Breaking Bad (news)

If you’re going to have to tell someone bad news, and working in medicine, it’s going to happen at some point, there are right ways to do it, and wrong ones.

See if you can spot the correct ways to break difficult news to someone, and the incorrect ways:

ROUND 1 – Introduction

  • A quiet, private room, with no interruptions and enough time to build rapport 
  • On a bus, with snacks and a megaphone 
  • Introduce yourself, explain your role and why you’ve come to talk to the patient
  • Enter the room wearing a hooded cloak holding a scythe 
  • Check the identity of the patient on their notes, wristband, and verbally
  • Shout to the ward “Which one of you f***ers is Barry?”
  • Ask the patient if they would like a family member or friend present
  • Isolate the sick from the herd

Um… hi, I’m here to talk about your scan?

ROUND 2 – Patient’s understanding

This is more of a ‘single best answer’ type of round… pick your favourites

  • “Please could you tell me what you’ve been told so far?”
  • “I bet I know more than you”
  • “Let’s play…. Guess the tumour!”
  • “I’d like to know what your understanding is so far”
  • “How many fingers do you really need?”
  • “If your life were a movie, which incredibly sad song would you like to have playing right now?”

ROUND 3 – Giving the information

The aim of this round is to give information gently, but without false reassurance. Decide which of the following would help you achieve this aim:

  • Fire a warning shot – “I’m afraid I have some rather difficult news…”
  • “You’ll never guess what!”
  • Fire an actual shot
  • Divulge the necessary information clearly, in small chunks
  • Produce textbook of palliative care opened at ‘caring for the dying patient’ 
  • Let the patient guide the conversation through questions
  • Respond entirely in questions
  • Respond in braille
  • Watch their body language
  • Watch only their body
  • Make eye contact
  • Do not make eye contact
  • Do not break eye contact
  • Sit next to them in a relaxed but attentive pose
  • kneel
  • lie prone

ROUND 4 – Empathy

Congrats on getting this far, now we really up the stakes. Your job is to persuade the person opposite you that you care. You might actually care, in which case you have a storming advantage for this round, but in case you don’t, here are some possible tips and tricks. But pick wisely:

  • Positioning
    • Sit close to the patient
    • Sit in next room and shout at patient
    • Sit on patient
  • Voice
    • Whisper
    • Quiet but clear voice
    • Yoda
  • Physical contact
    • Hand touch
    • Lip hook
    • Trap squeeze
    • PR
  • Posture
    • Open and relaxed
    • Marine squat
    • Teenage slump
    • Downward dog
  • Encouraging their response
    • “I’d like you to know you can say anything you want”
    • “So……”

ROUND 5 – Summarising

The final round! Which of the following do you feel is appropriate for concluding the discussion?

  • Understanding
    • Hand patient a leaflet with relevant information
    • Hand patient phone numbers of support groups and networks
    • Ask patient for their phone number
    • Hand patient a quiz on ‘what we’ve just learned’
    • “Do you have any questions at this stage?”
    • “It’s my lunch break, ciao”
  •  Follow up
    • Explain the next step, and the patient’s options at this time
    • Say what might happen, but who knows it’s a crazy world
    • Encourage patient to stay positive
    • Enquire about organ donation
  • Closing
    • Ask how they’re getting home
    • Ask if they still really need their home
    • Ask if you can have their watch
    • Determine when you will next meet
    • Shake hands
    • Fistbump

It should be fairly obvious which of these are the right way to go about a difficult discussion, but hopefully the wrong ones will make them easier to remember (scythe…probably not – introduce myself) and give you a bit of structure as to how to conduct one of these conversations.

GOLDEN RULE: stop talking. The patient is not going to hear a word you say. Their brain is full of panic and distress, there’s no space for anything else. When space becomes free, they’ll fill it by asking you questions. Answer these questions, and then let the silence wash over you, it’s strangely calming.

Good luck.

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