- Clinical situations in which “Bad News” needs to be disclosed.
- Acute/Prolonged/Chronic Illness
- Malignant/Disabling/Terminal Illness
- Who is best suited to share the “Bad News”?
- The person who knows the patient best.
- The person who knows most about the condition.
- Multidisciplinary approach with a team leader.
- At what stage should the interview occur?
- Must balance availability of accurate information with delay during which anxiety increases.
- Who should be present at the interview?
- Someone to support the patient or family.
- Someone to witness the interview who can provide support and back-up afterwards. This might be a nurse, doctor, social worker or clergy.
- Where should the interview take place?
- Preferable in a private place, free from interruptions and noise, that is comfortable for the patient/family.
- Make an appointment when possible, be on time and do not hurry through the meeting.
- What should you tell the Patient, Relative or Friend?
- Introduce yourself, establish names and relationships of others participating in the discussion
- Introduction: Ask what they already know/understand/suspect. Explain what has been done so far.
- Diagnosis: Accurate and honest, simple explanation. Avoid jargon and euphemisms and use simple analogies where relevant.
- Treatment: Accentuate the positive aspects (cure/symptom control) realistically to preserve hope, but avoid unrealistic expectations.
- Give some guidance/make your opinion clear without being overly forceful.
- Prognosis: Discuss “only” if asked/appropriate/useful to know.
- Provide written resources: If available, literature designed for patient information is very useful because usually patients will only remember a very small amount of what is said. Taping the initial interview may prove useful to the family and health care team because it can be used to review what has been said and serve as a basis for future discussion.
- Be prepared for anger/denial/sadness/disbelief/guilt/anxiety/silence as possible reactions to the news.
- Review salient points to summarize and end the discussion but leave instruction about where they may contact you.
- Emphasize your willingness to repeat explanations and answer further questions as they occur.
- How should you “Give Bad News”?
- Sit down and help to make the patient, family and yourself as comfortable as possible.
- Begin with the introduction as above and watch carefully for verbal and nonverbal cues.
- Give them an opportunity to react to what you’ve said (pause for silences, let them ask questions, etc.)
- Answer questions simply, directly and without using jargon. If you don’t know the answer, admit it, offer to find out, and follow-up later.
- Give them some private time alone, but reassure them that you will be close by when they need you. Give them instructions on how to reach you (call button/phone number, etc.).
- Make arrangements for a follow-up meeting.
Components of Sharing Bad News
Set up the Interview
Arrange for private place
Protected, uninterrupted time
Arrange so everyone can be seated
News giver – knows parents/information best
News recipients – tell parents together/support person
Include other health care professionals
Know parents’/child’s name and gender
Review what you want to communicate (may rehearse first 1-2 sentences)
Have relevant information available
Sharing the News
Shake hands if appropriate
Use of warning phrase
Get to point quickly
Allow parents time to absorb information
Be comfortable with silence
Name diagnosis/etiology if possible
DON’T MAKE ASSUMPTIONS
Balance truth with hope
Anticipate Parental Reactions
Be prepared for sadness, anger, guilt, blame
Allow expression of emotions
Respond to emotions when exhibited
Give parents choices when possible
Treat parents as partners
Acknowledge and address barriers
Follow up Meeting
Allow parents time to process information
Encourage them to write down questions
Meet within short time period (minutes, hours, days, weeks)
Physician Self Care
Understand own reactions, emotions
Sadness, anger, guilt, sense of responsibility
Seek colleagues to gain support
Essential to avoid burnout