INTRODUCTION
The most commonly used definition of bad news pertaining to medical settings is, “any information, which adversely and seriously affects an individual’s view of his or her future.”[1] Some of the common examples of bad news in medical settings include—A person is informed that he has tested positive for HIV, the wife is informed that her husband has been diagnosed with Alzheimer’s dementia, a patient is told that his lump has been diagnosed as cancer. Thus, bad news is a message which has a negative connotation and has the capability to alter the recipient’s hope, mental well-being, and upset his lifestyle.
EPIDEMIOLOGY
Gautam and Nijhawan[2] carried out a prospective study on 100 cancer points in India to find out if the diagnosis of cancer needs to be communicated to patients and their caregivers. They found out that most of the patients who knew about their condition (71%) wanted to be told the truth. The picture was similar in case of relatives who wanted that they should be told the diagnosis (81%) but their patients should not be disclosed the same (77%). In a study conducted among faculty and residents of Guilan University of Medical Sciences in Iran, only 13.6% of the participants were found to be trained in delivering bad news.[3] In another study carried out on 226 patients with cancer in Poland, it was found that the diagnosis was told to most of them as per steps laid down in the SPIKES protocol of breaking bad news.[4]
IMPLICATIONS OF BREAKING BAD NEWS
Breaking bad news is an art wherein the physician has to strike a fine balance between truth and hope and handle the emotional outcomes of the news on the recipients as well. There are ethical and medicolegal implications of breaking bad news which means that withholding vital information in terms of diagnosis and prognosis from the patient on the presumption that he will not be able to “handle” it may not always be justified in terms of the patient’s autonomy and “right to know.” Similarly, insensible pouring out of bad news with disregard for its emotional consequences on the patient may not be good for the mental health of the patient and the therapeutic relationship between the patient and the doctor. The technique employed in breaking bad news can influence to what extent they understand the information, to what extent they are satisfied with the care, and over and above all, to what extent they can adjust psychologically to the bad news.[5]
WHAT ARE THE BARRIERS TO BREAKING BAD NEWS?
Breaking bad news can take a heavy emotional toll on the doctor, he often feels burdened by negative news and anticipates negative reactions. The common barriers to breaking bad news are presented in Table 1:[6]
Table 1.
Common barriers to breaking bad news[6]
| 1. The doctor is not sure about what the patient is expecting |
| 2. The doctor fears that he may be destroying the hope of the patient. |
| 3. The doctor may fear that he himself may not be adequately capable of dealing with an uncontrollable disease. |
| 4. The doctor may fear that he is incapable of managing the emotional reactions resulting from breaking the news |
| 5. The doctor might have presented an overoptimistic picture of the patient’s condition in the past and this may be causing embarrassment in the current situation where he needs to break the bad news |
WHAT ARE THE GOALS OF BREAKING BAD NEWS?[7,8]
The basic goals of breaking bad news are summarized in Table 2.
Table 2.
Goals of breaking bad news
| 1. To collect information from the patient in order to develop an idea regarding the patient’s existing level of knowledge about the condition and what are his expectations |
| 2. To convey information with clarity keeping in mind what the patient needs and what he wants. |
| 3. Another important goal of the treating team is to provide proper psychological support and assistance to face the aftermath of the bad news |
| 4. Minimize loneliness and isolation (reassure about non-abandonment) |
| 5. To develop a treatment plan and long-term strategy in collaboration with the patient |
WHO SHOULD BREAK BAD NEWS?
The head of the unit or a senior consultant who is known to the patient and family members should deliver the bad news. A senior member of the nursing staff may need to be called to break the bad news in certain emergencies where the treating consultants may be absent.
Dos and Don’ts for breaking bad news are summarized in Table 3.[9]
Table 3.
