Breaking Bad News
Clare Warnock
Practice development sister
WPH
How would you describe breaking bad news
Who does it
What is bad news
Traditional view
◦
the moment when a doctor provides significant
information about diagnosis, prognosis or treatment to
patients and their families in a one to one consultation
◦
the role of the HCP is to be present
as a witness to what has been said and
providing support once the consultation is over
“Modern view”
◦
A wide range of HCPs are involved in BBN
◦
Other information can be classified as bad news
◦
BBN is a process
There may be multiple episodes of information provision
often “ad hoc” and not part of a pre-planned consultation
It also includes activities that take place before, during and
after bad news is given
any bad, sad or significant information that
negatively alters a person’s expectation or
perception of their present or future
(Fallowfield and Jenkins 2004)
Key items
◦
ANY information
◦
Individual expectation
◦
Individual perception
What do you think could classify as bad news
Examples
◦
informing relatives of a patient’s deterioration or death,
◦
advising a patient that they need to move into a
residential home,
◦
explaining the details of arduous treatment such as
renal dialysis or chemotherapy,
◦
providing daily updates to family members when a
patient’s condition is not improving
◦
explaining transitions in care for example from curative
to palliative to end of life
◦
failed discharge plans
◦
Telling someone they can’t drive any more
the same information could be interpreted as
good, bad or neutral by different people
influenced by subjective factors
◦
patient’s expectations, values, life experiences and
social situation
◦
the events leading up to and surrounding the
moment that the information is given
How might different people react to being
told they need to have surgery?
BBN is not about a single consultation
Dewar’s early work in spinal injury unit
◦
Initial moment
◦
Followed by multiple episodes of potential bad
news
Realising the implications of spinal injury over time
It also involves the activities that take place
before, during and after bad news is given
Assessing the needs of patients and relatives for further
information; recognising their cues and prompts
Working with the patient and family to achieve consensus
when there are issues about who should be informed
Identifying and prioritising the patient’s preferences for
information
Liaising with the appropriate members of the healthcare
team to initiate discussions where the need is identified or
requested
Coaching and supporting patients and relatives who find it
difficult to ask questions or talk to the doctors
Helping patients ask questions when they appear to
be confused or reluctant to do so
Supporting others who are providing the information
to find alternative words or explanations if the
patient appears not to understand or needs
clarification
Communicating what has been said in the
consultation to the rest of the healthcare team
Eliciting patient and relatives’ feelings about the
information they have received
Listening to and acknowledging the emotional
reactions of patients and relatives to bad news
Explaining and discussing the information received
and its implications
Answering questions as they arise, identifying and
clarifying misunderstanding and explaining complex
medical terminology
Providing information about the next steps in the care
pathway
Helping the patient and relatives make decisions about
care
Helping patients and relatives address complex issues e.g.
what is meant by DNAR, informed consent, advanced care
directives
Supporting patients and relatives when they realise the
implications of their situation or the information they have
been given
Helping the family reach a consensus when there is
disagreement between them about the plan of care
Acting as an intermediary between patients, relatives and
the healthcare team
Patient preference – research consistently
shows
◦
Most patients want to be informed
variations in the depth and level of knowledge desired
Other potential positive outcomes
◦
building a sense of trust between patients and the
healthcare team
◦
enabling patients and relatives to make appropriate
decisions and plans based on a realistic insight into
their situation
What are the negative consequences of not
providing patients with bad news?
Impact on treatment and decision making
Patients receiving burdensome, inappropriate
and unnecessary treatment
False optimism and being unable to marry what
is happening with the information received
Misunderstanding and confusion over the
intention and aim of treatment
Denying patients the opportunity to participate in
decision making
Unnecessary anxiety in worrying about the
unknown
Impact on end of life care
Depriving patients and families of essential time before
the patient’s condition deteriorates
Preventing the discussion of end of life preferences
Denying patients the opportunity to get their affairs in
order
Impact if relatives informed and the patient isn’t
Feeling isolated and unable to communicate with
each other
Unnecessary strain on family relationships
Families carrying the burden of deception
Impact on the healthcare team
Job stress and burnout
Poor job and role satisfaction
Disagreement and fractured relationships if
not all agree with the information provided
Some patients prefer not to receive some or all of
the facts as this is how they cope with their
illness
Cultural differences
◦
preferences and behaviours around information relating
to particular diagnoses, such as cancer, prognosis and
end of life decisions
◦
in some cultures it can be common for the family to be
given the information while the patient is shielded from
the full facts.
