Delivering Bad News

The goal of this CE offering is to provide nurses with current information about communicating bad news to patients that they can apply to their practice. After reading the article, you will be able to:

1. Identify key causes of communication problems between nurse and patient/family.

2. Summarize Buckman's six-step protocol for delivering bad news.

3. Recognize effective statements in delivering bad news.

With the exception of unrelieved pain, poor communication causes more suffering to patients and their families than any other problem.1 Therefore, communicating bad news is an essential skill for nurses.

Most times, an interdisciplinary healthcare team meets prior to the delivery of bad news to patients and families. The physician usually takes the responsibility of breaking bad news, but it is critical that the nurse is present so the nurse can clarify what is said as the discussion unfolds and so the nurse can hear, firsthand, the information that the patient and family receives. At this point, the nurse can continue to offer further support and explanations as questions arise throughout the course of care.

Patients and families depend on the expertise of the nursing staff to provide this information throughout the course of illness. With this team approach in place, there is a much smaller chance of mixed messages and misinformation.

However, there are times the nurse is not present at the delivery of the news and does not know exactly what was said. Therefore, it is important that the nurse know how to deliver bad news. Also, sometimes patients or family members were unable to hear what was said due to denial.

One definition identifies bad news as any news that drastically and negatively alters the patient's view of his or her future.2 Many nurses find it challenging to convey bad information, especially if it involves a life-threatening illness. But delivering bad news with compassion can support the patient emotionally and can strengthen the nurse/patient relationship.

Causes for Error

Medical jargon is a frequent barrier to adequate communication about the goals of care, diagnosis and prognosis. Differences in educational levels between the nurse and patients/families can also create comprehension problems, as can cultural differences. Therefore, it is crucial that information is provided in small, understandable amounts so that patients/families have time to assimilate the information shared.

For example, state, "The head scan shows a larger amount of blood in the brain," versus, "The head CT shows a large intercerebral hemorrhage." Also, frequent family meetings need to take place so that the accuracy of information is maintained between the family and the interdisciplinary team.

It has been estimated that approximately 80 percent of the communication occurs at the nonverbal level, making this aspect extremely important.3 For example, a nurse who avoids eye contact may communicate to the patient/family that she is discouraged about the patient's progress. Nurses need to get the support necessary to stay emotionally available and congruent to patients/families, or bring in other healthcare professionals to help with communication. By consulting pastoral care or patient relations, the nurse can receive support or offer these individuals as sources of support to the family. Too often, these individuals are pulled into the conversation when a crisis has already occurred.

Cultural Differences

Sometimes the need to "be polite," especially prevalent in Asian cultures, can prevent candid discussion about the goals of care. This approach often is an attempt to avoid conflict and offending others. This can create an illusion of harmony but may in fact be a cover for fear and/or frustration.

Nurses should make every effort to make sure patients/families understand the plan of care. You might say: "Sometimes in providing care we may misunderstand each other or mean different things about treatments and plans. Perhaps you could tell me what you believe the treatment is and then I can share my views so we know we understand each other."

When the patient and nurse do not speak the same language, more difficulties can arise when the nurse must communicate bad news. The assistance of experienced translators who understand medical terminology and are comfortable translating bad news is required. Avoid using family members as primary translators because it confuses their roles in the family unit and might raise issues of confidentiality. Additionally, family members may modify the news to the patient to protect them from the severity of the problem.

Prognosis and Miracles

Patients and their families frequently inquire about the prognosis. Patients who wish to plan their lives around their prognosis need information that is detailed. Others, who are terrified, may be better with answers that are more general. It is important to not give definitive answers because you run the risk of producing disappointment and anger if you are incorrect.

It may be most practical to indicate averages, such as hours to days or weeks to months, etc. It is also important to emphasize the limits of predictions by saying something like, "What this will mean for you I cannot tell. We need to hope for the best, while we plan for the worst. We will have a better sense over time how things will evolve specifically for you."

Family members may have concerns about "taking away hope" and therefore focus on over.emphasizing positive findings. This can lead to deception for the patient and an avoidance of the discussion of disease progression. It can also lead to missed opportunities for honest conversations among the family members.