Dos and don’ts for breaking bad news
| Dos for Breaking Bad News |
| Allow for silence as well as emotional reactions |
| Give time |
| Be sensitive to the nonverbal language |
| Document and liaise with the multidisciplinary team |
| Use simple language and honest communication |
| Ensure privacy and confidentiality |
| Listen to what the patient says |
| Don’ts for Breaking Bad News |
| Assuming that you know what concerns the patient |
| Make judgmental comments |
| Distort the truth |
| Keep talking all the time |
| Give false reassurance |
| Overload with information |
| Withhold information |
VARIOUS PROTOCOLS FOR BREAKING BAD NEWS
Over the years, various clinicians have developed separate protocols for delivering bad news. The SPIKES protocol[8] is the oldest and most commonly used worldwide [Table 4]. Subsequently, clinicians have modified this protocol to add certain steps which they felt were essential. For example, in 2005, a modified version, P-SPIKES was published,[10] where “P” stands for “Preparation” which includes reviewing all information about the patient that needs to be communicated and rehearsing them if necessary. Another criticism of this protocol is that it does not have a step on patient questions and clarifications. Another recent modification, SPwICES[11] includes “w” which deals specifically with “warning shot” and “ICE” which involves juggling with providing information, clarifying, and dealing with emotions. Other popular protocols include the ABCDE protocol [Table 5],[7] Kaye’s 10-step model[12] [Table 6], and BREAKS protocol [Table 7].[13] All these protocols have traditionally been devised by oncologists. Hence, in subsequent years, other specialists, including surgeons and emergency physicians, have come up with their own modified protocols. The PEWTER protocol [Table 8][14] has been devised for emergency physicians. Similarly, the SUNBURN protocol [Table 9][15] has been developed to suit the purpose of trauma and acute care surgeons. A simple step-by-step method is outlined in Table 10 which incorporates the essential elements of breaking bad news and has been incorporated more or less in every established protocol on breaking bad news. This method is simple and can be easily adopted by all clinicians. Otherwise, any of SPIKES, ABCDE, Kaye’s model, or BRAKES protocol may be used.
Table 4.
The SPIKES protocol[8]
| Setting up the interview- |
| • Arrange for some privacy |
| • Involve significant others as per the patient’s choice |
| • Sit down |
| • Make connection with the patient: maintain eye contact and/or touch the patient (if he/she is comfortable with you doing so) |
| • Manage time constraints and interruptions |
| Assess the patient’s perception |
| • Determine what the patient knows about the medical condition or what he (she) suspects |
| • Listen to the patient’s level of comprehension |
| • Determine if the patient is engaging in illness denial |
| Obtain the patient’s invitation |
| • Ask the patient if he (she) wishes to know the details of the medical condition and/or treatment • Accept the patient’s right not to know |
| • Offer to answer questions later if he (she) wishes |
| Give knowledge and information |
| • Warn the patient that bad news is coming; this may lessen the shock that can follow the disclosure of bad news |
| • Start at the patient’s level of comprehension and vocabulary |
| • Use non-technical words |
| • Avoid excessive bluntness |
| • Give information in small chunks, and periodically check the patient’s understanding |
| • Avoid using phrases such as “There is nothing more we can do for you” |
| Address the patient’s emotions with empathic responses |
| • Observe for any emotion on the part of the patient |
| • Identify the emotion experienced by the patient by naming it to oneself |
| • Identify the reason for the emotion |
| • Let the patient know you have connected the emotion with the reason for the emotion by making a connecting statement |
| Strategy and Summary • Summarize the information you have provided. If the patient is ready, discuss the treatment plan |
| • Sharing responsibility for decision making |
| • Check patient’s understanding/misunderstanding of the discussion |
Table 5.