Individual patient’s preferences for information
should guide the content, timing and delivery of
information
research reveals that providing honest
information does not remove hope
honest information can support patients in
their efforts to maintain hope
◦
reduces fear of the unknown
◦
enables patients to match their hopes with the
reality of their experience
Is this a contradiction?
“When we worry about destroying hope we
are generally referring to a very specific hope
of getting better or living longer.
But hope is a complex, multi-dimensional
and above all flexible construct...
One can shift from hoping for a cure...to
hoping to go home from the hospital.
Such a shift in the things one hopes for
requires a reframing of goals to meet the
realities at hand...(a reality) that none of us
would wish for”
Hopes described by patients with a life-limiting
illness include:
◦
living longer than expected
◦
good symptom management
◦
getting the most out of the time that is left
◦
making it to certain events or achieving certain goals
◦
mending damaged relationships
◦
spending special time with family and friends
This doesn’t mean people want to be in that situation
(or that they won’t be sad/angry/upset)
◦
It is a way of coping that can be used over time
Bad news includes many different types of
information
Information is defined as “bad news” by
individuals and cannot always be determined in
advance
BBN is a process with multiple episodes of
information provision
◦
as people experience the implications of their situation
and raise questions and concerns
It also includes the activities before, during and
after the news is given
◦
HCPs carry out a wide range of diverse roles in relation
to BBN
The way that bad, sad and significant information is given
is important
The consequences are long-lasting
How it is done can influence
◦
experiences and satisfaction with treatment
◦
relationships with the healthcare team.
◦
adherence and compliance with treatment
◦
coping with the consequences of illness
Providing information in a way that helps the patient
understand and cope with what they are told requires
skills and knowledge
Guidelines and good practice advice have been developed
to support staff
These will be explored in the next section of the study day
Breaking bad news in healthcare involves delivering any information that negatively impacts a person's present or future. This process can take various forms and includes informing patients or their loved ones about challenging diagnoses, transitions of care, or end-of-life decisions. The manner in which bad news is communicated can greatly influence how it is perceived and processed by individuals, highlighting the importance of sensitivity and empathy in healthcare interactions.
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Presentation Transcript
Clare Warnock Practice development sister WPH
How would you describe breaking bad news Who does it What is bad news
Traditional view the moment when a doctor provides significant information about diagnosis, prognosis or treatment to patients and their families in a one to one consultation the role of the HCP is to be present as a witness to what has been said and providing support once the consultation is over Modern view A wide range of HCPs are involved in BBN Other information can be classified as bad news BBN is a process There may be multiple episodes of information provision often ad hoc and not part of a pre-planned consultation It also includes activities that take place before, during and after bad news is given
any bad, sad or significant information that negatively alters a person s expectation or perception of their present or future (Fallowfield and Jenkins 2004) Key items ANY information Individual expectation Individual perception
What do you think could classify as bad news Examples informing relatives of a patient s deterioration or death, advising a patient that they need to move into a residential home, explaining the details of arduous treatment such as renal dialysis or chemotherapy, providing daily updates to family members when a patient s condition is not improving explaining transitions in care for example from curative to palliative to end of life failed discharge plans Telling someone they can t drive any more
the same information could be interpreted as good, bad or neutral by different people influenced by subjective factors patient s expectations, values, life experiences and social situation the events leading up to and surrounding the moment that the information is given How might different people react to being told they need to have surgery?
