BREAKING BAD NEWS: GUIDELINES TOWARDS BEST PRACTICE - "TRUTH LIKE MEDICINE, CAN BE INTELLIGENTLY USED, RESPECTING ITS POTENTIAL TO HELP AND TO HARM"
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BREAKING BAD NEWS:
GUIDELINES
TOWARDS BEST PRACTICE
“TRUTH LIKE MEDICINE, CAN BE
INTELLIGENTLY USED, RESPECTING ITS
POTENTIAL TO HELP AND TO HARM”
Approved by Clinical Guidelines Steering Group – May 2003
To be reviewed by Leads – May 2006Why use this guide?
The purpose of this guide is to support all healthcare professionals involved in the
process of Breaking Bad News and to improve practice. It contains a simple model for
Breaking Bad News and a framework for auditing current practice.
Why it is important
Breaking Bad News is essential to maintain trusting relationships. Honesty allows
open discussion regarding future management, reduces uncertainty, prevents
inappropriate hope and facilitates appropriate adjustment.
Who is the guide for?
The guide has been designed to enable relevant healthcare professionals to
communicate effectively and compassionately when delivering bad news.
The model is transferable to all settings and can be used by all professionals across the
Trust.
It is also hoped that the guide will support managers, enabling them to empower staff
to increase their skills and therefore improve practice.
WHEN TO USE THESE GUIDELINES
• To assist you in your practice of Breaking Bad News
• To audit current practice
• To assist you with reflection on your current practice
• To generate ideas for improving your practice and encourage further education
• To promote and support discussion between managers and clinical staff to
improve practice10 STEPS TO BREAKING BAD NEWS
1. Preparation
Know all the facts before the meeting. Find out who the patient wants present,
and ensure privacy and chairs to sit on.
2. What does the patient know?
Ask for a narrative of events from the patient (eg “How did it all start?”)
3. Is more information wanted? Prepare the Ground
Test the waters, but be aware that it can be very frightening to ask for more information
(eg “Would you like me to explain a bit more?”)
4. Give a warning shot
eg “I’m afraid it looks rather serious” – then allow a pause for the patient
to respond.
5. Allow denial
Denial is a defence mechanism and a way of coping. Allow the patient to
control the amount of information they receive.
6. Explain (if requested)
Increase the patient’s information to match the professional’s to the appropriate level. Details of
this information may not be remembered, the way you offer the information will.
7. Listen to concerns
Ask “What are your main concerns at the moment?” and then allow space for
expression of feelings.
8. Encourage ventilation of feelings
This is the KEY phase in terms of patient satisfaction with
the interview, because it conveys empathy.
9. Summary and plan
Summarise concerns, plan treatment, foster appropriate
hope.
10. Offer availability
Most patients need further explanation (the details will not have been
remembered) and support (adjustment takes weeks or months) and may
benefit greatly from a family meeting.
KEY RULES - Peter Kaye 1996
1. Ask questions first. What is known? What is wanted? Should relatives be involved?
2. Elicit concerns and encourage ventilation of feelings.Appendix 1
AUDIT TOOL
Section 1 Communication process
Section 2 The people involved
Section 3 The environmentThe Communication Process Appendix 2
Factors to Stage 1 Stage 2 Stage 3
consider Inappropriate practice Basic practice Best practice
Positioning Physical barriers created by distance, Where physical barriers The professional breaking
height etc. exist, steps are taken to the bad news positions
eg giving patient bad news from the reduce the effect of these. themselves at same level as
foot of the bed. person receiving the news.
Non-verbals Eye contact is avoided. ‘Closed’ Limited or intense eye Appropriate use is made of
defensive body language is used. contact; body language or eye contact, voice tone, body
No helpful non-verbals offered. tone of voice is perceived as language and touch.
aggressive or lacking in
confidence/credibility, rather
than knowledgeable and
caring.
Assessment There is no assessment of what the A partial assessment is made An assessment is made of
patient understands and no of the patient’s the patient’s understanding
assessment of what the patient wants understanding, needs and of situation, of what they
to know and the timing of this. preferences regarding timing want to know and the
of information given. preferred timing of
information.
Ownership of Information is withheld from person Information is given to Information given to person
information to whom it relates, eg due to pressure another person before patient it relates to. Consistent
from relatives OR news given to OR one or more parties get information given to all.
other people is inconsistent in detail. different messages OR All treatment/care options
options regarding future discussed.
treatment/care are missed.
