Dr. Neha Mahabal Dr. Neha Mahabal Docplexus Editorial Team

Communication is always considered as a bridge between a doctor and his patient. Every individual in the healthcare field usually have the precise skills of communicating with their patients. Interpersonal communications, either verbal or non-verbal are always considered for expressing subtle ideas. Yet there is one important factor in communication which requires to be done very carefully and with empathy. This is the delivery of bad news by the doctor to his patients or relatives of patients. Conveying bad news is a skilled communication but never easy.

Breaking the bad news
Breaking the bad news to the patient or his relatives is a critical issue that involves delivering information that can be potentially devastating to the patient. The impact of communication is high based on the recipient’s expectation and also his understanding of the situation (1). Delivering bad news is a complex yet, critical communication skill that needs to have a verbal context of actual news and also should involve a sympathetic approach of the doctor to manage the recipient’s reaction (2). If communication at this juncture is inappropriately put forth, it can ruin the goal of the doctor of providing support to the patient and also it affects the patient's co-operation in further treatments. A strategic approach is always useful while delivering bad news to the patient or relatives to provide the information according to the recipients understanding or expectations and also to avoid the emotional turmoil that follows (3). Below are some of the strategies that can impact effective communication

1. Creating an ambient atmosphere or physical setting
This is a very basic gesture that comforts the patient or relative. A quiet room with very selected participants in the discussion after the patient's consent about their presence can assure the patient (4). The appearance of the doctor, not being in a hurry to give away the news but to be enduring enough to give the recipient his time to absorb the truth.

2. Being primed up for the talk/discussion
Breaking the bad news is an unnerving task and one should be prepared mentally about its disclosure and also about the patient reactions. Doctors are regarded as one of the important sources of psychological support from the patients (3). Hence, the gestures and approach of the doctor, are critical so that the patient or relative feels supportive by the doctor.

3. Assessing the patient’s knowledge and attitude
According to Terry Canale, “The patient will never care how much you know until they know how much you care.” (5), this suggests that until the patient is satisfied with the doctor’s approach towards the patient’s issue, he/she will not show their willingness. Doctors can get more insights about patient's perceptions about the medical condition and can also assess the patient's preparedness for the bad news.

4. Actual breaking of the news
i. Ventilator withdrawal- procedure, outcome and the support
In the case of dying patients, who are under critical care and the one to be removed from the ventilator, the communication of the situation is equally important along with post-action outcomes. The family of the dying is involved in the decision making whether to withdraw life support or not. It should be primarily considered that the patient’s family does not understand the complications and outcomes after ventilator removal. The steps involved during and after, the life support removal should be completely explained to the relatives and subsequently, they should be supported for the outcomes.

ii. Treatment outcomes
Apart from ventilator withdrawal, there is also the impact of various treatments that are given when the patient is at the end stage and from where no medication can bring him/her to normal life. Patient relatives have a common attitude of “Do whatever you feel is necessary”, but behind this, there must also be the knowledge that reversal to the normal condition may not be possible. This knowledge must be delivered to the relatives by the physicians.

5. Addressing the patient’s emotions
After the patient receives the news, the reaction may vary. It can be silence, disbelief, denial of the news, crying or even anger against the doctor. Yet the doctor has to show an empathic response so that the patient understands the situation. Gestures such as holding the hands and using empathic statements help the patients but also acknowledge that the doctor is also equally aware of his sadness and emotion. The patient should be allowed to cry which helps them to overcome.

Absolute certainties about the life span of the patients cannot be given to the patients but definitely, an acceptable conclusion should be given in an empathic way (6). 

6. Supporting the patient’s decision
Whether the decision is about ventilator withdrawal or about complicated medications that may or may not result in a good way, the decision is always emotionally charged. Relatives always have second guesses about their decision and will always have a second thought that they are wrong. At this point, the support given by the physician is always crucial. The surety in words saying that “your decision is right” and the following support that lasts until the grief period has always been a pillar in building a healthy relationship with the patient’s family (7).

Conclusion
Breaking the bad news is the part and parcel of a physician’s life. Bad news will always be bad news however well it is communicated. But the concern and the attitude of presenting the news greatly impacts the recipient as well as the physician. Good communication has always been known to have a therapeutic effect on patients as well as relatives. Hence communication of bad news must have the gist of the complete condition along with a hint of sympathy towards the relatives.

References
1. Buckman R. How to break bad news: a guide for health care professionals. JHU Press; 1992.
2. Ranjan P, Kumari A, Chakrawarty A. How can doctors improve their communication skills? Journal of clinical and diagnostic research: JCDR. 2015 Mar;9(3): JE01.
3. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. The oncologist. 2000 Aug 1;5(4):302-11.
4. Rubenfeld GD, Crawford SW. Principles and practice of withdrawing life-sustaining treatment in the ICU.
5. Tongue JR, Epps HR, Forese LL. Communication skills for patient-centered care: research-based, easily learned techniques for medical interviews that benefit orthopaedic surgeons and their patients. JBJS. 2005 Mar 1;87(3):652-8.
6. Narayanan V, Bista B, Koshy C. ‘BREAKS’ protocol for breaking bad news. Indian journal of palliative care. 2010 May;16(2):61.
7. Weissman, D. Fast Fact and concepts #11: Delivering Bad News Part II- Talking to Patients and Precepting Trainees. June 2000. End of Life Physician Education Resource Centre

Delivering Bad News A Critical Communication Aspect

Dr. Neha Mahabal Dr. Neha Mahabal Docplexus Editorial Team

Communication is always considered as a bridge between a doctor and his patient. Every individual in the healthcare field usually have the precise skills of communicating with their patients. Interpersonal communications, either verbal or non-verbal are always considered for expressing subtle ideas. Yet there is one important factor in communication which requires to be done very carefully and with empathy. This is the delivery of bad news by the doctor to his patients or relatives of patients. Conveying bad news is a skilled communication but never easy.

