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The development of best practice in breaking bad news to patients

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The Department of Health requires that patients’ spiritual and cultural needs are provided for (DoH, 2000a; 2000b; 1994). And there can be few tasks that a health care practitioner has to undertake that impact more upon patients and their relatives, than that of breaking bad news. The level of skill with which this task is carried out will often make a huge difference to the way that patients and their families come to terms with, and continue to handle, their situation.

Abstract

VOL: 100, ISSUE: 15, PAGE NO: 28

David Lomas, is chaplain and head of department, Department of Pastoral and Spiritual Care;

Jonathon Timmins, is chaplain;Brian Harley, is chaplain;Angela Mates, is chaplains’ aide; all at the pastoral care team, United Lincolnshire Hospitals NHS Trust

The Department of Health requires that patients’ spiritual and cultural needs are provided for (DoH, 2000a; 2000b; 1994). And there can be few tasks that a health care practitioner has to undertake that impact more upon patients and their relatives, than that of breaking bad news. The level of skill with which this task is carried out will often make a huge difference to the way that patients and their families come to terms with, and continue to handle, their situation. 

Within the United Lincolnshire Hospitals NHS Trust, a working group comprising nurses, a clinician, patients, relatives, patients’ representatives, a chaplain and other health care professionals, was established to produce a document giving guidelines for best practice in breaking bad news. A document was designed as a tool to improve the way in which this important task is carried out. These guidelines are placed on every ward and patient-focused area, making the information readily and widely available for those who need to use it.

There are a number of factors that should be considered when breaking bad news:

- The people involved;

- The communication process;

- The environment.

These factors can be examined under four stages, which progress from stage 1 ‘inappropriate’ through to stage 4 ‘best practice’. We believe that this approach can help to promote best practice.

The people involved

An important factor in the passing on of bad news to patients and/or relatives is identifying who is responsible for giving the news. Within the hospital setting the lead person is often seen as the consultant. However, it is important that there is a clear consensus between health care professionals about what the patient will be told before she or he is informed.

In addition to agreeing who is the most appropriate health care professional to be present when the bad news is given, best practice should consider who is the best person to accompany the patient (Table 1). The importance of training in breaking bad news should be considered and both provision for expert training and a period in a supervised position of breaking bad news are recommended (Von Gunten et al, 2000). In addition the patient should know the person giving the news. Where this is not possible, proper introductions must be given before the news is broken. 

It is important to give the patient who is receiving bad news an opportunity to bring along another person such as a relative to offer support. In addition an independent person who can offer support and guidance, such as a chaplain or social worker, should be available if the patient wishes. 

The communication process

In good practice, the news giver initially takes steps to establish what the patient already knows and understands before any information is given. In addition, she or he will assess what information the patient wants to know, including whether the patient wants to know the bad news at that time (Von Gunten et al, 2000).

Once the patient has indicated that she or he is prepared to hear the news, the person giving the information should proceed, avoiding jargon and ensuring that everyday clear language is used, for example saying ‘cancer’ instead of ‘growth’ or ‘malignancy’.

Before the session ends, the news giver will need to make an evaluation of how well the information has been understood. News giving should be seen as a process and repeated as appropriate. The person receiving the news should be given the message that she or he is welcome to come back and seek further information and/or clarification.

It is generally considered that bad news should be given at the earliest appropriate opportunity. However, it is important to recognise that sometimes there are situations where there is pressure from families to withhold information from the patient. Wherever possible, best practice is to give the information to the person to whom it directly relates.

It is important that all those involved are given consistent and appropriate factual information. And the patient should be informed of her or his treatment options and the right to seek a second opinion. When verbal information is given it should be supported with written information (including standard leaflets) that is tailored, wherever possible, to the patient’s and the family’s needs (Table 2). When breaking bad news, it may be useful to remember the seven steps to good communication (Von Gunten et al, 2000):

- Prepare for the discussion;

- Establish what the patient and family know;

- Determine how information is to be handled;

- Deliver the information;

- Respond to emotions;

- Establish goals for care and treatment priorities;

- Establish a plan.

The environment

Careful consideration should be given to where the news is given (Table 3). Best practice is to use a private non-clinical area - for example a room with comfortable seating. Privacy should be maintained so there should be no disturbances, such as bleeps or telephones. Time should be given for the patient and relatives to use the private area after the news has been given.

Some environments are inappropriate for giving bad news, for example in a public setting such as a hospital corridor. Those giving bad news should also carefully consider the appropriateness of using other environments that compromise privacy, such as:

- Pulling curtains around beds where these are used to give minimal privacy;

- Semi-private areas, for example, a dayroom of a ward. Where news is given in a setting where there may be some people who are not involved;

- An area where there may be interruptions, such as a shared office.

Conclusion

The way bad news is given to patients has a significant impact on patients and needs to be done by a skilled practitioner with careful consideration to who is involved, how news is communicated, and the environment in which that communication takes place. 

It is recognised that it may not always be possible to achieve best practice but by using the guidelines practitioners can improve their own practice and that of the clinical team in which they work.

Further reading

Collick, E. (1986)Through Grief: The Bereavement Journey. London: Darton, Longman and Todd Ltd.

Cooke, H. (2000)When Someone Dies. Oxford: Butterworth-Heinemann. 

Sheldon, F. (1997)Psychosocial Palliative Care. Cheltenham: Stanley Thornes (Publishers) Ltd.

Worden, J.W. (1991)Grief Counselling and Grief Therapy. London: Routledge.

 

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