Presented by

Dr. Mohamud A. Verjee

A Conversational dilemma - reflections on how to break bad news

Mohamud Verjee

Weill Cornell Medicine - Qatar

mov2002@qatar-med.cornell.edu

The following contribution is an analytical summary of the efficacy of various Breaking Bad News techniques based on a literature review and the author’s 30-year practical experience in teaching and practicing clinical communication skills as a Physician and employing tools such as “SPIKES,” and “ABCDE.” This task is as difficult for the giver as well as the recipient. Nurses, physicians, relatives, and friends are all involved in delivering unpleasant news. Professional training and raising awareness of patient perceptions are essential and well established for empathy and gentleness. The settings, whether at home, an office, or at a bedside, need sensitivity for delivery. Preparing to say something that may be life-changing for the recipient requires the caregiver to think about impact and the immediate response. Having a clear idea of what to share is critical, as well as body language and tone of voice. Whether an accident, significant diagnosis, progressive or terminal illness, one needs to adapt to the receiver’s cues. We await an invitation to proceed. Informing adults differs from relating a story to a child or adolescent. Each need “emotional time” to accept the news. Consider privacy, comfort, and being undisturbed as significant factors. Choosing the right time is as vital as taking the time and not appearing hurried. Face-to-face contact is best, and occasionally, a warning telephone call has already happened – an unscheduled call back to a clinic, or from a hospital A & E Department. Support for the patient at the time is integral by a spouse, family member, or friend. Signaling impending and unpleasant conversation is helped by a transitional statement. After delivery, periods of silence while maintaining engagement by eye contact, provide space for reflection and support. Any communication needs to be sincere and empathetic. Knowledge of any illness or adverse event, requires eliciting with tact, together with the truthful sharing of information. Identifying and managing patients’ emotions are paramount skills. The initial shock, possible denial, tearfulness, and depression, can soon give way to acceptance, comprehending reality, energetic motivation, occasionally with a touch of humor, which breaks the solemnity. Encouragement with treatment decisions is also supportive, especially when patients feel a sense of hopelessness. It is valuable to check a person’s understanding after assessing how much and how ready they are. Their tentative goals should be appraised, along with professional input. All consultations need rapport for sound professional care to achieve the best chances of success. Answering questions truthfully avoids speculation. Every patient has an intrinsic situation to consider after hearing unwanted news when suitable arrangements are made for follow up. Then there is a more implicit comprehension of a “contract for the future,” with the patient’s best interests at heart. Concluding with a summary and inviting questions is a common practice. An overwhelmed patient may not appreciate everything related. Words of comfort are welcome, and trust built from the outset. This whole conversation should be unhurried.