The ABCDE protocol[7]
| Advance preparation |
| Ask what the patient already knows and understands. |
| What is his or her coping style? |
| Arrange for the presence of a support person and the appropriate family |
| Arrange a time and place that will be undisturbed (hand off beeper) |
| Prepare emotionally |
| Decide which words and phrases to use (write down a script) |
| Practice delivering the news |
| Build a therapeutic environment/relationship |
| Arrange a private, quiet place without interruptions |
| Provide adequate seating for all |
| Sit close enough to touch if appropriate |
| Reassure about pain, suffering, abandonment |
| Communicate well |
| Be direct (“I am sorry, have bad news”) |
| Do not use euphemisms, jargon, or acronyms Say “cancer” or “death” |
| Allow for silence |
| Use touch appropriately |
| Ask the patient to repeat his or her understanding of the news |
| Arrange additional meetings |
| Use repetition and written explanations or reminders |
| Deal with patient and family reactions |
| Assess patient reaction |
| * physiologic responses: flight/fight, conservation/withdrawal |
| * cognitive coping strategies: denial, blame, intellectualization, disbelief, acceptance |
| * affective responses: anger/rage, fear/terror, anxiety, helplessness, hopelessness, shame, relief, guilt, sadness, anticipatory grief Listen actively, explore feelings, express empathy |
| Encourage and validate emotions (reflect back emotions) |
| Correct distortions Offer to tell others on behalf of the patient |
| Evaluate the effects of the news |
| Explore what the news means to the patient |
| Address further needs, determine the patient’s immediate and near-term |
| plans, assess suicidality Make appropriate referrals for more support Provide written materials |
| Arrange follow-up |
| Process your own feelings |
Table 6.
Kaye’s 10 step model[12]
| 1. Prepare |
| • Know all the facts |
| • Ensure privacy |
| • Find out whom the patient would like present |
| • Introduce yourself |
| 2. Determine what the patient knows |
| • Start with open-ended questions (e.g., “How did it all start?”) |
| 3. Determine if more information is wanted |
| • Do not force information on to the patient (e.g., “Would you like me to explain a bit more?”) |
| 4. Give warning shots |
| • Not straight out with it! (i.e., “I’m afraid it looks rather serious”) |
| 5. Allow patient to refuse information at that time |
| • Denial is a defense mechanism and a way of coping |
| • Allow the patient to control the amount of information he (she) receives |
| 6. Explain if requested |
| • Go step by step |
| • Details might not be remembered, but the way you explain them will be |
| 7. Listen to concerns |
| • Ask “What are your concerns at the moment?” |
| • Allow time and space for answers |
| 8. Encourage feelings |
| • Acknowledge the feelings |
| • Be non-judgmental |
| 9. Summarize |
| • Review concerns, plans for treatment |
| • Foster hope |
| • Offer written information if asked |
| 10. Follow-up |
| • Offer further information |
| • Assure patient of your continued availability |
Table 7.
BREAKS protocol[13]
| Background |
| An in-depth study on the patient’s disease status, emotional status, coping skills, educational level, and support system is done before attempting to break the bad news |
| Rapport |
| Building rapport is essential. Physician should have unconditional positive regard. Present conditions should be probed through open-ended questions. |
| Explore |
| It is always preferable for the physician to start with what the patient knows about his/her illness |
| Announce |
| A warning shot is desirable |
| Give the information in short, comprehensible sentences |
| It is always desirable not to give more than three pieces of information at one go |
| Kindling |
| Allow adequate space for the free flow of emotions Ensure that the patient/relatives did not misunderstand the gravity of the disease |
| Summarize |
| Physician has to summarize the session and discuss the treatment plan |
Table 8.
PEWTER model[14]
| P: Preparing the one giving the news through education and training, and |
| preparing the setting and the approach for giving the news |
| E: Evaluating what the listener already knows |
| W: Warning by making a brief statement followed by a moment of silence to prepare the listener for the bad news that comes next |
| T: Telling the news |
| E: Emotional response: paying attention to and responding appropriately to the listener’s emotional responses |
| R: Regrouping by helping the listener move forward with the next steps |
Table 9.
SUNBURN protocol[15]
| S–Setup |
| U–Understand perceptions |
| N–Notify (‘Warning Shot’) |
| B–Brief narrative and break bad news |
| U–Understand emotions |
| R–Respond |
| N–Next steps |
Table 10.