Some patients and families will focus on miracles. It is best to suggest that they get their affairs in order so they won't be vulnerable if their miracle does not come true or an unexpected surprise happens. You could say something like, "Yes, I have seen miracles happen but in cases such as yours they are exceedingly rare."

Having family members share information among themselves becomes critical, so not all individuals are repeatedly asking the nurse the same questions. It has been found useful to maintain a log close to the patient that can be shared by all who provide care, including physicians. The log book often includes goals of care, treatment choices, what to do in an emergency, likes and dislikes, things to do and not do, and contact information for family and physicians.

Preparing for Palliative Care

Nurses must prepare for a particularly difficult conversation when it becomes apparent that the goals of care must shift from treatment to comfort care. This realization is a hard one for advanced disease patients and their families to accept.

As the nurse develops a care plan, it is important to anticipate the roadblocks that will occur because of patient and family dynamics, as well as the disease progression. Listen carefully to the needs, concerns and goals of the patient and family. Consult regularly with the physician and other health team members.

Whether it be the attending physician or the nurse, someone needs to step outside the usual path of continuing down the familiar and begin to gently and sensitively shift the discussions to palliative care. Therefore, the timing requires astute attention to the readiness of patients and families to consider such a change.

Because patient and family members can be at various stages of acceptance, the nurse will need to allow the expression of anger, fear, regret and grief. The patient and family have fears of being abandoned. Therefore, it is important to emphasize the continuing support and guidance that palliative care provides.4

The shift to palliative care usually requires several patient/family conferences, allowing all involved in the care to share their perspectives about the treatment plan. Reaching consensus requires diplomacy and respect for alternative points of view. It is important to find a common ground so the best possible plan can be achieved for all involved.

A Six-Step Protocol

The vast majority of Americans want to know if they have a life-threatening illness. Confusion over the goals of care, incomplete information, lack of access to information or inconsistent approaches can be interpreted by patients and families as a lack of respect. Delivering bad news in a direct and compassionate way can improve the patient's and family's ability to plan and cope, encourages realistic goals, and builds trust.

In his book, How to Break Bad News: A Guide for Health Care Professionals, Robert Buckman recommends a six-step protocol.5,6 The first three steps are preparatory in nature; the final two steps involve responding to the patient's reactions and planning for follow-up.

Step 1: Get the Setting Right

Create an environment conducive to effective communication by sitting down and alerting others to avoid interruptions. Confirm the medical facts of the case and ensure that you have information available. Ensure privacy and that a box of facial tissues is handy. For pediatric patients, have staff available to be with the child while the information is conveyed to the parents first. Determine if the patient would like other individuals present for the discussions.

Step 2: What the Patient Knows

Statements such as "What do you understand about your illness?" or "What did Dr. X tell you about your illness?" help determine the pa.tient's present knowledge. Clarify what the patient un.derstands about his medical history and recent tests/procedures.

Step 3: What the Patient Wants to Know

Before the discussion, the nurse should have determined if the patient is the type of person who likes to know a good deal about his treatment plan. Remember, a patient has a right to know, as well as a right not to know. Each person has a right to voluntarily decline to receive any information and designate someone else to be communicated to on his behalf.

Asking questions such as "If this condition turns out to be something serious, do you want to know?" or "Some people really do not want to be told what's wrong with them, but would rather have their family be told instead. What do you prefer?" If the patient prefers not to receive critical information, establish to whom information should be given.

Sometimes family members do not want to tell the patient the diagnosis or other important information. Rather than confronting their request, ask them why they don't want you to tell the patient, what it is that they are afraid you would say, or what their experience has been with bad news. You could also suggest that you go to talk with the patient together to ask how much he/she wants to know.

If parents do not want their child to be told about the illness, help them understand the effects of this on trust. It is a better plan to help the parents understand the child will feel distrustful as they experience treatments and procedures. Utilize child life specialists to help the parent and the medical team communicate im.portant information to the child at the age- appropriate level.

In particularly difficult cases, support from the institutional ethics committee may be helpful. Unless the patient has indicated that he wants no information, hiding any diagnosis or other important information about prognosis or treatment is neither ethical nor legally acceptable.

