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This page gives a brief overview of the model used for breaking bad
news. It moves at the patient's pace, is patient centred and acknowledges
that individuals will vary in their ability to absorb the news, and
may not be able to handle all the information in one session. If you
follow the links on the page or use the navigation bar you will be
able to explore each of the steps that are suggested, in more detail.
Ensure privacy and freedom from interruptions. See note 1
Have all relevant medical information to hand.
Take note of what is said and the reaction to it. See note 2
Check if patient would like anyone else (eg relative) to be included.
* It may not always be possible to prepare in advance, since spontaneous
questions may be asked. See note 2
Determine what patient knows or suspects. See note
3
Give warning that the situation is serious.
Assess emotional reactions.
See note 4
Check for understanding at all stages.
Proceed at patient's pace.
Cover the relevant topic: diagnosis, treatment, prognosis & support.
See note 5
Do not give more information than patient can absorb.
Identify and acknowledge reaction. See
note 6
Accept that patient may be shocked by news. See
note 7
Allow news to be absorbed before giving further information.
Identify concerns and handle difficult questions.
Acknowledge emotional reactions, typically anger, guilt and blame.
Clarify course of action. See
note 8
Provide support by giving a contact person and number. See
note 9
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The patient may feel most comfortable in their own bed space, with
the curtains drawn to give the illusion of privacy. If there is a
more private place, let the patient choose where they would rather
be for a serious discussion. Apologise for any interruptions that
you have not been able to control.
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The patient may or may not be expecting bad news. They may ask difficult questions to which you do not have the answers. Be prepared to say "I'm afraid I can't answer that just now, but I will find out and come back to you". Observe emotional indications that the patient is nervous of what they are about to hear.
A record of the conversation should be retained accurately in the notes.
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By asking the patient what they know or suspect, you can assess their
current understanding and take note of their vocabulary. This can
help in pitching the information given at an appropriate level.
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Give the news at the patient's pace, and stop if they indicate that they have heard enough. A common reaction to bad news is temporary "denial", which may act as a coping device. Check reactions carefully and proceed only when the patient is ready.
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Focus on the relevant matter to be covered. It may be diagnosis, or confirming treatment options and prognosis. The shock of diagnosis may mean that the detail of treatment options may need to be left to a later consultation. Be led by the patient on what are the most important areas to be covered at any one time.
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Throughout the process, empathise by acknowledging what you see: "I can see that has upset you", or "I imagine that this comes as a great shock". Avoid such expressions as "I understand how you feel".
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Even if bad news is expected, there will be an element of shock when it is put into words. The patient will need time before they are ready to proceed. It may be only a minute or two, but it may mean much longer and a further session.
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Be as specific as possible about the next course of action including when you will see them again - if not you then, if possible, identify who will and when. Cover all issues relevant to the patient, including their support network.
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If possible, give the patient a contact phone number and names of their caregivers so that they can be in touch in the event of any changes before the next planned meeting. It is important that the patient feels supported by the team.
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Ref: Faulkner. A. (1998) When the News is Bad. Stanley
Thornes (Publishers) Ltd.
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