Simple step-by-step protocol for communicating bad news[16]
| 1. Prepare for the encounter |
| • If possible, have an advance discussion with the patient about who will be present |
| • Find a location with adequate privacy |
| • Arrange an adequate time for discussion |
| • Review the clinical information |
| 2. Assess the patient’s understanding |
| • Ask the patient about his or her view of the situation |
| • Find out how much that patient wants to |
| 3. Disclose the news |
| • Consider giving a “warning shot” |
| • Provide information honestly and in simple language |
| • Tailor amount of medical details and technical language in accordance with the patient’s wishes |
| 4. Respond to the patient’s emotions |
| • Encourage the patient to express his or her emotions |
| • Acknowledge the patient’s emotions and empathize with concerns at this point |
| • Tolerate silence |
| 5. Offer to discuss the implications of the news, including |
| • Prognosis |
| • Treatment options |
| • Effect on quality of life |
| 6. Offer additional resources, including: |
| • Assistance talking to others |
| • Other support services |
| 7. Summarize the discussion |
| • Restate important points |
| • Ask if there are any other questions |
| 8. Arrange a follow-up time for patient and family questions and concerns |
| 9. Document the discussion in the medical record |
DOCUMENTATION
Documentation is very essential in breaking bad news—the detailed conversation, what was the information that was exchanged between the two parties, all these may be noted down properly. Detailed notes may be maintained in the patient’s files. The most important points to be kept in mind during documentation include the diagnosis, various options that were discussed regarding future management, and the exact words and expressions that were used while breaking the bad news. Maintaining accurate records will help in communicating with the treating team and facilitate proper follow-up care of the patient.
BREAKING BAD NEWS OVER TELEPHONE[17]
While it is generally advised to break bad news through face-to-face interactions, the exceptional challenge posed by the pandemic forced all nations to make newer adjustments, including breaking bad news over the telephone. Things to be kept in mind during a phone call:
TONE & PITCH
Ensure your tone captures the seriousness of what you are telling the patient
Note the patient’s tone and pitch as that may indicate how the patient is feeling.
LANGUAGE
Use “we” or “the team” as opposed to “I,” to help them to feel like the family member is managed by a team.
Keep it simple and use clear, direct language. If the patient is emotionally overwhelmed, he will not be able to process complex information.
UNDERSTANDING
One must find out to what extent the patient and his/her caregiver have understood the information conveyed by the team
The patient/carers must get adequate opportunities to ask questions and clarify doubts
Before delivering the news over the phone, the doctor must find out where is the person at the time of receiving the call. He must find out whether the person is in a position to take up an uninterrupted conversation. It is also important to find out whether there is anyone around for emotional support. One must have an empathetic tone of voice during conversation. Pauses and silence in the conversation has to be used effectively
Socio-demographic background of the patient/caregivers must be kept in mind while delivering bad news.
ROLE OF PSYCHIATRISTS IN BREAKING BAD NEWS
Many physicians consider that psychiatrists are best suited for breaking bad news since they are better at handling emotions as well as more effective in communication skills. The role of a psychiatrist becomes much more important in a consultation-liaison setup in this respect. Breaking bad news can be encountered by psychiatrists themselves while disclosing the diagnosis and prognosis of disorders like dementia, intellectual disability, and an autistic spectrum disorder. There are many similarities between medical and psychiatric settings in terms of breaking bad news [Table 11]. However, certain issues may create roadblocks like the patient’s understanding of the information being conveyed which may be affected by existing psychopathology or cognitive deficits and the long-term consequences of the stigma associated with mental illness. Psychiatrists should play a leading role in teaching communication skills and skills in breaking bad news to their fellow colleagues in other disciplines.
Table 11.
