Breaking Bad News

Breaking bad news comes in various forms. It is a regrettable but important duty that must be done conscientiously, yet it tends to receive scant attention in medical training.^1,2 Your patients will judge you on your performance.³

• If you get the news and it is your responsibility to tell the patient, get a receptionist to call the patient and make an appointment. Do not do so yourself as bad news must be transmitted in person and not over the telephone. If you do not speak to the person he does not have a chance to question you. The receptionist can plead ignorance.
• The patient may like to be accompanied by a spouse or someone close to them.
• Ensure you have protected time. This may mean turning off bleeps or mobile phones. It may mean making a longer than usual appointment. If it happens during a surgery in which you are running late, run later. You may get the patient to return in the near future to discuss the matter more but do not seem rushed or too eager to get on. To you this may be just another day at the office but to the patient and the family it is a pivotal day of their lives.
• Make yourself as fully conversant with the facts as possible. This means the facts about this case like the exact type of tumour and stage as well as more general issues about the disease. This applies not just to cancer but to all diseases that fall into the bad news category.
• You may feel that this is such an intimate moment that you do not want a registrar or medical student present but if they can be unobtrusive in the background this could be an important learning opportunity. Similarly, if you can video the consultation under the rules for consultation analysis it could be an excellent learning tool for you and for others but the matter of obtaining signed consent may make you feel uneasy. Do what you feel is right for that person at that time.

• Try to get structure to the interview.
• Use language that the patient will understand and give plenty of opportunity to interrupt if they want something elucidated. The level of comprehension will depend upon the education of the patient but avoid jargon, technical terms and abbreviations. It is a common complaint from patients that medical staff spoke to them in language that they did not understand. Give pauses and check understanding.
• Find the patient's starting point. What do they know already? What have they been led to expect?
• A warning shot to prepare them may be helpful. "I'm afraid that it is rather bad news". Give this a moment to sink in.
• How much detail does the patient want to know? What is the level of education? "Do you want me to go over the results with you?"
• Break the consultation into stages like diagnosis, implications, treatment, prognosis and if appropriate, be reassuring about terminal care. It is the terminal stages that people fear most. It is not essential to cover all aspects immediately if you feel it will be too much to take in at once.
• Try to be optimistic but still realistic and honest. Honesty includes being honest about what you do not know. As a GP you cannot be expected to be able to give exact figures for survival rates and a suitable reply might be, "With your cancer at your stage the chances are quite good. I am unable to give you exact figures but the consultant would probably know and he may even have his own figures for those whom he treats".
• Make sure that they understand the nature of risk and what these figures mean. What is 5 year survival? There is a tendency to interpret any survival rate above 50% as a certain cure and any below 50% as certain death. A 95% cure rate still means that 1 person in 20 will die of the disease. An 80% mortality means that 1 person in 5 will survive. Look at the figures from both directions. You are talking risk. You do not have certainty about the outcome. It is also worth being positive about continuing medical advances.
• Observe the patient and see how he or she is coping. Is now the time to discuss treatment or will that be better in a few days time? How much does the patient really want to know? Read the subtle signs. If in doubt ask outright. Do not expect to deal with everything in one session.
• Agree a plan for further follow up. If there has been a lot of information to impart this will need repetition or clarification in the future.

Finish with a summary and try to conclude on an "upbeat note".

It may go something like this: You do have cancer and it is a serious illness but it is not necessarily a death sentence, especially these days. You will need a major operation followed by some treatment that will make you feel very unwell but you can get through it. You are in good hands and you have lots of people around who care about you. If the worst does come to the worst we can control pain without knocking you out and without loss of dignity. You have a fight on and we can win. One of the most important features is your attitude. Remember that if you have any problems or want to discuss anything we are here for you.

You may also make a follow up appointment. Try to leave on a positive note.

Record the consultation as you would any other. If appropriate, inform other colleagues involved in care, such as consultants.

This type of consultation fortunately does not happen very often, but it is an ideal learning experience. Reflect on what went well, and what if anything you would have liked to have done better.

Imparting bad news is an emotional experience for the doctor as well as for the patient, so take a moment to recognise this and calm yourself down before moving on to the next consultation.

There are traps for the unwary that must be avoided.

