Here are various examples of communication issues which frequently require careful thought and handling.
I have received two wonderful graces. First, I have been given time to prepare for a new future. Secondly, I fi nd myself—uncharacteristically—
calm and at peace.
Cardinal Basil Hume, breaking the news of his imminent death from cancer to the priests of the Westminster diocese, 16 April, 1999.
Breaking bad news
Breaking bad news is such a fundamental aspect of communication in palliative care because it requires an understanding of so many other aspects of the healthcare professional/patient relationship. It is unusual for patients not to voice diffi cult or awkward questions, and strong emotions are likely to be elicited. The steps required for the successful breaking of bad news can act as a template for most other communication problems encountered.
Patients and relatives need time to absorb information and to adapt to bad news. Breaking bad news takes time, and issues often need to be discussed further and clarifi ed as more information is imparted.
There is increasing evidence that most patients want to know about their illness. Many patients who have been denied this knowledge have diffi culty in understanding why they are becoming weaker and are then relieved and grateful to be told the truth. They may be angry with the family who has known about the illness all along and have not thought it right to tell them.
Professionals often become involved unwittingly in a potential conspiracy of silence when the family demand information before the patient has been appraised of the situation. The family might say, ‘Do not tell him the diagnosis/prognosis because he will not be able to cope with it. We know him better than you do.’ The family needs to know that their concerns, of not wanting to cause any more hurt to the patient, have been heard. They also need to be aware that the bad news may be more painful for them-selves than for the patient. The family also needs to know that it would be unwise for clinical staff to be untruthful if the patient appeared to want to know the truth and was asking direct questions, because of the inevitable breakdown in trust that this could cause.
Advising patients and families with regard to prognosis is important since they may want (and often need) to organize their affairs and plan for the time that is left. However, it is not possible to be accurate with prognosis.
Overestimating or underestimating the time that someone has to live can cause untold anguish. It is therefore more sensible to talk in terms of days/
weeks, weeks/months and months/years as appropriate.
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There is a balance to be made between fully informing the patient about their disease and prognosis, completely overwhelming them with facts and fi gures, or providing only minimal and inadequate information.
While it is important to avoid being patronizing, it is also important not to cause distress by ‘information overload’.
It is important to be aware that people have divergent attitudes to receiving bad news and that this needs sensitive handling. Patients and families respond badly to being told bad news in a hurried, brusque and unsympathetic manner with no time to collect their thoughts and ask questions. However sensitively bad news is imparted, patients and families are naturally devastated and the impact of the news can obliterate a great deal of the communication that took place. Patients may either not remember or misinterpret what has been said, particularly if they use denial as a coping technique.
A strategy for breaking bad news
Nothing in all the world is more dangerous than sincere ignorance and conscientious stupidity.
Martin Luther King 1929–68: Strength to Love (1963).
Outlining a strategy for breaking bad news is diffi cult because it turns a process which should be natural and unforced into something which seems constrained and awkward. The following advice encompasses the techniques that health professionals have found, through trial and error, to be helpful. It can be used as a guide to develop an individual’s personal confi dence and skills in breaking bad news.
The goals of breaking bad news
The process of breaking bad news needs to be specifi cally tailored to the needs of the individual concerned, for every human being will have a dif-ferent history and collection of fears and concerns. The goal of breaking bad news is to do so in a way that facilitates acceptance and understanding and reduces the risk of destructive responses.
The ability to break bad news well involves skills which need to be coveted and trained for, audited and kept up to date with as much objec-tive determination as that shown by a surgeon in acquiring and maintaining surgical skills. The consequences of performing the process badly may have immediate and long-term damaging effects for all involved, every bit as catastrophic as surgery going wrong. For example, patients and families may lose trust. Having awareness of strategies to complete the process well is vital, but breaking bad news must never become so routine that patients, or their families, detect little individual caring compassion.
Break bad news well and you will always be remembered, break bad news badly and you will never be forgotten.
Prepare to tell bad news
Acquire all the information possible about the patient and their family.
(A genogram is particularly useful in quickly assimilating the important people in the patient’s life, and the web of relationships within the family.) Read the patient’s notes
For:
Diagnostic information Test results
An understanding of the patient’s clinical history The support system for the individual
Background knowledge of the patient’s life—making basic mistakes will undermine the patient’s confi dence
The patient’s understanding of spoken language, e.g. English. If not, arrange for an interpreter to be present
Discuss with other members of the team, and then select the most appro-priate team member to break the bad news. Decide which other member of the team should be present during the interview. Ensure there is an interpreter or advocate present for those with special needs or language diffi culties.
