Six Step Protocol for Breaking Bad News (Based on Robert Buckmans Protocol)

Step 1. Getting started

Create a conducive environment. o Allow adequate time and avoid interruptions (e.g., turn off beeper). o Select a private quiet setting, where all can be comfortably seated at eye level.

Avoid sitting on the patients bed or across a desk. o Sit close enough to the patient so you can touch their arm of hand if needed (not

all patients may be comfortable with this) Make sure you have all the information you need in advance (records, prognosis, plan

for follow-up care) Determine who else the patient would like to be present. Start with a question like, "How are you feeling right now?" to indicate to the patient that

this conversation will be a two-way affair.

Step 2. Finding out how much the patient knows. By asking a question such as, "What have you already been told about your illness?" or

what is your understanding of the reason we did the biopsy you can begin to understand what the patient has already been told ("I have lung cancer, and I need surgery"), or how much the patient understood about what's been said ("the doctor said something about a spot on my chest x-ray"), the patients level of technical sophistication ("I've got a T2N0 adenocarcinoma"), and the patient's emotional state ("I've been so worried I might have cancer that I haven't slept for a week"). Correct any misinformation.

Step 3. Finding out how much the patient wants to know.

Ask the patient what level of detail you should cover. For instance, you can say, "Some patients want me to cover every medical detail, but other patients want only the big picture or prefer that I talk to their family -- what would be best for you?" This establishes that there is not one right answer, and that different patients have different styles. Also assess who the patient wants to know.

Recognize and support patient preferences. o Some patients prefer to designate someone to communicate on their behalf.

Be sure to re-evaluate patients preference and desire for information. o Patients may want to know more during their next conversation with you.

Step 4. Sharing the information. Decide on the agenda before you sit down with the patient, so that you have the relevant information at hand. The topics to consider in planning an agenda are: diagnosis, treatment, prognosis, and support or coping. However, an appropriate agenda will usually focus on one or two topics. For a patient on a medicine service whose biopsy just showed lung cancer, the agenda might be: a) disclose diagnosis of lung cancer; b) discuss the process of workup and formulation of treatment options ("We will have the cancer doctors see you this afternoon to see whether other tests would be helpful to outline your treatment options").

Give a warning shot to let the patient know bad news is coming. For example I am afraid I have some bad news for you or The test results did not come out as we had hoped.

Use clear unambiguous language when deliver the bad news. After giving the bad news, pause. Allow the patient to digest the initial information. Give the information in small chunks, and be sure to stop between each chunk to ask the

patient if he or she understands ("I'm going to stop for a minute to see if you have questions"). Long explanations are overwhelming and confusing.

Asking the patient to summarize in their own words the information you just gave them is a helpful way to assess their understanding.

Remember to translate medical terms into English; don't try to teach pathophysiology. Discuss prognosis/life expectancy without getting bogged down in specific numbers or

percentages (unless the patient asks for this). Depending on the scenario providing a range (months to a year, weeks to months, days to weeks, or hours to days) may be appropriate. An example: Most patients with your type of cancer have a life expectancy of weeks to months. For reasons that are not fully understood a very small group of patients with your type of illness live longer, but survival beyond a year is unlikely.

Always communicate hope. Avoid saying there is nothing more that can be done. This may not be hope about being able to cure the illness, but it can be hope that things can be done to maximize quality of life. Address any fears or worries the patient may have.

Step 5. Responding to the patients feelings. Be prepared for outbursts of strong emotion and a broad range of reactions.

Affective response tears, anger, sadness, love, anxiety, relief Cognitive response denial, blame, guilt, disbelief, fear, loss, shame, intellectualization. Psychophysiologic response fight-flight

If you don't understand the patient's reaction, you will leave a lot of unfinished business, and you will miss an opportunity to be a caring physician. Learning to identify and acknowledge a patient's reaction is something that definitely improves with experience, if you're attentive, but you can also simply ask ("Could you tell me a bit about what you are feeling?").

Give the patient time to react. Listen quietly and attentively. Encourage descriptions of feelings and acknowledge their feelings (e.g., I can see you

are very worried right now) Use nonverbal communication.

Step 6. Planning and follow-through. At this point you need to synthesize the patient's concerns and the medical issues into a concrete plan that can be carried out in the patient's system of health care.

Outline a step-by-step plan, explain it to the patient, and contract about the next step (treatments, additional tests, referrals).

Be explicit about your next contact with the patient ("I'll see you in clinic in 2 weeks") or the fact that you won't see the patient ("I'm going to be rotating off service, so you will see the Doctor back in clinic").

Give the patient a phone number or a way to contact the relevant medical caregiver if something arises before the next planned contact.

Before allowing the patient to leave, assess their safety. Discuss potential sources of support (e.g., religious or spiritual advisor).

Repeat this process at the next visit.

References: Avery, J. A. (2002). Ethical Issues in the Management of Geriatric Cardiac Patients. American Journal of Geriatric Cardiology. 11(6), 413-415. [online: Last accessed Aug 13, 2013 from http://www.medscape.com/viewarticle/447467] Buckman, R. (1992). How to Break Bad News: A Guide for Health Care Professionals. Baltimore: Johns Hopkins University Press Creagan, E. T. (1994). How to Break Bad News And Not Devastate the Patient. Mayo Clinic Proceedings. 69(10), 1015-1017. [online: Last accessed Aug 13, 2013 from http://www.mayoclinicproceedings.org/article/S0025-6196(12)61833-3/fulltext]