Giving Bad News
Posted by Dr. Vollmer on May 12, 2020
Delivering bad news is one of the most daunting task faced by health care professionals. During this COVID-19 crisis, this often involves patients they have known for only a few hours. Additionally, they are called upon to deliver the news with little planning or training.
Historically communication skills have not been a priority in medical education. This leaves clinician unprepared for the communication complexity and emotional intensity of breaking bad news. The fear clinicians have about delivering bad news include being blamed, evoking a reaction, expressing emotion, not knowing all the answers, fear of the unknown and untaught, and personal fear of illness and death. This can lead to the clinician becoming emotionally disengaged from their patients. Additionally, bad news delivered inadequately or insensitively can impair patients’ and relatives’ long-term adjustment to the consequences of that news.
Some surveys done have shown that 85% of. both residents and attendings felt that they needed additional training to be effective when delivering bad news. Experience does help with skill-building, but learning good communication skills is always valuable, and during COVID 19, those skills are now critically important.
Given the negative consequences of delivering bad news poorly for both patient and clinician, clinician training in delivering bath news is sorely needed. The best training will include the patient’s family. When the clinician involves the patient’s family, the patient perceives the clinician to be emotional, available, expressive of hope and not dominant.
Ideally, the clinician takes into account the cultural, spiritual and religious beliefs and practices of the family. The clinician must check for understanding. This is in contrast to the clinician expressing sadness, which can hinder information exchange.
As a resource, there is a 1992 book by Rob Buckman, entitled “How to Break Bad News: A Guide for Health Care Professionals.” He suggests finding out how much the patient knows, sharing information, and assuring that the message is understood.
Further, the Irish Hospice Foundation has put together a YouTube to help clinicians deliver bad news.
In this, they describe five important steps.
1. Prepare yourself
2. Make a connection
3. Warn, then deliver the news
4. Acknowledge the impact
5. Make a plan
They also remind the clinician that there is body language, tone of voice, and word choice. All of these are important in talking to patients. COVID-19 adds the additional hardship that the clinician is masked and gowned and therefore not “seen.” However, some hospitals are creating name tags for clinicians with their photos to help the patients feel more comfortable. I think this was a wonderfully soulful intervention during this most traumatic time. Further, the PPE makes it more imperative that the clinician focus on tone of voice and word choice when giving bad news.
As with all difficult situations, the clinician must be open to a variety of responses including denial, anger, sadness, and fear for themselves and their other loved ones. The clinician must learn how to name the dominant feeling that they experience after the bad news has been conveyed. For example, the clinician could say to the patient or their family member, “I am sensing this difficult news is bringing up very angry feelings for you, which is understandable. You are likely to go through a lot of different feelings and I, and my staff, are here to help you with those feelings, as we recognize this is a very difficult time for you and for your loved ones.” The goal here is not to get defensive. Although it may seem, for example, that the patient is angry with the staff, it is more likely that they are angry over the helplessness of the situation, and understanding that helpless feelings can sometimes lead to angry feelings, will help the clinician not get defensive, and remain empathic.
Other factors to consider when delivering bad news include the physical and social setting of the message. Although hospitals may be crowded, it is important to provide a space which is quiet, comfortable, and private. It is also important that there will be no interruptions and that the clinician has set aside protected time to discuss the bad news. Even if this protected time is only 10 minutes, that is far superior than being interrupted while giving bad news.
Finally, delivering bad news requires that the clinician do self-care as a way to acknowledge the wear and tear on the clinician in giving bad news. First, the clinician must recognize that each time the clinician gives bad news, there is increased vulnerability in the clinician. This increased vulnerability may require a break from medical practice, be it ten to twenty minutes for deep breathing or meditation. If this break, still leaves the clinician feeling vulnerable, then the clinician should seek the help of a colleague to de-brief on the situation. Finally, if the clinician still feels out of sorts, or internally disrupted, then the clinician should seek out mental health care. As discussed in a previous podcast, this mental health care should be done by a specialist in COVID-19, as treating clinicians during COVID 19 is a specialty and requires extra training.
To recap, delivering bad news is a skill set which is both cognitively and emotionally demanding. Historically, this has not been a major part of health care training. Going forward, there should be training by communication specialists/mental health providers to help clinicians develop this skill set. Being prepared for a variety of affective responses is important in not becoming defensive after giving bad news. Further, after giving bad news, there should be an immediate opportunity for self-care which includes deep breathing, meditation, talking with a colleague and considering mental health intervention.
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Shirah Vollmer MD 
Shelly Tannenbaum said
This is a very important piece, which I hope will be read by many. However, given the Covid overload at the moment, there are so many painful deaths, I fear that physicians are unable to take your excellent advice and they will become quite numb and the giving of the bad news becomes almost routine. What are your thoughts on this? Of course when the physicians actually have some down time and they can process it, they will have terrible thoughts, regret, guilt and shame, but at the time, they won’t be able to practice the steps you advise here.
Dr. Vollmer said
Yes and no Shel. I agree that there will be a “postmortem” meaning a review of procedures after this pandemic ends. I also think some health care workers are more intuitive than others, and so they know how to give bad news. Other healthcare professionals have already learned this through their training program. Having said all that, I agree that being overwhelmed at work yields a loss of sensitivity to patients and their families. There is sensitivity fatigue which is frightening because no one wants to think back and realize how callous they were in a family’s time of great need. At the same time, there is a sense that this is such an overwhelming situation, one can be forgiven for forgetting that people are losing loved ones without a chance to say goodbye in person. Again, this is all a very messy situation, and as such, those with vulnerable or fragile mental health before the pandemic are at greater risk of feelings of guilt and low self-esteem. To make matters worse, in general, teaching clinicians to give bad news, to my knowledge, has been a neglected part of the curriculum, and so their training may indeed be poor in this area. All of this to say, one can hope that a positive outcome in this crisis is that communication tools will be sharpened, and that teaching communication skills will be a priority. Thanks, as always.