Check That you have:
A place of privacy where there will be no interruptions. Unplug the telephone and switch off the mobile phone, etc.
Tissues, a jug of water and drinking glasses Time to carry out the process
Your own emotional energy to do so—this job is better done earlier in the day than late
Pressing tasks are completed so that there will be minimal interruptions
Plan
Prepare a rough plan in your mind of what you want to achieve in the communication, and what you want to avoid communicating. Having a rough goal will bring structure to the communication, though it is important to avoid imposing your agenda on that of the patient.
Set the context
Invite the patient to the place of privacy Introduce yourself clearly
Let the patient know that they have your attention and how long you have got
Ensure that the patient is comfortable and not distracted by pain or a full bladder, etc.
Give a ‘warning shot’ indication that this is not a social or routine encounter
Sit at the same eye level as each other and within easy reach
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A warning shot is concerned with preparing a patient that bad news is coming. This allows them to be more receptive than if it comes ‘out of the blue’. An example would be, ‘I’m sorry to say that the results were not as good as we had hoped.’
Assess
How much the patient knows already How much the patient wants to know
How the patient expresses him/herself and what words and ways he/she uses to understand the situation
‘Are you the sort of person that likes to know everything?’
Acquire empathy with the patient What would it be like to be the patient?
How is the patient feeling?
Is there anything that is concerning the patient which he or she is not verbalizing?
What mechanisms has the patient used in the past to deal with bad news?
Does the patient have a particular outlook on life or cultural understanding which underpins his or her approach to dealing with the situation?
Who are the important people in the patient’s life?
Respond to non-verbal as well as verbal clues.
Encourage the patient to speak by listening carefully and responding appropriately.
Share information
Having spent time listening, use the patient’s words to recap the story of the journey so far, checking regularly with the patient that you have heard the story correctly
‘Would you mind if I repeated back to you what I have heard you tell me to make sure I have understood things correctly?’
Slowly and gradually draw out the information from the patient while regularly checking that they are not misunderstanding what you are saying
Use the ‘warning shot’ technique to preface bad news to help the patient prepare themself
Use diagrams to help understanding and retention of information if appropriate and acceptable to the patient
Avoid jargon and acronyms which are easily misunderstood
Do not bluff. It is acceptable to say ‘I do not know, and I will try to get an answer for you for our next meeting’
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Remember Ensure that:
The patient understands the implications of what you are saying The patient is in control of the speed at which information is being imparted
The patient can see that you are being empathic to their emotional response. It can be very appropriate to say something like ‘Being told something like this can seem overwhelming’
You address the patient’s real concerns, which may be very different from what you expect them to be
You offer a record of the consultation, for example a tape recording or short written notes if appropriate
Response
You should respond to the patient’s feelings and response to the news You should acknowledge the patient’s feelings
You should be prepared to work through the patient’s emotional response to the bad news with them
It can be very distressing to get such news, and it is not unusual to feel very angry, or lonely or sad on hearing such news.
Let the patient speak fi rst Use open questions, such as:
How are you feeling today?
Can you tell me how this all came about?
How do you see things going from here?
Make concrete plans for the next step
Your appointment to see Dr Brown the oncologist is provisionally booked for next Thursday at 2 o’clock. How would that fi t in with your other arrangements?
Immediate plans
‘What are you doing now?’ ‘How are you getting home?’ ‘Who will you tell?’ ‘How will you tell them?’ ‘What will you say?’ ‘How will they cope?’
Such questions can help the patient to start formulating the answers that they will need for their family or friends.
Summarize For the patient
Try to get the patient to repeat the key points to ensure they have understood
For other healthcare professionals
Record details of the conversation in the patient’s notes clearly Convey information quickly to those who need to know, most importantly the patient’s GP
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Deception is not as creative as truth. We do best in life if we look at it with clear eyes, and I think that applies to coming up to death as well.
Cicely Saunders, in Time 5 September, 1988 Deal with questions
‘Are there any questions which you would like me to deal with at this point?’
Contract for the future
I know the news today was not what you were hoping for but you are not going to go through this on your own. We are there for you, your family is there for you and we are going to go through this together.
Dr Brown will be seeing you next Thursday and I’ll see you back here on Monday morning.
Closing remarks should identify support networks, including contact telephone numbers and times of easy access. Be fairly concrete about the next meeting but also allow the patient the option to postpone if they do not feel able to attend.
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