Breaking Bad News In Emergency: How Do We Approach It? Muhammad Saaiq and Khaleeq-Uz-Zaman

Medical Ethics In Debate

Breaking Bad News In Emergency: How Do We Approach It?

Breaking bad news has far reaching implications on the overall management of the patient and his illness. It should not be taken casual and must rather be respected as an indispensable component of health care equivalent to other procedural sessions such as biopsy and surgery. This realization will prompt application of the relevant knowledge in clinical practice. In order to structure the process of breaking bad news in emergency situations , the authors introduce SAAIQ emergency approach that has five components. i.e. Setting the scene as soon as possible, Assessing the understanding of the news’ recipient, Alerting about the bad news, Informing clearly and Quickly summarizing the communication with information based hope. Adherence to this new approach ensures quick delivery of bad news in an empathic, compassionate and tactful manner.

Pakistan Institute of Medical Sciences (PIMS)

KEY WORDS: Breaking bad news , Communication skills , SAAIQ emergency approach.

Muhammad Saaiq* Khaleeq-Uz-Zaman** *Medical officer, Department of Surgery, PIMS, Islamabad. **Professor of Neurosurgery, PIMS, Islamabad Correspondence: Dr Muhammad Saaiq Medical Officer, Department of Surgery,

Islamabad. e-mail: muhammadsaaiq5 @ gmail.com

In this evidence based era it is imperative to redesign the entire health care delivery from the patient’s perspective. Breaking bad news to patients or their relatives is one of the most challenging aspects of medical practice. Effective communication skills hold the key to solve such knotty issues of clinical practice as a well communicated message though tragic, not only enhances the patient’s understanding of and adjustment to his illness but also improves the overall satisfaction of both the patient as well as the care giver.1,2

Communication skills training programmes are becoming an integral part of medical curriculum in UK and USA. Moreover there is growing concern about the need for even training the experienced clinicians. 3

What constitutes a bad news?

Bad news is an upsetting information which drastically changes a person’s self-image and sense of interpersonal meaning. It is often associated with a terminal diagnosis such as cancer. However bad news can come in many forms as for example the diagnosis of a chronic illness like diabetes mellitus, loss of function such as impotence, a treatment plan that is burdensome, painful or costly, a pregnant lady’s ultrasound verifying a fetal demise, a middle aged lady’s MRI scan confirming the clinical suspicion of multiple sclerosis4; diagnosis of a potentially incurable illness such as AIDS, a disease that ultimately mutilates the body such as rheumatoid arthritis and disabling treatment such as a permanent colostomy.

In the last few decades, the traditional paternalistic model of patient care has been replaced by one that emphasizes patient autonomy, empowerment and full disclosure. Many recent studies have found that majority of patients want to know the truth about their illness.7 One review of studies on patient preferences regarding disclosure of a terminal diagnosis found that 50-90 percent of the patients desired full disclosure.8 In fact honest disclosure of diagnosis , prognosis and treatment options allows patients to make informed health care decisions that are consistent with their goals and values. A small percentage of patients still may not want full disclosure and hence physicians need to ascertain the information needs of their patients.9 The doctor has to adopt a sartorial approach and individualize the manner and content of information according to the needs of the patients. The unique situation in our set up arises when the relatives request that the actual facts be withheld from the patient. Such situations must be handled with great care and a tactful approach would better serve neither to harm the patient nor his miserable relatives.

Why to withhold bad news from patients ?

We in Pakistan face similar situation as did Hippocrates5 and Thomas Percival6 because we are forced by circumstances to withhold the bad news.

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Breaking Bad News In Emergency: How Do We Approach It? Muhammad Saaiq and Khaleeq-Uz-Zaman

Why breaking bad news a difficult task?

