Breaking Bad News (BBN)

Strategies for Breaking Bad News

Breaking bad news (BBN) is an important clinical skill for doctors and nurses.

While the most common perception of bad news is terminal illness, it can be any life-altering diagnoses ranging from fetal demise to degenerative conditions to debilitating infections.

BBN can be about diagnosis, treatment, prognosis, cost or impact of the disease on an individual or family.

BBN skills do not make the bad news good, but soften the impact of the same.

BBN allows the patients and relatives to deal with the impact of bad news, and encourages them to express their feelings. Most of the clinicians and nurses are not trained in BBN.

The bearer of bad news often experiences strong emotions such as anxiety. This stress creates a reluctance to deliver bad news, which is named as the mum effect Opens in new window.

There are several strategies that can be used to deliver bad news.

1. SPIKES model

This is the most well-known model for delivering the bad news proposed by Buckman. The steps in this model are as follows:

• S – Setting: Ensure privacy and appropriate setting and environment for the discussion
• P – Perception: Understand the patient’s perception of the illness
• I – Invitation: Explore how much information the patient needs. In other words, obtain the patient’s invitation for details regarding the illness
• K – Knowledge: Warn the patient about the imminent bad news before breaking it and provide the information in chunks, all the while ensuring that s/he understands what is being conveyed
• E – Empathy: Listen to the patient, identify the emotions, and address the patient’s emotions with empathic responses
• S – Strategy and summary: Summarize the information you have provided and formulate a clear plan with the next steps neatly chalked out

2. ABCDE

Another practical model suggested by Rabow and McPhee uses the mnemonic Opens in new window ABCDE.

• Advance preparation
• Build a therapeutic environment/relationship
• Communicate well
• Deal with patient and family reactions
• Encourage and validate emotions

3. BREAKS protocol

This includes another systematic and easy strategy for BBN; and consists as follows:

• Background information about the illness
• Rapport building
• Exploring the patient’s knowledge about the illness
• Announce the bad news with a warning
• Kindling the patient’s emotions
• Summarize the information and plan of action

The underlying concepts across all the above strategies are:

1. Deciding the amount of bad news to be delivered or the extent of truth to be divulged
2. Managing psychological reactions

Challenges

The following are challenges in implementation of the above models for BBN, especially in the Third World setting:

1. Poor literacy and lack of information about illnesses: Patients and family members are not equipped with sufficient prior knowledge about the illness to process the news given to them.
2. Cultural and social norms related to terminal illness and death: Family members do not wish the physician to discuss end-of-life care with the patient.
3. Discussing psychological stress and issues openly is still not a norm in some cultures (e.g. rural India), and patients and their family members do not engage with the physician in such discussions.
4. Inadequate preparation to deliver bad news: Residents and physicians are not equipped to deliver bad news.

Recommendations

Recommendations to address specific challenges are as follows:

1. Identify the literacy level of the patient and tailor the information in the native language of the patient such that s/he comprehends it. Generously use pictures to explain what cannot be put across in words.
2. Discuss patient autonomy and medical proxy in the first consultation. If the patient chooses not to know about his/her diagnosis, ensure that a responsible medical proxy is identified who is acceptable to the patient. Assure the patient that anytime during the process, s/he can choose to know his/her diagnosis or change his/her medical proxy. This helps maintain the trust the patient reposes in the physician and does not make him/her feel abandoned.
3. Try to understand family dynamics before broaching sensitive subjects. Assure the patient about absolute confidentiality before discussing emotional and psychosocial stress. Offer appropriate counseling to the patient and caregivers as they play a crucial role in the entire decision-making process.
4. It is essential to train undergraduate medical students in the art of listening and speaking to patients, providing information effectively and showing empathy, which forms the basis of BBN.