Delivering Bad News – Part 2
Fast Fact Number: 11
By: Bruce Ambuel PhD, David E Weissman MD
Published On: June 3, 2024
Case Scenario: You are caring for a previously healthy 52-year-old man with a one-month of abdominal pain and weight loss. On exam he had a 2 cm hard left supraclavicular lymph node. A CT scan showed a focal mass with ulceration in the body of the stomach and numerous densities in the liver compatible with liver metastases. The radiologist feels that the findings are consistent with metastatic stomach cancer. How do you discuss these test results with the patient?
Steps in Delivering Bad News. See Fast Fact #6 for details on preparation and self-reflection when delivering bad clinical news. Of note: multiple models and mnemonics exist for delivering bad news such as SPIKES and REMAP which can be employed for teaching a standardized approach for learners who may not prefer a step-based model. General points to keep in mind are to speak slow, deliberately, and clearly; provide information in small chunks; check reception of information delivered frequently. It is important to present information at the patient/surrogate’s pace and not overwhelm with detail.
- Determine what the patient & family knows; make no assumptions. Examples: What is your understanding of your present condition? What have the doctors told you?
- Before presenting bad news, consider providing a brief overview of the patient’s course so that everyone has a common source of information.
- Give fair warning – I am afraid I have some bad news – then pause for a moment.
- Present bad news in a succinct and direct manner. For example, “The CT scan showed masses in the stomach and liver which are very worrisome for cancer.” Be prepared to repeat information and present additional information in response to patient and family needs.
- Sit quietly. Allow the news to sink in. Wait for the patient to respond.
- Listen carefully and acknowledge patient’s and family’s emotions, for example by reflecting both the meaning and emotion of their response.
- Normalize and validate emotional responses: for example, feeling numb, angry, sad, and fearful. See Fast Fact #29 and Fast Fact #59 for more guidance in how to respond to emotions.
- Give an early opportunity for questions, comments. This discussion is like peeling an onion. Provide an initial overview; assess understanding; answer questions; provide the next level of detail or repeat more general information depending upon the patient and family’s needs.
- Assess thoughts of self-harm if appropriate.
- Agree on a specific follow-up plan (I will return later today, write down any questions.). Make sure this plan meets the patient’s needs. Involve other team members in follow-up.
Resources
- Buckman R. How to break bad news: A guide for health care professionals. Baltimore, Johns Hopkins University Press: 1992.
- Faulkner A. Breaking bad news – a flow diagram. Palliative Medicine. 1994: 8;145-151.
- Iverson, VK. Pocket protocols—Notifying survivors about sudden, unexpected deaths. Tuscon, Arizona, Galen Press: 1999.
- Ptacek, JT, Eberhardt, TL. Breaking bad news: A review of the literature. JAMA. 1996; 276(6): 496-502.
- Quill TE. Bad news: delivery, dialogue and dilemmas. Arch Intern Med. 1991; 151:463-468.
- Girgis A, Sanson-Fischer RW. Breaking bad news: consensus guidelines for medical practitioners. J Clin Onc. 1995; 13:2449-2456.
- Von Gunten CF, Ferris FD and Emanuel LL. Ensuring competency in end-of-life care: Communication and Relational Skills. JAMA. 2000; 284:3051-3057.
- Mahendiran M, Yeung H, Rossi S, et al. Evaluating the effectiveness of the spikes model to break bad news – a systematic review. American Journal of Hospice and Palliative Medicine®. 2023;40(11):1231-1260.
Version History: 2nd Edition published September 2005. 3rd Edition May 2015; 4th Edition in June 2024 after being reviewed and updated by Laura Johns MD.
Conflicts of Interest: None to report.
Fast Facts and Concepts are edited by Sean Marks MD (Medical College of Wisconsin) and associate editor Drew A Rosielle MD (University of Minnesota Medical School) with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW). The authors of each individual Fast Fact and the Fast Fact and Concepts editors are solely responsible for that Fast Fact’s content. The full set of Fast Facts are available at Palliative Care Network of Wisconsin with contact information, and how to reference Fast Facts.
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