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Breaking bad news in cancer care Part 2: practical skills

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Donna Higgins, BSc (Hons), RN

Macmillan Prostate Cancer Nurse Specialist, Frimley Park Hospital NHS Trust, Surrey

Being able to break bad news such as a diagnosis of cancer to a patient in a reassuring manner will be of immense help to the person at a difficult time. Excellent communication skills and good preparation are key to this task.

 

Being able to break bad news such as a diagnosis of cancer to a patient in a reassuring manner will be of immense help to the person at a difficult time. Excellent communication skills and good preparation are key to this task.

 

 

Responsibilities of breaking bad news
Who, how and when are the most frequently asked questions in relation to the bad news situation. Whose responsibility is it to break bad news? Health care has changed since the end of the 1960s with the realisation that the patient-centred approach is key to the effective delivery of care (Bruera et al, 2000).

 

 

It is well-known that the majority of health professionals do not want to be bearers of bad news (Faulkner, 1998; De Valck and Van de Woestijne, 1996). Most feel uncomfortable and unprepared for the interaction (Dosanjh et al, 2001). One study looked at the bad news consultation between doctor and patient (Ford et al, 1996) and found that the most frequent dominating behaviour was that of biomedical information-giving. It identified that patients were rarely given ‘space’ to respond to queries and had little time given to psychosocial concerns.

 

 

Doctors are not the only ones who fare badly in this area. Nurses have also been shown to lack the key skills and qualities necessary (De Valck and Van de Woestijne, 1996). However, nurses have been identified as integral to the patient’s experience of receiving bad news (Dunniece and Slevin, 2000). Patients have said that encounters with nurses and other caring health professionals can increase their well-being, self-image, sense of security, sense of acceptance and internal sense of healing (Halldorsdottir, 1997). Therefore, ‘the responsibility of breaking bad news should rest with a member of staff with whom the recipient can feel most comfortable’ (Faulkner, 1998).

 

 

The bad news consultation
Preparation is key. This encounter should not take place at a moment’s notice, in the middle of a ward round for example.

 

 

- Who? The person delivering the bad news should be someone whom the patient trusts and feels comfortable with (Faulkner, 1998). If this is a doctor, a nurse’s presence will be invaluable. This has been shown by Macdonald (2001), who looked at the impact of nurses on the psychological well-being of patients during their cancer journey. The patients felt an increase in security and support in the presence of a nurse. Nurses have also emphasised the importance of ‘being there’ for a patient (Dunniece and Slevin, 2000)

 

 

- When? Is it the best time for the patient? Check with the patient whether it would be convenient to talk. Does he or she want to be alone or have someone else present (Faulkner, 1998)?

 

 

- Where? Preferably, this meeting should take place somewhere private (Dosanjh et al, 2000).

 

 

Psychosocial issues - Ask questions about psychosocial issues - this has been shown to promote increased disclosure of sensitive information by patients. The health professional should also make supportive statements and listen attentively (Ford et al, 1996).

 

 

Allow space for the patient (Faulkner, 1998). This will give him or her time to assimilate the information received and to ask questions and seek clarification (Faulkner, 1998).

 

 

Assessment skills - It is imperative to find out exactly how much the patient knows or wants to know at the beginning of the discussion (De Valck and Van de Woestijne, 1996). De Valck and Van de Woestijne (1996) discovered from studying communication problems in an oncology ward that patients differed significantly in the way in which they wanted to be informed of their diagnosis, with some patients complaining of receiving too much information and others of too little. Lack of information has also been linked to patients and relatives displaying unsuitable behaviour and high stress levels (Osuna et al, 1998).

 

 

Questioning and listening skills - Open and closed questions can be used to ascertain information from the patient. These skills can be used to realise how the patient has perceived the situation and his or her understanding of what has been said (Morton, 1996). Listening also means watching for non-verbal signs from the patient. The patient may give non-verbal cues to his or her reaction to the news. For example, the patient may look anxious or appear nervous. Acknowledgement of the cues and further investigation may lead to extra information about how the patient is interpreting the news (Faulkner, 1998).

 

 

Information skills - When giving information such as bad news, the use of jargon should be completely avoided, as well as medical terminology such as carcinoma, metastases, staging investigations. Statements should be clear and simple to understand in a language appropriate to the patient. It is also important to offer back-up to the verbal information in the form of written leaflets, pictures or audio tapes (Morton, 1996). Body language is also important (Box 1).