Barriers to effective disclosure of bad news include physician’s own issues such as the fear of being blamed by the patient, of not knowing all of the answers sought by the patient , of inflicting pain on the patient , and even the physician’s own fear of illness and death. Many physicians have no adequate training in how to break bad news and many perceive a lack of time in which to present the news. Moreover patients may have multiple physicians , making it unclear who should break the bad news. 10

Bad news delivery in a proper way is a relatively new area of communication skills and is literally still in its infancy. Several professional groups have published consensus guidelines on how to discuss bad news , however few of those guidelines are evidence based.1 The clinical efficacy of many standard recommendations has not been empirically demonstrated 2 Majority of articles on breaking bad news are rather opinions and reviews by physicians.1,2 and fewer than 25 percent of publications on breaking bad news are based on studies reporting original data and those studies commonly have methodological limitations. 4 Owing to the lack of adequate training, doctors and

nurses fail to give a crisp and clear message . There is lack of empathy and professionalism in their approach which at times confuse the scenario even more. They typically display blocking behaviours such as telling patients that any distress is normal, switching the subject to neutral topics, giving information and advice before patient’s concerns have been identified, focusing only on physical aspects of the condition and using leading, closed and multiple questions. This as negative psychological consequences for patients as well as anxiety and depression is more among patients who have unresolved

For effective delivery of bad news various authorities have attempted to devise comprehensive models of their own. Girgis A et al 14 undertook pioneering work and published guidelines on how to convey bad news to patients. They placed special emphasis on ensuring privacy and allowing adequate time, assessing patient’s understanding , giving simple and honest account of diagnosis and prognosis, avoiding euphemisms, encouraging patients to express feelings, being empathic, giving a broad but realistic time-frame concerning prognosis and arranging a review.

Objective evidence has proved the superiority of the proper communication skills and there is growing recognition of the role of intradisciplinary and multidisciplinary workshops in overcoming the communication deficiencies of health care professionals.

Rabow and Mc Phee devised ABCDE mnemonic 15 for breaking bad news. i.e. Advance preparation, Build a therapeutic environment / relationship, Communicate well, Deal with patient and family reactions, Encourage and validate emotions. This mnemonic has been expanded by adding F for follow-up plan and hence ABCDEF.16 Baile WF et al 7 devised the mnemonic SPIKES for bad news delivery i.e. Setting up, patient’ s Perceptions, Invitation to break bad news, Knowledge, Emotions, Strategy and summary. This approach aims to enable physicians break bad news in a straightforward and empathic manner.

What matters to the patients? Intensive patient satisfaction research is underway to explore what matters to patients in an emotionally charged situation entailing breaking bad news. Parker PA et al 12 found that physician’s competence, honesty and attention, the time allowed for questions, a straightforward and understandable diagnosis, and the use of clear language are the factors which matter to the patients in breaking bad news. Jurkovich GT et al13 worked on how family members evaluate delivery of bad news and found that privacy, physician’s attitude, competence, clarity of the message and time for questions were the top rated areas.

How to tackle the issue of bad news delivery?

The authors have enjoyed working at the busy Accident and emergency department of Pakistan Institute of Medical Sciences (PIMS), Islamabad for quite some time. PIMS is a premier medical institution of the country and its catchment area not only includes the twin cities of Islamabad and Rawalpindi but also Northern Areas , North West Frontier Province (NWFP), Azad Jammu Kashmir and upper Punjab. In emergency situations bad news often must be delivered in an entirely different context. Here neither the settings are conducive to intimate neither conversations nor the situation permits adequate forewarning. Obviously the information can’t be furnished in small chunks and usually the swiftly changing clinical scenario rather warrants it to be delivered in heavy bolus doses. There is often hectic

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Breaking Bad News In Emergency: How Do We Approach It? Muhammad Saaiq and Khaleeq-Uz-Zaman pace of clinical activity and yet the doctor has to pay attention to administrative responsibilities as well. Mostly the patient himself is critical and bad news must often be conveyed to the emotionally charged relatives. In such a touchy situation even words can easily shift the balance of the situation in any direction. In order to overcome these challenges and yet convey bad news in an empathic, compassionate and tactful manner, the authors devised the mnemonic SAAIQ for breaking bad news in emergency. (The mnemonic uses the name of the first author)

Conclusion

Breaking bad news has far reaching implications on the overall management of the patient and his illness .It should not be taken casual and must rather be respected as an indispensable component of health care equivalent to other procedural sessions such as biopsy and surgery. This realization will prompt application of the relevant knowledge in clinical practice.

