Understanding and Communicating Bad News in Healthcare
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Clare Warnock
Practice development sister
WPH
How would you describe breaking bad news
Who does it
What is bad news
Traditional view
◦
moment
◦
doctor
◦
diagnosis, prognosis or treatment
◦
one to one consultation
◦
The HCP
acts as witness to what has been said
provides support once the consultation is
over
“Modern view”
◦
range of HCPs involved
◦
information that can be classified as bad news
◦
a process
multiple episodes of information provision
often “ad hoc”
not part of a pre-planned consultation
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
Examples
◦
informing relatives of deterioration or death,
◦
moving into a residential home,
◦
explaining the details of arduous treatment
◦
providing daily updates when a patient’s condition is not
improving
◦
explaining transitions in care
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
◦
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?
Not about a single consultation
◦
This is an important part
Dewar’s work in spinal injury
◦
Initial moment
◦
then 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
Preparation
During
After
Assessing needs for further information;
recognising their cues and prompts
Working with the patient and family to achieve
consensus with issues about disclosure
Identifying and prioritising the patient’s
preferences for information
Liaising with the healthcare team to initiate
discussions where the need is identified or
requested
Coaching and supporting those 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
Supporting decision making about care
Explaining complex issues e.g. what is meant by
DNAR, informed consent, advanced care directives
Support with realising the implications of their
situation /the information 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
◦
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
◦
Treatment and decision making
◦
End of life care
◦
Family and relative dynamics
disclosure issues – not tell family, not tell patient
◦
Staff in the healthcare team
Confusion over the intention and aim of
treatment
Having inappropriate and unnecessary treatment
False optimism
Being unable to marry what is happening with the
information received
Patients not able to participate in decision
making
Unnecessary anxiety in worrying about the
unknown
Patients and families deprived of essential time
before deterioration
Preventing the discussion of end of life preferences
Patients not having the chance to get their affairs
in order
Feeling isolated and unable to communicate
with each other
Unnecessary strain on family relationships
Families carrying the burden of deception
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
◦
In some cultures it can be common for the family to be
given the information while the patient is shielded from
the full facts.
◦
However, individuals are not cultures
Patient preferences for information should guide
the content, timing and delivery of information
Does BBN destroy hope?
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 often mean a specific hope of getting better or
living longer”
hope is complex, multi-dimensional and flexible
The source of hope can change
◦
E.g. from hoping for a cure...to hoping to go home
reframing of goals to meet the realities at
hand
◦
Even though it is a reality not wished 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
◦
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
◦
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
◦
HCPs carry out a wide range of diverse roles in
relation to BBN
The way that significant information is given is
important
◦
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 are available
These will be explored in the next section of the
study day
Exploring the different views on breaking bad news in healthcare, this content discusses traditional and modern approaches, defines bad news, and provides examples of such news. It also delves into how individuals perceive and react to bad news, emphasizing the importance of effective communication in sensitive situations like delivering news about deteriorating conditions or end-of-life care.
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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 moment doctor diagnosis, prognosis or treatment one to one consultation The HCP acts as witness to what has been said provides support once the consultation is over
Modern view range of HCPs involved information that can be classified as bad news a process multiple episodes of information provision often ad hoc not part of a pre-planned consultation 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
Examples informing relatives of deterioration or death, moving into a residential home, explaining the details of arduous treatment providing daily updates when a patient s condition is not improving explaining transitions in care 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 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?
Not about a single consultation This is an important part Dewar s work in spinal injury Initial moment then 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
Preparation During After
Assessing needs for further information; recognising their cues and prompts Working with the patient and family to achieve consensus with issues about disclosure Identifying and prioritising the patient s preferences for information Liaising with the healthcare team to initiate discussions where the need is identified or requested Coaching and supporting those 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
Supporting decision making about care Explaining complex issues e.g. what is meant by DNAR, informed consent, advanced care directives Support with realising the implications of their situation /the information 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 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
Treatment and decision making End of life care Family and relative dynamics disclosure issues not tell family, not tell patient Staff in the healthcare team
Confusion over the intention and aim of treatment Having inappropriate and unnecessary treatment False optimism Being unable to marry what is happening with the information received Patients not able to participate in decision making Unnecessary anxiety in worrying about the unknown
Patients and families deprived of essential time before deterioration Preventing the discussion of end of life preferences Patients not having the chance to get their affairs in order
Feeling isolated and unable to communicate with each other Unnecessary strain on family relationships Families carrying the burden of deception
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 In some cultures it can be common for the family to be given the information while the patient is shielded from the full facts. However, individuals are not cultures Patient 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 often mean a specific hope of getting better or living longer hope is complex, multi-dimensional and flexible The source of hope can change E.g. from hoping for a cure...to hoping to go home reframing of goals to meet the realities at hand Even though it is a reality not wished 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 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 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 HCPs carry out a wide range of diverse roles in relation to BBN
The way that significant information is given is important 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 are available These will be explored in the next section of the study day
