How do I Break Bad News to Patients and Their Families?
Do you worry about having to break bad news to patients and their families? As healthcare professionals breaking bad news is part of our role.
“Regardless of which specialty you’re in, knowing how to break bad news is a very important skill to develop and falls under the wider skill of communication. Whatever field you’re in being a good communicator with your patients and their relatives is important.”
Generation Leader founder and Intensive Care Doctor, Hanieh Asadi, interviewed Consultant Intensivist, Dr Adrian Steele, to gain his insights and tips in tacking this discipline . Understanding how to tackle real life challenges by learning from current senior practitioners is key, as is the sharing of collective intelligence so we hope you find this article valuable. The full masterclass is available on the Medical Leader Programme.
Question 1- How important is it for healthcare professionals to know how to break bad news?
“ Depending on your discipline it’s fundamental.”
It’s something that matters an awful lot to families. The importance of knowing how to break bad news becomes more important as you get older, partly because other duties become more routine and partly because you’ve probably been in the situation where you’ve had bad news broken yourself so you see how crucial it is,” says Dr Steele. As you get older it’s easier to put yourself in the situation and become more sympathetic.
Question 2: What method or strategies do you use to break bad news?
“You have to give one message. This can be frustrating sometimes if you have strong feelings but there’s nothing worse than the team appearing fractured.”
The first thing is to be well briefed, “this can be more difficult than it sounds if you’re in a busy job and maybe you are not directly involved and your team has imparted the information on to you.”
Know everything you can about the family. “ In my situation I’m generally speaking with families rather than with patients.”
It’s vital for the team to be prepared and agree on the bad news. “In intensive care medicine there are other disciplines involved, so we could be talking to an oncology patient or a neurosurgical patient, for example. You must absolutely make sure that your colleagues agree with you. One of the worst things that can happen for a family is for one part of the team to say the situation is serious and for the other part of the team to be more optimistic. You have to give one message. This can be frustrating sometimes if you have strong feelings but there’s nothing worse than the team appearing fractured.”
Question 3: Would you advise for patients to be present when you’re breaking bad news?
“ The rule is they really must be present.”
“A lot of our patients are unconscious but not all,” says Dr Steele, “ I think it can be appropriate to speak with the family and the patients in separate conversations. If a patient has capacity I would always ask the them if they mind me talking with their family. I think that’s acceptable but certainly in the UK I can’t think of any circumstances where it would really be ok just to talk with the family when the patient has got capacity. This is a 100% rule.”
Question 4: What helped you to prepare and equip you with handling situations such as these?
“Utilising the skillsets of peers is a fantastic resource.”
“ One of the most useful things I found over the years is having conversations with colleagues and nurses and observing how other people are doing it and sometimes you pick up really good tips and sometimes you learn from others doing it poorly”. Says Dr Steele. “It’s useful to learn from watching others and this is something you have to make an effort to do as you become more senior because your practice can become more isolated.”
“ I generally like to have someone else present. Because I’m a doctor it tends to be a nurse and this can be useful because they can often relate to the family in a different way and it can also be useful for emotional support as well.”
Draw upon your past experiences of how you’ve had bad news broken to you. “You can see when it was done really well and perhaps when it was done really badly,” says Dr Steele.
Question 5: What advice can you give to healthcare professionals?
“if you feel emotional that’s not something to be afraid of and certainly not ashamed of.”
“When I had to break bad news early on in my career I found it emotionally quite distressing, what advice would you give to junior healthcare professionals?” says Dr Hanieh Asadi.
Dr Adrian Steele; “Breaking bad news is emotionally distressing and it doesn’t necessarily get any emotionally easier as you get older so don’t be afraid of that, take it as part of the role. I think patients and families sometimes want to see a level of emotional engagement from their healthcare professional. They probably don’t want to see the person in floods of tears but I think if you feel emotional that’s not something to be afraid of and certainly not ashamed of.”