• Do not avoid seeing the patient or leave them anxiously waiting for news. Sometimes anticipation can be worse than even the worst reality. Treat others as you would wish to be treated yourself.
• Read the notes. Get the facts before you start.
• You need privacy and no interruptions. In a hospital, hospice or residential home, make sure you will not be disturbed. If necessary switch off phones or bleeps.
• Be factual but sympathetic. Always be empathetic however you may feel personally. You may feel that the person's lifestyle makes him responsible for his HIV, cirrhosis or lung cancer but never let it show. Better still, do not let yourself become judgmental. For as you judge others so too you will be judged and Let he who is without sin cast the first stone.
• Give time for the information to sink in and the opportunity to ask questions before moving on. Do not seem rushed.
• If the patient does not seem able to take any more be prepared to end the consultation and to take it up again later. Look for all the cues, verbal or others. "Do you want to leave it for now and we can discuss it more when you are feeling ready?" Perhaps they would like you to speak to someone else or to have someone with them for the next meeting.
• If asked the question, "How long have I got to live?" never be precise. You will always be wrong. To the patient and family 6 weeks means 6 weeks and not 5 weeks or 7.
• Never say that nothing can be done or the patient will lose all hope.⁴
• If you have written material to give that may be useful.
• Whilst trying to be positive never lose track of the fact that this is a serious and potentially fatal disease. Be optimistic but do not promise success or anything else that may not be delivered.
• Be mindful of the recent changes in legislation concerning consent. If the patient 'lacks capacity' under the terms of the The Mental Capacity Act 2005 (enacted 2007), you must act in the best interests of the patient. You must take all factors into account, including the views of carers, persons with lasting powers of attorney, deputies appointed by the court, and anyone whom the patient has previously indicated should be consulted about their views.⁵

Quite often a doctor is called to a house where a relative, police or ambulance personnel believe that a person is dead. They are very rarely wrong. The doctor is needed to confirm the fact of death.

Check the patient's records before going out. Was there disease that would make this a likely event or was this an apparently fit and healthy person? How old was the patient and which doctor did he or she normally see? Being in possession of these facts makes the presentation more impressive but for the out-of-hours doctor these facts are probably not available, at least until we have the National Care Record System in operation.

Attend with reasonable promptness and having confirmed death, and possibly noting temperature of the body and rigor mortis if the person has been dead for many hours, return to give the verdict. It is best to have the spouse or relatives sitting. They are expecting the news that is about to be broken. Then, in a sympathetic tone, convey the fact in words that are unequivocal and cannot be misinterpreted. Ask about recent history, particularly any symptoms likely to signal an impending medical catastrophe such as breathlessness or chest pain. The situation concerning contacting the coroner varies across the country, but they would require the doctor to inform them of an unexpected death or if you had not seen the patient in the 14 days prior to the death. You may feel it appropriate to ask the relatives if they would like you to call an undertaker and if so whom. Most undertakers provide a 24 hours service to collect the recently deceased. If you are not referring to the coroner give instructions about the collection of a death certificate and where the death has to be registered.

You have to return to your duties and other charges but try not to let the bereaved feel abandoned. Suggest that they may wish to make an appointment to see you or their usual doctor in the near future to see how they are coping. Tell them that usually life is quite busy until the funeral and it is after this that the loneliness and emptiness strikes. It is usually best to wait until after the funeral to see the doctor.

We tend to think of this as informing the patient that he has cancer but there are many other diagnoses that fall into the category. It may be a neurological disease or a psychiatric diagnosis like schizophrenia, or HIV counselling when reporting a positive test. It may be about a child who has brain damage or a serious congenital condition.

Remember that if you are asked to discuss the medical condition with a concerned third party - e.g. relatives or carers other than the parent or guardian of a child - you must have the patient's consent if he is in a position to give it.

Do not be lured by calls from relatives such as, "If it's cancer he mustn't know or it would crack him up". You must treat your patients as intelligent adults, even if their family fails to do the same. No one has any right to withhold the diagnosis from a person of sound mind and nowadays such deceit would undermine the patient's trust. It is often worth responding to such a request with the question, "If you had cancer would you want me to tell everyone else but not you or would you want to know?" In the unlikely event of the relative saying that he would want others told but not himself, say that it is your duty to impart the information to the patient and it is up to him to decide who, if anyone, he wishes to tell. As recently as the early 1970s it was standard practice to deny a diagnosis of malignancy, even when it was obvious to the casual observer and the patient was receiving radiotherapy. This is now totally unacceptable.

Having to tell a spouse or relative that a patient has been the subject of an adverse event is much less common in primary than in hospital care. It is a very difficult thing to do and to do well, but the situation can be made easier with a structured approach.⁶ Confirm the identity and relationship of the person to whom you speak. Express regret at what has happened. Be factual. Do not blame anyone. Keep full notes.