Style/Manner Disrespectful manner, inappropriate Caring, respectful style. The professional breaking
and insensitive remarks used. Unclear and inappropriate the bad news is gentle,
Medical jargon used. language. respectful and uses clear
Style patronising. language. Style is
appropriate to patient’s age
and understanding.
Timing of News is withheld from the person to News is withheld from News is communicated to
information whom it relates. person to whom it relates, the person to whom it relates
until it is too late to tell the at the earliest appropriate
patient, eg telling a patient opportunity.
they have cancer when they
are about to die.
Supporting No relevant information given. Verbal information only is Verbal information is given
information given and/or standard supported by written
given information only. information that is tailored
to the individual’s needs.
Information is given
regarding relevant
professionals and supportive
teams.
Understanding/ News broken quickly. Patient’s News broken appropriately. Patient’s understanding is
follow-up understanding not checked. No opportunity for checked and clarified if
No follow-up offered. clarification or follow-up needed. Opportunity given
appointment. Patient’s for questions. Follow-up
understanding is scant. and support offered.
Communication Either no communication with GP or GP and/or Primary Health GP and/or Primary Health
events have superseded it. Care Team informed. Care Team informed
No written record of consultation. Information given regarding promptly (within 2 working
facts. Partial or inconsistent days). Given full and clear
information is recorded. information regarding
patient’s diagnosis,
prognosis, understanding
and treatment plan. Written
record is full, accurate and
includes words and phrases
used with the patient.Appendix 3
The People Involved
Factors to Stage 1 Stage 2 Stage 3
consider Inappropriate practice Basic practice Best practice
Relatives/friends Relatives/friends present whom The patient is given no The patient receiving the
present patient does not want present. opportunity to have a bad news is given the
Presence of inappropriate people, relative/friend present. opportunity to bring along
eg maintenance staff. another person of their
choice.
Continuity of There is a different professional Well briefed team members A named professional, who
people involved involved on each occasion. (who have been present is the same person on each
Poorly briefed team members are previously) are involved patient visit, is responsible
involved with follow-up. with follow-up. for follow-up.
Responsibility No clear responsibility for breaking There is clear responsibility The Consultant is seen as
for breaking bad bad news exists, resulting in for who will break the bad lead person, but does not
news (within confusion. news. Communication necessarily have to be
hospital) with Primary Health Care person who delivers the
Team poor. bad news. There is clear
consensus regarding what
patient will be told. When
Primary Health Care Team
is involved, responsibility
is clear.
Training Professionals are assumed to possess Minimal training but no Professionals have
skills which are, in fact, non-existent. supervised practice. undergone specific training
and have had adequate
practice, supervised by an
expert.
Person giving The professional giving the bad The professional giving the The professional giving the
the bad news news is not known to the patient. bad news is not known to bad news is known to the
No introduction made. There is the patient, but somebody patient OR new
nobody available whom the patient who is known is either professional makes
knows. present or available. appropriate introduction.
Professional has knowledge
and skills to break bad
news and to answer
questions.
The Environment
Factors to Stage 1 Stage 2 Stage 3
consider Inappropriate practice Basic practice Best practice
Environment No designated area available. Area available – but this Designated non-clinical
Inappropriate public setting used. has dual use, eg Ward area available.
office. Number of
uninvolved people likely to
be present.
Privacy No privacy given. News given in a Privacy is compromised by No disturbances.
public setting eg hospital corridor. environment eg curtains Soundproof room available
used in busy, noisy ward. with appropriate door sign.
Interruptions by other staff Time allowed for patient
eg office. and relatives to use private
area.Appendix 4
Suggested Reading
Breaking Bad News
Peter Kaye, 1996, EPL Publications
How to Break Bad News
Rob Buckman, 1992, Papermac
Talking to Cancer Patients
Faulkner A & Maguire P, 1994, Oxford Medical Publications
Education
Breaking Bad News Training Calderdale & Huddersfield NHS Trust
Telephone: Bev Foden Huddersfield Royal Infirmary 01484 347142
Margaret Hipwood Calderdale Royal Hospital 01422 224756
For further discussion regarding use of guidelines and audit contact:
Huddersfield Palliative Care Team
Calderdale & Huddersfield NHS Trust
Huddersfield Royal Infirmary
Tel: 01484 342965
References
Kaye, P Breaking Bad News (1996) EPL Publications
Breaking Bad News Guidelines
Lincoln & Louth NHS TrustYou can also read