BBN is not about a single consultation Dewar s early work in spinal injury unit Initial moment Followed by multiple episodes of potential bad news Realising the implications of spinal injury over time It also involves the activities that take place before, during and after bad news is given
Assessing the needs of patients and relatives for further information; recognising their cues and prompts Working with the patient and family to achieve consensus when there are issues about who should be informed Identifying and prioritising the patient s preferences for information Liaising with the appropriate members of the healthcare team to initiate discussions where the need is identified or requested Coaching and supporting patients and relatives who find it difficult to ask questions or talk to the doctors
Helping patients ask questions when they appear to be confused or reluctant to do so Supporting others who are providing the information to find alternative words or explanations if the patient appears not to understand or needs clarification Communicating what has been said in the consultation to the rest of the healthcare team Eliciting patient and relatives feelings about the information they have received Listening to and acknowledging the emotional reactions of patients and relatives to bad news Explaining and discussing the information received and its implications
Answering questions as they arise, identifying and clarifying misunderstanding and explaining complex medical terminology Providing information about the next steps in the care pathway Helping the patient and relatives make decisions about care Helping patients and relatives address complex issues e.g. what is meant by DNAR, informed consent, advanced care directives Supporting patients and relatives when they realise the implications of their situation or the information they have been given Helping the family reach a consensus when there is disagreement between them about the plan of care Acting as an intermediary between patients, relatives and the healthcare team
Patient preference research consistently shows Most patients want to be informed variations in the depth and level of knowledge desired Other potential positive outcomes building a sense of trust between patients and the healthcare team enabling patients and relatives to make appropriate decisions and plans based on a realistic insight into their situation
What are the negative consequences of not providing patients with bad news?
Impact on treatment and decision making Patients receiving burdensome, inappropriate and unnecessary treatment False optimism and being unable to marry what is happening with the information received Misunderstanding and confusion over the intention and aim of treatment Denying patients the opportunity to participate in decision making Unnecessary anxiety in worrying about the unknown Impact on treatment and decision making
Impact on end of life care Depriving patients and families of essential time before the patient s condition deteriorates Preventing the discussion of end of life preferences Denying patients the opportunity to get their affairs in order Impact Feeling isolated and unable to communicate with each other Unnecessary strain on family relationships Families carrying the burden of deception Impact on end of life care Impact if relatives informed if relatives informed and the patient isn t and the patient isn t
Impact on the healthcare team Job stress and burnout Poor job and role satisfaction Disagreement and fractured relationships if not all agree with the information provided Impact on the healthcare team
Some patients prefer not to receive some or all of the facts as this is how they cope with their illness Cultural differences preferences and behaviours around information relating to particular diagnoses, such as cancer, prognosis and end of life decisions in some cultures it can be common for the family to be given the information while the patient is shielded from the full facts. Individual patient s preferences for information should guide the content, timing and delivery of information
research reveals that providing honest information does not remove hope honest information can support patients in their efforts to maintain hope reduces fear of the unknown enables patients to match their hopes with the reality of their experience Is this a contradiction?
When we worry about destroying hope we are generally referring to a very specific hope of getting better or living longer. But hope is a complex, multi-dimensional and above all flexible construct... One can shift from hoping for a cure...to hoping to go home from the hospital. Such a shift in the things one hopes for requires a reframing of goals to meet the realities at hand...(a reality) that none of us would wish for
Hopes described by patients with a life-limiting illness include: living longer than expected good symptom management getting the most out of the time that is left making it to certain events or achieving certain goals mending damaged relationships spending special time with family and friends This doesn t mean people want to be in that situation (or that they won t be sad/angry/upset) It is a way of coping that can be used over time
Bad news includes many different types of information Information is defined as bad news by individuals and cannot always be determined in advance BBN is a process with multiple episodes of information provision as people experience the implications of their situation and raise questions and concerns It also includes the activities before, during and after the news is given HCPs carry out a wide range of diverse roles in relation to BBN
The way that bad, sad and significant information is given is important The consequences are long-lasting How it is done can influence experiences and satisfaction with treatment relationships with the healthcare team. adherence and compliance with treatment coping with the consequences of illness Providing information in a way that helps the patient understand and cope with what they are told requires skills and knowledge Guidelines and good practice advice have been developed to support staff These will be explored in the next section of the study day
