Breaking Bad News

Introduction

Bad news is any information that seriously and adversely alters a person's view of their future. That includes a cancer diagnosis, but equally a diagnosis of motor neurone disease or dementia, an abnormal antenatal scan, infertility, the failure of a treatment, the news that a relative has died, or telling someone they can no longer drive.

How it is done matters clinically, not merely as a courtesy. The way news is delivered affects psychological adjustment, subsequent anxiety and depression, trust in the clinical team, how much the patient recalls, and the treatment decisions they go on to make. Patients who feel the news was broken badly remember it for the rest of their lives, and families remember it after the patient has died.

It is also a skill that improves with structure. The instinct when facing someone's distress is to fill silences, to reassure prematurely, and to retreat into information - and a framework exists precisely to interrupt those instincts. The one you will be examined on is SPIKES.¹

The SPIKES framework

Preparation

• Know the facts. Read the notes, the histology and the imaging report yourself, and know what the MDT decided and what the next step is. Not knowing the answer to "what happens now?" undermines everything else.
• Get the environment right - a quiet, private room, not a bay with curtains drawn, not a corridor. If the patient cannot leave the bed, do what you can to create privacy and acknowledge its limits.
• Protect the time. Hand over your bleep or phone. An interruption at the wrong moment is remembered as being told you did not matter.
• Ask who they want with them. Some people want family; some very much do not, and asking is the only way to know.
• Arrange a professional interpreter where needed. Using a family member - especially a child - to interpret bad news is unacceptable: it is unreliable, and it places an unbearable burden on the interpreter.
• Bring a colleague who will continue the care - the clinical nurse specialist or key worker, who will be the person the patient rings afterwards
• Sit down. Sitting is consistently associated with patients perceiving the consultation as longer and more attentive than standing for the same duration.
• Think about yourself - if you have just had a difficult conversation, take a minute before the next one

Delivering the news

The warning shot

A short phrase that signals difficult news is coming, followed by a pause, gives the person a few seconds to prepare themselves - "I'm afraid I have some difficult news", or "the results have come back, and they are not what we hoped". Then stop and let them respond. Some will say "go on"; some will say "it's cancer, isn't it", which tells you a great deal.

The words themselves

Give the information in small chunks, using the patient's own vocabulary where possible, and check understanding between chunks - "is that making sense so far?" rather than "do you understand?". After the central fact, stop. Do not move straight on to staging, treatment options and clinical trials; the patient has stopped listening, and everything said in the next minute or two will be lost.

Responding to emotion

Silence is the most useful and least used tool. Allow it. If the patient cries, wait, offer tissues, and do not rush to fill the space with facts. The NURSE mnemonic is a useful way of structuring an empathic response:⁴

• Name the emotion - "this seems to have come as a real shock"
• Understand - "I can see why that would be frightening"
• Respect - "you have coped with a great deal already"
• Support - "we will go through this with you, and you will have a named nurse you can ring"
• Explore - "what is worrying you most at the moment?"

Difficult questions and situations

"How long have I got?"

First check what lies behind the question - "that is an important question; can I ask what makes you want to know just now?" Sometimes there is a wedding, a birth, or a practical decision behind it. Then give a range in units of time (hours to days, days to weeks, weeks to months, months to years), state plainly that you may be wrong in either direction, and advise doing anything important sooner rather than later. Refusing to answer at all is unhelpful; a precise number is dishonest.⁵

Collusion - "don't tell my mother"

This is a common OSCE station and a common ward situation. The family are almost always acting out of love, and treating them as an obstacle makes things worse.

1. Acknowledge their motive - "I can see you are trying to protect her, and that comes from caring about her"
2. Explore their fear - "what is it that worries you most about her being told?" Often it is a previous experience, or a belief she will give up.
3. Explore the cost of collusion - patients usually already suspect, and secrecy isolates them at the point they most need to talk; it also prevents them putting their affairs in order
4. Explain your position clearly and without confrontation - that you will not force information on anyone, but that you cannot lie to her if she asks you directly, because she has a right to information about her own health²
5. Negotiate a way forward - ask permission to explore what she already knows and what she wants to know, and offer that the relative is present when you do
6. Offer to see them again, since this rarely resolves in one conversation

Note the counterpart: a patient also has the right not to know. If someone says clearly that they do not want details, that must be respected and documented, and revisited later - people change their minds.

Anger

Anger after bad news is usually displaced grief, though it may also reflect a genuine failing in their care. Do not defend, do not become defensive, and do not match the tone. Acknowledge it - "you sound very angry, and I would like to understand why" - listen, apologise for what genuinely went wrong, and be honest about what you do not know. Keep yourself safe and end the conversation if it becomes threatening.

Denial

Denial is a normal and often protective coping mechanism, and dismantling it forcibly serves the clinician rather than the patient. Note it, avoid colluding with it in ways that lead to harmful decisions, and gently test it later - "is there ever a time when you worry it might not turn out that way?" Most denial softens over days or weeks.

Breaking bad news by telephone

Avoid it where a face-to-face conversation is possible. Where it is unavoidable - a relative at a distance, an urgent result - confirm who you are speaking to, ask whether they are somewhere they can talk and whether anyone is with them, give a warning shot, deliver the news plainly, allow silence, and arrange a definite follow-up. Never leave bad news on a voicemail or with a third party.

After the conversation

• Summarise and check understanding - "it would help me to know what you will tell your husband when you get home" is more revealing than "any questions?"
• Give the concrete next step and a timescale - who will contact them, when, and about what. Uncertainty about process is a large share of the distress.
• Provide a named contact - the clinical nurse specialist or key worker, with a phone number
• Write things down for them, or offer to, given how little is recalled. Some units offer a recording of the consultation, which patients value highly.
• Offer written information and details of support organisations, but not a stack of leaflets at the moment of diagnosis
• Offer to speak to family with the patient's consent, or to repeat the conversation another day
• Arrange follow-up - a further appointment, or a phone call in a few days, both of which give a place to put the questions that arrive later
• Document what was said, in what terms, who was present, what the patient appeared to understand, and what was agreed - so that everyone else uses the same language
• Hand over to the ward team and the GP, so the patient does not have to explain their own bad news to the next person who walks in

Pitfalls

Outcomes

Communication is the aspect of cancer care that patients rate most variably and complain about most often, and national surveys consistently show that patients who felt they were told sensitively, given time, and given a name to contact report much better overall experience - independently of their prognosis.^3,6

Communication skills training measurably changes behaviour, and the specific behaviours that improve are the ones described above: asking before telling, using silence, naming emotion and checking understanding. This is genuinely a learnable skill rather than a personality trait, which is why it is examined.

The final point is one of proportion. You will rarely be able to make the news better. What you can control is whether the person is told in a private room by someone who has read their notes, in words they understand, with time to react, and with a clear idea of what happens next and who to ring. That is the whole of the task, and it is achievable every time.