Breaking the bad news
Breaking the bad news to the patient or his relatives is a critical issue that involves delivering information that can be potentially devastating to the patient. The impact of communication is high based on the recipient’s expectation and also his understanding of the situation (1). Delivering bad news is a complex yet, critical communication skill that needs to have a verbal context of actual news and also should involve a sympathetic approach of the doctor to manage the recipient’s reaction (2). If communication at this juncture is inappropriately put forth, it can ruin the goal of the doctor of providing support to the patient and also it affects the patient's co-operation in further treatments. A strategic approach is always useful while delivering bad news to the patient or relatives to provide the information according to the recipients understanding or expectations and also to avoid the emotional turmoil that follows (3). Below are some of the strategies that can impact effective communication

1. Creating an ambient atmosphere or physical setting
This is a very basic gesture that comforts the patient or relative. A quiet room with very selected participants in the discussion after the patient's consent about their presence can assure the patient (4). The appearance of the doctor, not being in a hurry to give away the news but to be enduring enough to give the recipient his time to absorb the truth.

2. Being primed up for the talk/discussion
Breaking the bad news is an unnerving task and one should be prepared mentally about its disclosure and also about the patient reactions. Doctors are regarded as one of the important sources of psychological support from the patients (3). Hence, the gestures and approach of the doctor, are critical so that the patient or relative feels supportive by the doctor.

3. Assessing the patient’s knowledge and attitude
According to Terry Canale, “The patient will never care how much you know until they know how much you care.” (5), this suggests that until the patient is satisfied with the doctor’s approach towards the patient’s issue, he/she will not show their willingness. Doctors can get more insights about patient's perceptions about the medical condition and can also assess the patient's preparedness for the bad news.

4. Actual breaking of the news
i. Ventilator withdrawal- procedure, outcome and the support
In the case of dying patients, who are under critical care and the one to be removed from the ventilator, the communication of the situation is equally important along with post-action outcomes. The family of the dying is involved in the decision making whether to withdraw life support or not. It should be primarily considered that the patient’s family does not understand the complications and outcomes after ventilator removal. The steps involved during and after, the life support removal should be completely explained to the relatives and subsequently, they should be supported for the outcomes.

ii. Treatment outcomes
Apart from ventilator withdrawal, there is also the impact of various treatments that are given when the patient is at the end stage and from where no medication can bring him/her to normal life. Patient relatives have a common attitude of “Do whatever you feel is necessary”, but behind this, there must also be the knowledge that reversal to the normal condition may not be possible. This knowledge must be delivered to the relatives by the physicians.

5. Addressing the patient’s emotions
After the patient receives the news, the reaction may vary. It can be silence, disbelief, denial of the news, crying or even anger against the doctor. Yet the doctor has to show an empathic response so that the patient understands the situation. Gestures such as holding the hands and using empathic statements help the patients but also acknowledge that the doctor is also equally aware of his sadness and emotion. The patient should be allowed to cry which helps them to overcome.

Absolute certainties about the life span of the patients cannot be given to the patients but definitely, an acceptable conclusion should be given in an empathic way (6). 

6. Supporting the patient’s decision
Whether the decision is about ventilator withdrawal or about complicated medications that may or may not result in a good way, the decision is always emotionally charged. Relatives always have second guesses about their decision and will always have a second thought that they are wrong. At this point, the support given by the physician is always crucial. The surety in words saying that “your decision is right” and the following support that lasts until the grief period has always been a pillar in building a healthy relationship with the patient’s family (7).

Conclusion
Breaking the bad news is the part and parcel of a physician’s life. Bad news will always be bad news however well it is communicated. But the concern and the attitude of presenting the news greatly impacts the recipient as well as the physician. Good communication has always been known to have a therapeutic effect on patients as well as relatives. Hence communication of bad news must have the gist of the complete condition along with a hint of sympathy towards the relatives.

References
1. Buckman R. How to break bad news: a guide for health care professionals. JHU Press; 1992.
2. Ranjan P, Kumari A, Chakrawarty A. How can doctors improve their communication skills? Journal of clinical and diagnostic research: JCDR. 2015 Mar;9(3): JE01.
3. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. The oncologist. 2000 Aug 1;5(4):302-11.
4. Rubenfeld GD, Crawford SW. Principles and practice of withdrawing life-sustaining treatment in the ICU.
5. Tongue JR, Epps HR, Forese LL. Communication skills for patient-centered care: research-based, easily learned techniques for medical interviews that benefit orthopaedic surgeons and their patients. JBJS. 2005 Mar 1;87(3):652-8.
6. Narayanan V, Bista B, Koshy C. ‘BREAKS’ protocol for breaking bad news. Indian journal of palliative care. 2010 May;16(2):61.
7. Weissman, D. Fast Fact and concepts #11: Delivering Bad News Part II- Talking to Patients and Precepting Trainees. June 2000. End of Life Physician Education Resource Centre

Delivering Bad News A Critical Communication Aspect

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