One to One



Assessment  Reading

A framework for breaking bad news
Preparation,   Beginning the session / setting the scene ,    Sharing the information
Being sensitive to the patient
Planning and support  Follow up and closing  References  

·         set up appointment as soon as possible

·         allow enough uninterrupted time; if seen in surgery, ensure no interruptions

·         use a comfortable, familiar environment

·         invite spouse, relative, friend, as appropriate

·         be adequately prepared re clinical situation, records, patient’s background

·         doctor to put aside own “baggage” and personal feelings wherever possible

Beginning the session / setting the scene

·         summarise where things have got to  date, check with the patient

·         discover what has happened since last seen

·         calibrate how the patient is thinking/feeling

·         negotiate agenda

  Sharing the information

·         assess the patient’s understanding first: what the patient already knows, is thinking or has been told

·         gauge how much the patient wishes to know [1]

·         give warning first that difficult information coming e.g. "I'm afraid we have some work to do...." "I'm afraid it looks more serious than we had hoped...."

·         give basic information, simply and honestly; repeat important points

·         relate your explanation to the patient’s framework

·         do not give too much information too early; don’t pussyfoot but do not overwhelm

·         give information in small “chunks”; categorise information giving

·         watch the pace, check repeatedly for understanding and feelings as you proceed

·         use language carefully with regard given to the patient's intelligence, reactions, emotions: avoid jargon

  Being sensitive to the patient

·         read the non-verbal clues; face/body language, silences, tears

·         allow for “shut down” (when patient turns off and stops listening) and then give time and space: allow possible denial

·         keep pausing to give patient opportunity to ask questions

·         gauge patient’s need for further information as you go and give more information as requested, i.e. listen to the patient's wishes as patients vary greatly in their needs

·         encourage expression of feelings, give early permission for them to be expressed: i.e. “how does that news leave you feeling”, “I’m sorry that was difficult for you”, “you seem upset by that”

·         respond to patient’s feelings and predicament with acceptance, empathy and concern

·         check patient’s previous knowledge about information given  

·         specifically elicit all the patient’s concerns

·         check understanding of information given ("would you like to run through what are you going to tell your wife?")

·         be aware of unshared meanings (i.e. what cancer means for the patient compared with  what it means for the physician)

·         do not be afraid to show emotion or distress

Planning and support                

·         having identified all the patient’s specific concerns, offer specific help by breaking down overwhelming feelings into manageable concerns, prioritising and distinguishing the fixable from the unfixable

·         identify a plan for what is to happen next

·         give a broad time frame for what may lie ahead

·         give hope tempered with realism (“preparing for the worst and hoping for the best”)

·         ally yourself with the patient (“we can work on this together  ...between us”) i.e. co-partnership with the patient / advocate of the patient

·         emphasise the quality of life

·         safety net

Follow up and closing    

·         summarise and check with patient

·         don't rush the patient to treatment

·         set up early further appointment, offer telephone calls etc.

·         identify support systems; involve relatives and friends

·         offer to see/tell spouse or others

·         make written materials available

  Remember doctor's anxiety  - re giving information, previous experience, failure to cure or help

 This framework for “breaking bad news” is based on a number of people’s work:

Brod et al, 1986; Maguire and Faulkner, 1988; Sanson-Fisher, 1992, Buckman, 1994;  Cushing and Jones 1995). 

From Silverman J., Kurtz S.M., Draper J.  (1998)  Skills for Communicating with Patients. Radcliffe Medical Press  Oxford


Brod T.M., Cohen M.M., Weinstock E.  (1986)  Cancer disclosure: communicating the diagnosis to patients - a videotape.  Medcom, Inc.  Garden Grove CA.

Buckman R. (1994) How to break bad news: a guide for health care professionals. Papermac, London

Cushing A.M., Jones A. (1995) Evaluation of a breaking bad news course for medical students. Medic al Education. 29: 430-35

Maguire P., Faulkner A. (1988) Improve the counselling skills of doctors and nurses in cancer care  BMJ 297, 847-849

Sanson Fisher (1992) How to break bad news to cancer patients.  An interactional skills manual for interns.  The Professional Education and Training Committee of the New South Wales Cancer Council and the Postgraduate Medical Council of NSW Australia, Kings Cross, NSW Australia

[1] various authors make different recommendations about how this task should be accomplished. Buckman suggests a direct preliminary question such as “if this condition turns out to be something serious, are you the type of person who likes to know exactly what is going on?”. Maguire suggests a hierarchy of euphemisms for the bad news, pausing after each to gain the patient’s reaction. Other authors suggest making a more direct start to giving the news after a warning shot and gauging how to proceed as you go: they argue that patients who wish to use denial mechanisms will still be able to blank out what they do not want to hear



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