 

 

Picking up the pieces
‘Picking up the pieces’ is a common scenario for the vast majority of nurses involved with the bad news consultation. Often, the doctor will give some bad news, such as a cancer diagnosis or terminal prognosis, and will leave the patient/ relatives to absorb the news as the doctor continues with his or her work. It will be a natural reaction for the patient/relatives to be in a state of shock and disbelief following the news, even when they may have been prepared for it (Faulkner, 1988). In the majority of situations, time and space is necessary to allow the patient to absorb the information. Sitting quietly with the patient may be all that is necessary at this time. Later, there will be questions asked and different reactions may be evoked from the patient/relatives.

 

 

Patient’s possible reactions
These will vary from patient to patient. If employing the above skills and considerations, it will be easier to recognise certain emotions.

 

 

- Denial. This is used as a defence mechanism against difficult situations and can be healthy in the short term (Morton, 1996). Using words such as ‘warts’ or ‘tumour’ when discussing cancer can often aid a patient’s denial (Faulkner, 1998). It can lead the patient to believe that their problem, whatever it may be, is not life-threatening (Faulkner, 1998). The delay between denial and acceptance varies and space and time, as well as giving back-up information, is essential (Faulkner, 1998)

 

 

- Anger. This can take many forms. Anger can be directed at the patient’s self in the form of blame or guilt, or towards the health professional giving the news (Faulkner, 1998). The anger has to be acknowledged and allowed (Morton, 1996)

 

 

- Despair/depression. The patient should be encouraged to express feelings of despair (Morton, 1996). Time and adaptation to the situation usually helps to dispel these feelings (Faulkner, 1998).

 

 

- Awkward questions. Questions such as ‘Why me?’ or ‘How long have I got?’ may be asked. Sometimes questions are impossible to answer. Responses such as replying with an open question, offering an empathic response or remaining silent have been offered as suitable actions (Morton, 1996).

 

 

Collusion
Relatives often think they know what is best for their loved one and will ask the doctor not to tell the patient the diagnosis. This is done usually in an attempt to protect them. Collusion can be very damaging and reasons for the collusion should be explored. However, a health professional’s duty is to the patient first and foremost (Faulkner, 1998).

 

 

Conclusion
These are just some of the essential skills that are necessary when breaking bad news or taking part in the consultation. Survival strategies for the bearer of bad news also need to be considered. Competent and caring communication in a cancer diagnosis is an essential part of the patient’s trajectory along the cancer journey. If dealt with properly, it can aid the patient’s progress towards acceptance and realisation.

 

 

 

 

Bruera, E., Newmann, C.M., Mazzocato, C. et al. (2000)Attitudes and beliefs of palliative care physicians regarding communication with terminally ill cancer patients. Palliative Medicine 14: 287-298.

 

 

De Valck, C., Van de Woestijne, K.P. (1996)Communication problems on an oncology ward. Patient Education and Counselling 29: 131-136.

 

 

Dosanjh, S., Barnes, J., Bhandari, M. (2001)Barriers to breaking bad news among medical and surgical residents. Medical Education 35: 197-205.

 

 

Dunniece, U., Slevin, E. (2000)Nurses’ experience of being present with a patient receiving a diagnosis of cancer. Journal of Advanced Nursing 32: 3, 611-618.

 

 

Faulkner, A. (1998)ABC of palliative care: communication with patients, families and other professionals. British Medical Journal 316: 130-132.

 

 

Ford, S., Fallowfield, L., Lewis, S. (1996)Doctor-patient interactions in oncology. Social Science and Medicine 42: 11, 1511-1519.

 

 

Halldorsdottir, S., Hamrin, E. (1997)Caring and uncaring encounters within nursing and health care from the cancer patient’s perspective. Cancer Nursing 20: 2, 120-128.

 

 

Macdonald, B.H. (2001)Quality of life in cancer care: patients’ experiences and nurses’ contribution. European Journal of Oncology Nursing 5: 1, 32-41.

 

 

Morton, R. (1996)Breaking bad news to patients with cancer. Professional Nurse 11: 10, 669-671.

 

 

Osuna, E., Perez-Carceles, M.D., Esteban, M.A., Luna, A. (1998)The right to information for the terminally ill patient. Journal of Medical Ethics 24: 106-109.

 

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