SAAIQ emergency approach of

breaking bad news is summarized as under:

• Set the scene as soon as possible.

Review the case in detail so that all the necessary information is at hand. 3 Hulsman RL, Ros WJG, Winnubst JAM , Bensing JM. Teaching

clinically experienced physicians communication skills. A review of evaluation studies. Med Edu 1999 ; 33 : 655-68.

Arrange privacy .Our emergency department now has a room for counseling the relatives of serious patients. Prepare to act naturally Introduce yourself

• Assess the understanding of the attendant / news’ recipient.

Assess what he knows and how much further he wants to know. This can be elicited by a probing question such as What do you know about the critical condition of your patient .Also inquire as to whether he wants to know all the details or may simply be given a broad picture of the situation.. This helps to tailor the subsequent transfer of information. • Alert them that I have bad news .

There is no need to display misleading optimism. • Inform in clear and understandable words about the

serious state / demise etc. • Quickly repeat summary of the communication

with information based realistic hope.

This SAAIQ emergency approach has been of great help not only for us but was also found very helpful by our colleagues . This new approach is being scientifically validated in a prospective study on critically ill patients presenting as acute emergencies and the results will be published as soon as the study completes.

15 Rabow MW, McPhee SJ. Beyond breaking bad news : how to help

patients who suffer . West J Med 1999 ; 171 : 260-3.

16 Moses S . Breaking bad news . Family Practice Notebook: 2004. (Serial online ) : (Cited 2004 Feb 2 ) : (3 screens ) : Available from : URL : www.fpnotebook.com/HEM 209.htm.22 k

References 1 Girgis A, Sanson –Fisher RW. Breaking bad news I : current best

advice for clinicians. Behav Med 1998 ;24 (2) : 53-9. 2 Walsh RA , Girgis A , Sanson – Fisher RW. Breaking bad news

2: What evidence is available to guide clinicians ? Behav Med 1998 : 24 (2) : 61-72.

4 Vandekieft GK Breaking bad news. Am Fam Physician 2001: 64 (12) : 1975-8.

5 Hipporcates . Decorum, XVI. In : Jones WH , Hippocrates with an English Translation. Vol 2. London : Heinemann , 1923.

6 Percival T. Medical ethics : or , A code of institutes and precepts, adapted to the professional conduct of physicians and surgeons. Manchester, England : S. Russel , 1803 : 166.

7 Baile WF, Buckman R, Lenzi R . SPIKES ----A six step protocol for delivering bad news : application to the patient with cancer . Oncologist 2000 ; 5 (4) : 302-11.

8 Ley P. Giving information to patients . In : Eiser JR ed . Social psychology and behavioral medicine . New York : Wiley, 1982 : 353.

9 Kutner JS, Steiner JF, Corbett KK, Jahnigen DW, Barton PL. Information needs in terminal illness. Soc Sci Med 1999 ; 48 : 1341-52.

10 Buckman R. Breaking bad news : Why is it so difficult ? Br Med J 1984 : 288 (6430) : 1597-9.

11 Maguire GP. Breaking bad news : explaining cancer diagnosis and prognosis. MJA 1999 ; 171 : 288-89.

12 Parker PA , Baile WF , de Moor C. Breaking bad news about cancer patients ’preferences for communication. J Clin Oncol 2001 : 19 (7) : 2049-56.

13 Jurkovich GJ, Pierce B, Pananen L, Rivara FP. Giving bad news : the family perspective . J Trauma 2000 ; 48 : 865-70.

14 Girgis A, Sanson-Fisher RW. Breaking bad news: consensus guidelines for medical practitioners. J Clin Oncol 1995; 13 : 2449-56.

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