Similarities in breaking bad news in medical and psychiatric settings[18]
| The patient has the right to know about his condition |
| The information should be shared in a setting that has adequate privacy. |
| The primary treating team should take responsibility for breaking bad news |
| The treating team must determine to what extent the patient/caregivers know about the condition |
| The treating team must provide psychological support following emotional reactions to the news |
| The information must be provided in short chunks, and understanding on the part of patients/caregivers must be checked |
| The treating team/doctor must ask whether the patient/caregiver wishes to know more |
| Finally, further steps and future plans need to be discussed |
BREAKING BAD NEWS IN PSYCHIATRIC CONDITIONS
Diagnostic disclosure has been a problem area in various psychiatric disorders, especially psychoses. Studies conducted toward the end of the last century reported low rates of disclosure of diagnosis for both schizophrenia and other psychiatric conditions (30–65%). In contrast, studies conducted in the last two decades reported higher rates of disclosure of psychiatric diagnoses for various psychiatric disorders (77–88%). In western studies, however, the diagnosis was discussed to a much lesser extent if the patient belonged to the immigrant community (22%). The most important factor determining diagnostic disclosure is the nature of the diagnosis—schizophrenia was disclosed much less often (7–59%) in comparison to other diagnoses like depression (71–98%), bipolar disorder (61–96%), or anxiety-related disorders (58–96%).[19] Schizophrenia was frequently replaced by alternative terminology like “psychosis,” “severe mental illness,” and “chemical imbalance.” Findings from most of the studies have revealed that discussing the mental health condition led to better outcomes in terms of satisfaction among patients and caregivers; the negative effect of stigma has been reported in some studies. Overall, the evidence has been overwhelmingly in favor of disclosure.
BREAKING BAD NEWS TO PATIENTS WITH PSYCHIATRIC CONDITIONS: A PROPOSED MODEL
Certain psychiatric diagnoses, particularly schizophrenia, involve many complex issues while conveying the diagnosis to the patient and significant others. The patients lack insight and cognitive capacity, especially during the initial phase of the illness, which may interfere with their ability to understand the diagnosis and long-term treatment implications. The stigma associated with psychiatric diagnoses, especially schizophrenia, is another issue that often deters clinicians from discussing the diagnosis with the patients and caregivers. Keeping in mind all these complexities, psychiatrists have a tendency to withhold information related to diagnosis. One study examining the implementation of the SPIKES protocol in breaking bad news to patients with schizophrenia[20] found that rates of implementation of this protocol were very low among psychiatrists despite studies, showing that psychiatric patients want to know and should be informed about the diagnosis. The authors concluded that the SPIKES protocol is applicable for breaking bad news to patients with schizophrenia though the role of the family while breaking the news and during shared decision making was emphasized.[20] Researchers have reviewed the available literature and concluded that the SPIKES protocol may be applied for delivering the diagnosis of schizophrenia although certain modifications were necessary, especially regarding the inclusion of family members, demystifying the diagnosis and treatment process through proper psychoeducation and instilling hope, and most importantly, addressing stigma.[21] Another model has been proposed by Levin et al.[22] for delivering the diagnosis of schizophrenia to patients and caregivers [Table 12]. We propose a protocol suitable for breaking bad news to patients and their significant others regarding psychiatric diagnoses of all types, including severe mental illnesses like schizophrenia, bipolar disorder, severe depression with psychotic symptoms, catatonic syndrome as well as neurodevelopmental disorders like attention-deficit hyperactivity disorder, intellectual developmental disorder, and autistic spectrum disorder [Table 13]. The model is derived from all essential elements that are common to various protocols for breaking bad news. Since families are an essential part of breaking bad news in the context of psychiatric diagnoses, the involvement and role of family members and significant others have been specifically emphasized in a separate step. Our model has also incorporated patient and caregiver perspectives that have emerged from the available research on delivering information related to psychiatric diagnosis. This includes open sharing of information, instilling realistic hope of future recovery, stigma reduction, recognizing the changing nature of the diagnosis, and providing adequate psychoeducation. The steps can be easily remembered by the acronym—ASKS WIVES.
Table 12.
A practitioner’s model for communicating a diagnosis of schizophrenia[22]
| Prepare for the meeting |
| Review the patient’s and family member’s understanding of the mental illness Negotiate the agenda in a collaborative manner with patient and guardians Discuss the prognosis including the best and worst possible outcomes. |
| Explain the meaning of the term “schizophrenia” |
| Empathic communication with patients and families |
| Discuss the follow-up plan |
Table 13.
