Breaking a bad news is an art in Healthcare. Everyone has a different style.But here is a guideline.......

1. Breaking a Bad News
Dr. Md. Saddam Hossain
MBBS (PMC,DU)
Bangladesh
Phone No: +8801770980080

2. This presentation includes:

3. “Nothing travels faster than the speed of light with the
possible exception of bad news, which obeys its own special
laws‘’
……….. Douglas Adams

4. What is a bad news?
“……… any information which adversely and seriously affects an
individual’s view of his or her future. ‘’
……………….. Buckman, 1992.

5. Examples:
Death of a patient
Life threatening conditions, e.g.: MI, Carcinoma
Any condition where emergency surgery needed, e.g.: Acute gangrenous
intestinal obstruction, rupture of any aneurismal artery.
Chronic illness, e.g.: chronic pancreatitis
Failure of a surgery

6. To Whom BBN can be given?
To the patient
To the
parents of a
patient
To the legal
guardian

7. What patient/patient party expect:
For themselves:
• more time to talk
• show feelings
From the doctors:
• more information, caring, hopefulness, confidence
• a familial face

8. What are the Challenges in BBN?
Lack of:
Guidelines
Training
Experience
Good role models
Concerns of:
The provider
The patient & family

9. Why is BBN so important ?

12. Case Discussion:
Abdullah is a patient of yours who comes to see you one day
with his wife Sharefa. Sharefa is also a patient of yours who
was admitted to hospital for investigations for liver. The results
of the liver biopsy showed a well differentiated hepatocellular
carcinoma. This result had been disclosed to Abdullah only. He
has come to you today asking for your assistance in telling his
wife the results of her investigations.
How would you handle this situation?

13. Methods of BBN:
Rabow and Mc phee - ABCDE approach
Baile and Buckman - SPIKES approach
SAAIQ emergency approach – Pakistan
BREAKS approach – IJPC
SAD NEWS approach - Canada

14. SPIKES protocol
S – Setting
P – Patient’s perception
I – Invitation
K – Knowledge
E – Empathy
S – Summary

15. SPIKES
Settings and listening skills:
(1) Where to break news.
eg: A quiet room preferably not during ward round.
(2) By appointment.
eg: After ward round, at 3p.m.
(3) Ask whether prefers to have relatives.
(4) Physical context of interview.
eg: Sitting down, body language, eye contact
(5) Introduce your self and ascertain how others are related to the patient.
(6) Listening skills – open questions to start, do not interrupt.

17. SPIKES
Patient’s perception:
(1) Ask what he already knows about the medical condition or what he suspects.
(2) Listen to level of comprehensions.
(3) Accept denial but do not confront at this stage.

18. SPIKES
Invitation to give information:
(1) Ask patient if s/he wishes to know the details of the medical condition and/or
treatment.
(2) Accept patient’s right not to know.
(3) Offer to answer questions later if s/he wishes.

19. SPIKES
Knowledge:
(1) Use language intelligible to patient.
(2) Give to patient’s level – Consider educational level, socio-cultural background, current
emotional state
(3) In small chunks
(4) Check whether patient understood what you said.
(5) Respond to patients reactions as they occur.
(6) Give any positive aspects first.
eg: Cancer has not spread to lymph nodes, highly responsive to therapy, treatment available
locally etc.
(7) Give facts accurately about treatment options, prognosis, costs etc.

20. SPIKES
Explore emotions/Empathy:
(1) Identify emotion.
(2) Identify cause/source of emotion.
(3) Respond in a way that you have recognized connection between 1 and 2.
(4) In empathetic response not necessary for you to feel same emotion or agree
to patient’s view point.

22. SPIKES
Strategy and summary:
(1) Close the interview.
(2) Ask whether they want to clarify something else.
(3) Offer agenda for the next meeting.
eg: I will speak to you again when we have the opinion of cancer specialist.

23. In a summary:

24. Level of language :

25. Emotional responses to a bad news:
Denial
Despair
Anger
Bargaining
Depression
Acceptance

26. How to overcome the Emotional responses:
1. If patient begins to cry
(a) Allow sometime to cry.
(b) Could say, “I can see you are very upset”
(c) Could touch the patient appropriately.
(d) After a few moments you should continue talking even if patient
continue to cry.

27. 2. If patient becomes angry
(a) Defensive or irritation with patient are unhelpful.
(b) Acknowledge patient’s position and avoid talking about it.

28. 3. If the patient refuses to accept the diagnosis
(a) Explore reasons for patient’s denial.
(b) Do not be combative.
(c) Appreciate that there is an information gap and try to educate the
patient.
(d) Check that patient has a clear understanding of the problem.
(e) Empathize with patient.
(f) Get family members involved if appropriate.
(g) Give time to adjust to new information.

29. What not to do…….
1. Jargon and technical language
2. Euphemisms
3. Evasion
4. Conflicting informations
5. “everything is going to be fine’’

31. The Task of Breaking Bad News:
“If we do it badly, the patients or family members
may never forgive us; if we do it well, they may
never forget us.”
……………(Buckman, 1992)

33. Thank you