we can do to improve your qality of life
    • Suggest it may be in the best interest to have "their last moments of life in dignity and peace - a natural peaceful death", not to prolong the dying experience with procedures that have little benefit
  • Arrange definitive follow-up opportunities to assess impact and understanding