The proposed model for breaking bad news to patients with psychiatric diagnoses (ASKS WIVES)
| 1. Adequate preparation—Make sure that adequate information has been gathered to reach a provisional diagnosis at least. Involve family members and significant caregivers at this stage in cases of severe mental illness, neurodevelopmental disorders |
| 2. Setting of the interview with adequate privacy—It is desirable to avoid discussing diagnostic information in a busy outpatient setup in the presence of other, unrelated individuals. Ensuring adequate privacy and confidentiality is of utmost importance |
| 3. Assess the level of Knowledge and understanding—Reviewing the existing knowledge and understanding is necessary before delivering information. This is the right opportunity to clear myths and misconceptions |
| 4. Involve Significant others and assess their background knowledge too—If the patient has adequate mental capacity, his opinion should be sought regarding which family member/caregiver should be involved |
| 5. Warning shot—Rather than abruptly breaking the news, it should be preceded by a warning that serious information is about to be divulged. A brief period of silence may be helpful |
| 6. Information regarding the illness—Apart from sharing all relevant information about a diagnosis, this is the right opportunity to provide psychoeducation. Sharing information should include instilling hope in a realistic manner. |
| 7. Encourage ventilation of emotions and deal with emotional reactions—This is the stage to provide empathy and reduce stigma |
| 8. Explain all possible implications as per queries in detail—Use this opportunity to clear myths and misconceptions; also provide details of available supports and networks which can be accessed |
| 9. Summarize the discussion, arrange a follow-up meeting, and document everything |
HOW TO APPLY THE MODEL IN VARIOUS SITUATIONS
In our proposed model, involving significant others has been mentioned in Step 4. However, in certain situations like acute schizophrenia, mania, severe psychotic depression, catatonia, or advanced stages of dementia, it may not be possible to convey the information to the patient. In such cases, the involvement of significant others should begin from step 1 and proceed accordingly. The choice of significant others would also not depend on the patient’s consent but on the judgment of the treating team. These conditions apply to situations where the judgment of the patient is severely impaired as laid down in the Madrid Declaration.[23]
The timing of disclosure of diagnosis is an important consideration. In the acute stage of a severe mental illness, the patient may not be in a position to understand or discuss the diagnosis or treatment issues. In the preliminary stages, the diagnosis is often provisional in nature and may change over time. Both these factors should be kept in mind when planning to communicate with patients or caregivers at the initial stages. The caregivers may be involved in the initial stages and discussion may include the provisional nature of the diagnosis with a mention that it may change over a period of time. As the team reaches a confirmed diagnosis over a period of time, the team may sit down with the caregivers as well as the patient who may have settled down by that time.[24] In the case of Alzheimer’s disease, there is general consensus about disclosure. However, one has to determine when and how to disclose. The general consensus is on disclosing to the patient in the presence of family members/caregivers. This disclosure should be done as early as possible after a diagnosis has been established. Apart from diagnosis, the disclosure should involve available support, care, and long-term planning. The physician should give accurate and reliable information, using simple language. It should also be clearly explained that a properly planned and organized family network can reduce the burden on the primary caregiver and maintain quality of life as far as possible.[25] There are certain situations where the diagnosis may not be disclosed (may be temporarily) to the patient: (1) severe dementia where the patient is not likely to be able to understand the diagnosis, (2) when there is a phobia about the condition, or (3) when the patient is severely depressed.[23]
There is no specific recommendation regarding how or whether to convey a diagnosis of mild cognitive impairment or probable dementia. On the one hand, there is a concern for patient autonomy, and his right to know and take necessary interventions. On the other hand, a full disclosure of such a state where there is a lack of certainty regarding progression to dementia may lead to serious psychiatric issues including suicidality. In such cases, the psychiatrist may use his own judgment keeping “therapeutic privilege” in mind.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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