Step 4: Share the Information

Deliver the information in a sensitive but straightforward manner. Use simple language that is easy to understand, avoiding medical jargon. Pause to check for understanding. Do not minimize the severity of the situation. Well-intentioned efforts to "soften the blow" may lead to vagueness and confusion. You might choose to break the bad news by using any of the following.7

 "I'm afraid the news is not good. The biopsy showed that you have breast cancer."

 "I'm afraid I have bad news. The colonoscopy revealed that you have cancer in your colon."

 "I feel bad having to tell you this, but the growth turned out to be cancer."

 "I wish we had more effective treatment for your condition."

 "I wish I had some other kind of good news to give you."

Nurses often talk too much when they are nervous and uncomfortable. So remember to give a "warning shot" that prepares them such as "I do not have good news" and then deliver the message and stop to listen.

Step 5: Respond to Feelings

People respond to bad news in a variety of ways. Some respond with tears, others with anger and others with outbursts. Others recoil and may even intellectualize why the situation is happening. Some may even run from the room or totally withdraw into themselves.

Parents in particular may become very emotional when they are told their child has a bad prognosis. Even though the nurse may be uncomfortable, it is important to give the patient and family time to react. It is critical to listen attentively. Acknowledge their emotions. In responding to their expressions, you could use some of the following phrases.

 "I imagine this is very difficult news for you."

 "Tell me more about how you are feeling about what I just said."

 "Is there anyone you would like me to call to be with you right now or to talk to?"

 "I wish we had better treatments that could turn things around and allow your father to wake up."

 "This sounds like this is a terrible loss for you. I wish it hadn't turned out this way."

 "This is so hard for you - just when your hopes were so high for her to have this complication. I wish it had been otherwise."

Remind them their responses are normal. Con.sider touching the patient/family in an appropriate, reassuring manner. Offer a drink of water, a cup of tea or something else that might be soothing. Don't rush them. Offer the family private time alone. Once the emotion is "spent," most people will be able to move on.

If they demand more aggressive treatment when the prognosis is very poor, a statement might include: "It must be very hard to come to the intensive care unit every day and see so little change. I wish medicine had the power to turn things around."

Step 6: Planning and Follow-Up

Establish a plan for the next steps. This might include further tests. It might be setting up hospice or a consultation from pain management service. It may include having parents to tell a child about their illness and what treatment will be like for them. Discuss potential sources of emotional and practical support for the patient and the family.

Reassure the patient and family that you will be available to help them while they are in your care, as well as how to reach the physician to answer any additional questions. It is also important to ensure the family is safe when they leave the hospital. You may need to contact patient relations and arrange for a taxi to take them home.

Conclusion

The vast majority of Americans want to know if they have a life-threatening illness. Nurses need to overcome the barriers to effectively communicating at these difficult times.

By using Buckman's six-step protocol, the nurse can deliver bad news with compassion.

References

1. Kristjanson, L. (2001) Establishing goals: Communication traps and treatment lane changes. In B. Ferrell & N. Cole (Eds.), The textbook for palliative care (pp. 331-338). New York: Oxford University Press.

2. Quill, T. (2000). Initiating end-of-life discussions with seriously ill patients: Addressing the elephant in the room. JAMA, 284(19), 2502-2507.

3. Gotcher, J. (1997). Interpersonal communication and psychosocial adjustment. Journal of Psychosocial Oncology, 10(3), 21-39.

4. Institute of Medicine. (1997). Approaching death: Improving care at the end of life. Washington, DC: National Academy Press.

5. Buckman, R. (1992). How to break bad news: A guide for health care professionals. Baltimore: The Johns Hopkins University Press.

6. Larson, D.G., & Tobin, D.R. (2000). End-of-life conversations: Evolving practice and theory. JAMA, 284(12), 1573-1578.

7. Quill, T.E., Arnold, R.M., & Platt, F. (2001). "I wish things were different": Expressing wishes in response to loss, futility, and unrealistic hopes. Annals of Internal Medicine, 135(7), 551-555.

Vicki D. Lachman assists organizations and individuals to deal with end-of-life and organizational ethical issues. You may contact her at vdlachman@comcast.net. <% footer %>




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