Breaking bad news to patients

• Prepare well. Plan what you want to say and how you will say it.
• It is essential to demonstrate genuine concern and an appreciation of the patient’s perspective.
• Share a plan with the patient that outlines how they can follow up and have more questions answered.

On any normal working day you could be delivering news to a patient that might change their life. Bad news may be related to a terminal diagnosis, or telling an athlete about the prognosis after a significant injury, or a young woman about fertility issues.

Advising a patient of a serious diagnosis or poor prognosis is an unavoidable part of a medical practitioner’s job. For most practitioners, it is also difficult and does not necessarily come naturally. Doing this part of your job well is an important aspect of patient care. Giving it significance and preparing, practising and seeking training can help ensure such consultations go as well as possible, for the patient and for you.

Wherever possible, plan how you will approach advising a patient of a serious diagnosis or poor prognosis. Even if you can only spend a few moments before you see the patient, collect your thoughts and think about how to approach the discussion. Some doctors find it helpful to have planned for and practised common scenarios in their field.

Consider whether you are the right person to have the conversation with the patient and whether any other practitioners should be involved in the discussion.

Before the consultation:

• Select a meeting place that is private.
• Allow enough time so you do not appear rushed or impatient.
• Consider whether the patient might want culturally appropriate support such as friends, family or spiritual advisers, and whether they need an interpreter.
• Be adequately prepared with information about the patient’s clinical situation – this includes being familiar and up-to-date with the facts and results.
• Have contact details and information about relevant referral and support services available.
• You may want to rehearse some parts of the conversation.

The link at the end of this factsheet provides evidence-based guidelines for these conversations and includes suggestions of phrases that may help you.

Consider the patient’s perspective

Keep in mind that a patient’s or family member’s perspective of bad news will most likely be different from yours. Each will have their own, very personal fears and are likely to have a different clinical understanding. Be mindful of the impact of the news on their life, hopes and goals.

Showing that you care is essential in these discussions. Even if you don’t know a patient well, showing respect and concern can greatly support the patient. Sometimes you may need to deliver bad news to a patient you don’t know. Simple things like greeting the patient by name, introducing yourself and explaining your role in this patient’s care can make a difference.

Understanding

Even if you have an existing care relationship with the patient, it is important not to make assumptions about their knowledge or concerns. Questions such as “can you tell me what you understand about your condition”, or “what have others told you about your condition” might assist you to focus on the patient’s particular needs for information. These can also help you to understand what the patient is expecting to hear.

Details of clinical situation and treatment options

Try to gauge how much information the patient wants. Some patients want to know every detail of their clinical situation, others cannot process too much information at once, and others prefer some initial information and more detail later.

Giving information in small chunks gives the patient the opportunity to digest it. Speak clearly and avoid medical jargon. It can also help to warn the patient before you deliver difficult news. As an example, saying "that the news is not what we had hoped for” might be appropriate under some circumstances if you know the patient.

Ideally, treatment options should be discussed over more than one consultation to help the patient gain a greater understanding of each option. Ensure this is a two-way conversation allowing the patient to consider, discuss and ask questions about each option. Written materials with diagrams, when appropriate, can help to facilitate the patient’s understanding.

When providing the patient with information it is important to also provide a broad timeframe of the next steps to be taken.

Questions

Answer the patient’s questions to the best of your ability. Where you can, provide an explanation of the areas you plan to follow up and when you expect to have an answer.

Discuss potential treatment options and realistic goals, expectations and coping strategies but do not offer false or misleading hope.

Allowing for emotions

Show care and understanding. Give the patient an opportunity to express their worries, concerns and emotions. Moments of silence can allow the patient to feel comfortable raising questions. Sometimes it can be helpful to ask the patient what is on their mind and how they are feeling about the news.

Dealing with fears

Patients often feel very alone and threatened when given bad news, even if it is not totally unexpected.

Exploring and, where possible, working alongside the patient to mitigate their fears can be helpful. You might provide reassurance that they will be supported by you, or a team, as their care proceeds. Reassurance that you will be available to provide support and advice can help the patient feel less alone.

Dealing with shock

Sometimes a patient will be quite shocked immediately after hearing bad news. In this case, don’t rush through complex details but try to be empathetic while providing support. It may be best to offer another appointment to go over more of the detailed information.

Sharing the news with others

It can be helpful to offer to speak with the patient’s relatives or carers with the patient’s permission. Keep in mind that the patient may be the bearer of this bad news to their relatives and carers and you might offer to help them with that process. Identify support systems for both the patient and their family and friends as appropriate.

It can be important for the rest of the care team to know what you have told the patient. Be sure to discuss this with the patient and agree on the plan for informing other professionals.

At the end of the discussion

• Summarise the discussion and encourage the patient to contact you (or a colleague) directly with further questions and ensure the patient has appropriate contact details to do this.
• Arrange or advise about appropriate follow up appointments with other doctors and for tests as needed.
• Ensure the patient is aware of relevant support services.
• Provide any appropriate pamphlets, factsheets or other reputable resources. (It may also be appropriate to warn about the limitations of a general internet search).

Throughout the conversation assess the patient’s response and be alert to any significant psychological concerns. Additional support or expertise may sometimes be needed.

If possible, try to end with reassurance. For example: "l though this is a serious condition, we can work together and I want you to know I am, and will, be here for you.”

Finally, make sure the patient is able to make their way home safely. Be sure they leave knowing how to access help and that you and, where appropriate, your colleagues are available for questions and assistance.

Document the discussion

The impact of psychological shock means patients often fail to remember, or mishear, information they are given in a bad news consultation. It is essential to thoroughly document the details of the consultation, including the names of anyone else present, the matters discussed with the patient and information provided.

Dealing with patients’ distress can be draining for even the most experienced practitioner. It is important to acknowledge that these conversations can affect you and to find ways of looking after yourself. At the most practical level, if you know you will have to deliver bad news in a consultation, try to keep some space free so you are not pressed to deliver the bad news quickly and you have time to recover your own emotions.

You might discuss with colleagues ways of taking time out or supporting each other after a particularly difficult encounter.

Always make sure you seek assistance and support if you require it.

Clinical practice guidelines published in the Medical Journal of Australia provide a good reference including useful phrases that might help you with some of the more difficult aspects of delivering bad news.