Communication Along the Disease Trajectory
Strategies for Breaking Bad News
When existential concerns are translated to the clinical setting, the optimal method of breaking bad news becomes a primary concern. Breaking bad news abruptly has been found to increase its negative impact. Patients also report particularly negative reactions as a result of the following circumstances:
- News delivered over the telephone or in the recovery room.
- Doctors withholding information.
- Clinicians' failure to provide information about the availability of additional help.
- Information given bluntly and factually (e.g., "You have a terminal cancer and you have 6 months to live").
Patients also report that letters and tapes of the bad news consultation are helpful and may increase their level of satisfaction with and retention of the information provided.
One survey found that most physicians do not have a consistent plan or strategy for breaking bad news to their patients. Among a sample of physicians who attended an annual meeting of the American Society of Clinical Oncology, 22% reported that they did not have a consistent approach to the task of breaking bad news to patients, and 51.9% reported that they had several techniques or tactics but did not have an overall plan. Determining what patients believe to be important in the interaction may help refine the current guidelines and yield specific, evidence-based recommendations for facing this challenging task.
Some general guidelines and recommendations for how bad news interviews should be conducted have been published.[4,19,41,42,43] However, these recommendations have usually taken the form of practical advice formulated on the basis of anecdotal experiences or opinions with little empirical foundation. For example, in one review of more than 300 articles from the published literature between 1973 and 1993, only 23.2% of authors reported descriptive data on breaking bad news, and almost two thirds were opinions, reviews, letters, case reports, or non–data-based descriptive studies. Although there are some subtle differences between approaches recommended for giving bad news, there are also many common elements. For example, each of the strategies referenced above recommends giving the news in an appropriate setting (quiet place, with uninterrupted time), assessing the patient's understanding of their illness, providing the information the patient wants, allowing the patient to express emotions and responding appropriately, summarizing the information provided, and coming up with a plan for the next step(s). Additional research is needed to empirically support these techniques.