Hematology and Oncology Book

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Breaking Bad News

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  1. See Also
    1. Discussing Terminal Illness
  2. Indications
    1. Example: Telling patient about a terminal illness
  3. Approach
    1. Overall Approach (Mnemonic: ABCDEF) - see below
      1. Advanced Preparation
      2. Build a therapeutic environment
      3. Communicate well
      4. Deal with reactions of patient and their family
      5. Encourage and validate emotions
      6. Follow-up plan
    2. References
      1. Rabow (1999) West J Med 171:261
      2. Vandekieft (2001) Am Fam Physician 64(12):1975
  4. Step 1: Advanced Preparation
    1. Assign clinician responsible for telling the patient
    2. Review patient's case and therapeutic options
    3. Rehearse your plan to deliver the bad news
  5. Step 2: Build a therapeutic environment
    1. Allocate adequate time in suitable, quiet environment
    2. Invite participants patient would like present
    3. Participants introduce themselves
    4. Be sensitive to patient's preferences (touch, humor)
    5. Foreshadow the bad news (e.g. I have bad news)
  6. Step 3: Communicate well
    1. Patient has right to accurate information
      1. Ask what the patient already knows
      2. Determine how much the patient wishes to know
    2. Speak slowly, pause and repeat important points
    3. Express information clearly so patient understands
      1. Speak simply and honestly
      2. Express compassion (e.g. I am sorry)
      3. Avoid euphemisms (use words such as death)
      4. Implications clearly laid out
      5. Avoid medical jargon and technical language
      6. Avoid overwhelming with too much information
    4. Assume time for patient to assimilate information
      1. Encourage questions
      2. Write down summary of information on paper
  7. Step 4: Deal with reactions of patient and their family
    1. Be aware of body language
    2. Understand coping mechanisms of meeting participants
    3. Avoid arguments and defensiveness
  8. Step 5: Encourage and validate emotions
    1. Understand how patient feels about the news
    2. Offer realistic hope
      1. Describe prognosis generally (e.g. weeks to months)
      2. Emphasize what can be done (e.g. comfort)
  9. Step 6: Follow-up plan
    1. Schedule follow-up meetings
    2. Establish community support services (e.g. Hospice)
  10. References
    1. Abeloff (2000) Clinical Oncology, Churchill, p. 609-10
    2. Ambuel (2001) Prim Care 28(2):249
    3. Rabow (1999) West J Med 171:261
    4. Vandekieft (2001) Am Fam Physician 64(12):1975

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