“During the COVID-19 crisis we never really meet families, we are talking with them on the phone. So it’s key to have a system where we speak with the same family everyday so you get to know them. It’s terribly upsetting when you realise the relatives are often at home on their own, with no support themselves. That has been one of the most upsetting things I’ve had to do as a doctor”, says Dr Steele.
The message is don’t be afraid of being emotional but keep it under some form of control.
People only take in a fraction of what they are told so it’s important to offer a repeat conversation later in the day or more likely later in the week. Giving the opportunity for relatives to ask questions at the end of the conversation is also important.
Some relatives take notes during the meeting and sometimes this can feel intimidating because you can feel they are not trusting you or going to keep it on record to hold it against you. “In fact it’s a very good tip for people because if they make notes they can refer back to them and remind themselves of information they may have forgotten, so don’t be intimidated by people taking notes,” says Dr Steele.
Question 6: How do you react when people are in extreme distress?
“It’s important to be sympathetic and empathetic and let people show their emotions”
It’s very difficult and there are different ways of showing distress:
For example, Sometimes people can become quite angry; “ I think you need to go slowly and not to be afraid of silences. It’s important to say that you are sorry but there’s no need to talk too much,” says Dr Steele.
“Some healthcare professionals feel more comfortable putting arms around a relative to console them. But some people, myself included, might find that quite difficult. I think you need to do what comes naturally. It’s important to be sympathetic and empathetic and let people show their emotions. If someone is in floods of tears let this happen and be as sensitive as you can.”
Your body language is important, you need to be open and friendly and not sitting with your arms closed.
“When you are talking with a patient in bed, try and sit down, not on the bed, but on a chair and be at their level otherwise they have a figure standing over them and it’s quite imposing. So open body language and being sympathetic is essential” says Dr Steele.
Question 7- Are there any considerations that you would take when breaking bad news with people from different cultures or different religious backgrounds?
“You need to be careful about imposing your own cultural values on families and patients.”
“We often have conversations about withdrawing care or limiting care and I think there are cultural and religious differences in what people expect. My view is that you should be sensitive to this. You need to be careful about imposing your own cultural values on families and patients,” says Dr Steele.
In terms of how people react there are international and cultural differences on how people show their grief. “ You need to be sensitive to this and to allow people to react how they want to.”
Question 8: What are the things you wish you knew when you were in training?
“People react to bad news in very different ways.”
“Not to be afraid”, says Dr Steele. “ I think a lot of people are afraid of breaking bad news and you can be quite self-conscious. There is no need for this because the family are not think about you, they are obviously thinking about their relative, so don’t be afraid.”
“To have known that people react to bad news in very different ways. Some people are full of emotion and some are quite cold and passive, some can get angry and even quite aggressive. You have to accept that people are in complete turmoil and no one knows how they are going to react in that situation,” says Dr Steele.
“One thing I learnt quite late in my career is that people react to bad news at different speeds. Take the scenario of an intensive care patient who clearly has a poor prognosis. Maybe they got ill very suddenly or perhaps had a serious accident. Some people will realise straight away that their relative is going to die and they will accept that news. Other people, perhaps a relative who is very close to the patient, may take longer to accept the news. This is a natural reaction. Sometimes we absorb news quickly and sometimes it takes a long time. You need to give relatives time and be patient. It’s also important to note that people in the same family react differently and at different speeds.”
It’s important to be aware of the family dynamic. Not all families are happy and you may get situations where siblings aren’t talking to one another or maybe not talking to the wife or husband of the patient.
Question 9- What management and leadership skills do you look for in team members?
“To be a team player”
To be a team player. “It may be a cliché but it’s so important,” says Dr Steele. “ If you have a team of three people there will be three different views as to how you should approach a difficult situation but this should never be shown to the family. You have to agree by consensus that you are collectively going to say one thing.”
Being sensitive and kind. “These are things we would all want in a doctor, nurse or healthcare professional.”
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