Keywords: Bad news; breaking bad news protocols; communication; oncology
There are several basic definitions of bad news, which
have various difficulties concerning both breaking and
receiving it. Buckman [
Bad news in medicine presents a wide range of
challenges both for the person receiving the news and
for the physicians breaking it. Having bad news about a medical condition may cause negative feelings and
worries about the future. In addition, not only the bad
news itself but also the way the news is given affects
the person"s perception of the news, his/her coping behavior,
his emotional reactions to the disease, his compliance
with the treatment and his confidence in the
physician.[
Professor Doctor Füsun Yarış, a physician and a
faculty member, described the bad news about her as
follows: "Was it an advantage for me to be a physician?
Maybe it wasn"t. Actually, I was also an ordinary person
and a regular patient. I was deserving to get the bad
news in the right way just as much as anyone. However,
with the ultrasound probe on me, the physician
said to me, "Ah yes, Füsun, this is a terrible thing, you
have two huge masses. Moreover, there is acid as well,
and this may be stage 4, I must check the other organs."
The physician who had carried out the examination
had so forgotten the necessities of his profession and
ignored the patient, so he could say these words the
fellow doctor next to him: "Come and look. You rarely
see such an image." Just 10 minutes ago, I was Professor
Füsun or his colleague Füsun. But at that moment, I
was transformed into an entity called stage 3C, maybe
stage 4. Your whole life changes at that moment, "If I
were alone at home that night, I would have committed
suicide".[
We should note that 90% of the physicians in the
United States preferred not to tell the patient the diagnosis
of cancer in the 1950s and 60s. Until the concept
of the patient"s right to information emerged,
Hippocrates" motto was widely accepted: "saying a bad
diagnosis increases mental anguish and psychological
pain, so protect patients." Today, in Western countries,
most physicians prefer to tell the patient the diagnosis
of the cancer. However, this rate is low in eastern countries.[
Most of the patients prefer to learn the diagnosis
and treatment information. Fujimori et al. (2007), in
their research, found that approximately 90% of the
patients wanted to discuss their current medical condition
and treatment options with the physicians.[
Breaking bad news protocols
The most commonly used protocols are listed below:
Table
Considering the critical common features in the protocols,
the course of actions that the physician should follow
in the process of breaking bad news is listed below:
Who should give the bad news? The physician who
knows the patient communicates with the patient and has a trust relationship with the patient should break
the bad news given that the bad news is given by the
physician who has established a trust relationship with
the patient can make the patients feel safe.
Who should be given the bad news? The patient himself
or his relative(s)? The patient should be informed
about the diagnosis, treatment, or positive/negative developments
in the process concerning legal responsibility
and to maintain a trust relationship. However, if the
patient has previously declared that he does not want
to know the diagnosis and treatment information with
a legally valid document, the information can be given
to his relatives. Families, in particular in the case of elderly
patients, often try to ensure that the patient does
not know about the disease. In this case, it is necessary
to understand whether the family has hidden agendas
(such as heritage issues). Furthermore, the patient has
the right to learn any information about his life, regardless
of age. Of course, the patient should be able-minded
and not in any dementia process. Relatives or families
of patients in our community mostly urge the physician
not to provide the patient with accurate information. Interview(
s) should be conducted with the patient to confirm
whether such statements are realistic.
What kind of preparations should the physician make
before breaking the bad news? The physician must have
developed oral and nonverbal communication skills. A
physician who makes eye contact with the patient, who
uses the tone of voice and body language effectively, listens
to the patient effectively, can be empathic with the
patient, and has a sensitive attitude towards the patient"s
feelings and behaviors are indispensable for the breaking
bad news process. The physician must have prepared
himself to break the bad news concerning knowledge,
emotion, and thought. He/she should know where to
speak and where to remain silent and be prepared for
possible questions from the patient. The patient should
be asked if he/she wants someone from his family to accompany
him/her during the process. If there is someone
in the outpatient clinic with the patient, he/she
should first be taken to a room alone and asked who they
are and whether he/she wants them to be with her.
Where should the bad news be given? The place
where bad news is given is of critical importance. Thus,
a place should be identified that is quiet, calm, and
where speech cannot be interrupted, and time should
be allocated for this process. The interview should
not be performed standing. If an inpatient is to be informed,
efforts should be made to ensure privacy. If
possible, another available room should be allocated,
and the conversation should take place there.
What should be said, and how should it be said? The
physician should try to find out what the patient knows
before he/she breaks the bad news. What did the previous
physicians say about the diagnosis and treatment
processes? What does the patient think his/her disease
is? What are his/her fears? Once these issues are clear,
the physician should learn how much information the
patient wants to have. For example, the following question
may be asked: "Some patients want to have detailed
information about their disease; others want shorter information.
Which one do you prefer?" When starting to
break the bad news, the physician is advised to use some
transition sentences. For example, transition sentences,
such as "if I had good news for you" or "I would have like
to give you good news," will help to prepare the patient
for the bad news. The physician should wait a short time
after the transition sentence, summarize the findings
and explain the diagnosis or relapse. Sentences should
be short and concise. Descriptive sentences should not
be overwhelmed by figures and statistics. It is essential to
speak in a way that the patient can understand, instead
of using medical jargon. It is also not recommended to
give statistics related to a lifetime. "Quantitative statistics
are for academic research, not for hospital rooms!"
[
What should be done after breaking bad news? If the
patient expresses his/her feelings or cries, it is necessary
to wait and listen to the patient without interrupting. The
physician should wait until he/she is sure that the patient
has acknowledged the information received and then
discuss treatment options. The physician may propose
scientifically understandable resources and websites to
direct the patient to the right sources of information or
provide informative guides and brochures, if any. The
physician shares his/her contact information or phone
numbers of the hospital with the patient. Often, a single
interview may not be enough for the patient to acknowledge
the new information. If this is the case, a second
interview can be planned. If the physician considers that
the patient needs psychological support or psychiatric
help, he or she may make some referrals. This sometimes
happens at the request of the patient and sometimes at
the advice of the physician.
As a result, how the bad news is given may have
negative emotional and psychological consequences for both the patient and/or relatives and the physician.
Therefore, the physician should plan all the steps, use
the communication skills effectively and break the bad
news in a sensitive and empathic manner.
The way bad news is given is as important as breaking
the bad news. Breaking bad news protocols gain
importance in this context. Considering the critical
importance of bad news reporting, several researchers
have developed breaking bad news protocols to establish
a standardized approach.
- The six-step protocol [
- The SPIKES protocol [
- ABCDE protocol [
- BREAKS Protocol [
Peer-review: Externally peer-reviewed.
Conflict of Interest: The authors declare no conflict of interest.
Financial Support: None declared.
