II. Indications
- Telling patient about a terminal illness, serious chronic disease (HIV, MS) or life altering change (e.g. amputation)
III. Precautions
- Breaking Bad News impacts medical provider stress regardless of years of experience
- Medical providers are often fearful of Breaking Bad News, being blamed for bad outcomes, expressing emotions
IV. Efficacy
- Planful End-Of-Life Care (e.g. Hospice, Palliative Care) results in improved quality of life, and longer survival
- Phone delivery of bad news is not inferior to in person communication of bad news
- Does not affect anxiety, depression or satisfaction of care
- Mueller (2023) J Gen Intern Med 38(16): 3589-603 [PubMed]
V. Approach: General
- Overall Approach (Mnemonic: ABCDEF) - see below
- Advanced Preparation
- Build a therapeutic environment
- Communicate well
- Deal with reactions of patient and their family
- Encourage and validate emotions
- Follow-up plan
- References
- Other mnemonics (nearly identical approach to the ABCDEF Protocol)
- BREAKS Protocol
- Steps: Background, Rapport, Explore, Announce, Kindle, Summarize
- Narayanan (2010) J Palliat Care 16(2): 61-5 [PubMed]
- SPIKES Protocol
- Steps: Setting, Perception, Invitation, Knowledge, Emotions, Strategy and Summary
- Balle (2000) Oncologist 5(4): 302-11 [PubMed]
- BREAKS Protocol
VI. Approach: Step 1 - Advanced Preparation
- Assign clinician responsible for telling the patient
- Review patient's case and therapeutic options
- Rehearse your plan to deliver the bad news
- Invite the patient to discuss in person (not over phone) and allocate adequate, dedicated time to speak
VII. Approach: Step 2 - Build a therapeutic environment
- Allocate adequate time in suitable, quiet environment
- Invite participants patient would like present
- Participants introduce themselves
- Foreshadow the bad news (e.g. I have bad news)
- Be sensitive to patient's preferences (touch, humor)
VIII. Approach: Step 3 - Communicate well
- Patient has right to accurate information
- Ask what the patient already knows
- Determine how much the patient wishes to know
- Some patient groups tend to want more detailed information
- Younger patients
- Female patients
- Higher education levels
- Speak slowly, pause and repeat important points
- Express information clearly so patient understands
- Speak simply and honestly
- Express compassion (e.g. I am sorry)
- Avoid euphemisms (e.g. use words such as death)
- Implications clearly laid out
- Avoid medical jargon and technical language
- Avoid overwhelming with too much information
- Avoid witholding key information or overestimating survival
- When treatment options are discussed, intent of treatment should be made clear
- Is the treatment intent cure or palliative?
- Assume time for patient to assimilate information
- Encourage questions
- Write down summary of information on paper
- Some racial and ethnic groups are more family centered in their decision making, while other more individual centered
- Family-centered decision making: Mexican American, Korean American
- Individual-centered decision making: African American, European American
- Be aware of preconceived expectations and beliefs that patients and their families may hold
IX. Approach: Step 4 - Deal with reactions of patient and their family
- Be aware of body language
- Stop and address emotions as they arise
- Understand coping mechanisms of meeting participants
- Avoid arguments and defensiveness
X. Approach: Step 5 - Encourage and validate emotions
- Understand how patient feels about the news
- Offer realistic hope
- Describe prognosis generally (e.g. weeks to months)
- Emphasize what can be done (e.g. comfort)
XI. Approach: Step 6 - Follow-up plan
- Summarize the bad news and the patient's concerns
- Schedule follow-up meetings
- Establish community support services (e.g. Hospice)
XII. References
- Abeloff (2000) Clinical Oncology, Churchill, p. 609-10
- Ambuel (2001) Prim Care 28(2):249-67 [PubMed]
- Berkey (2018) Am Fam Physician 98(2): 99-104 [PubMed]
- Rabow (1999) West J Med 171:261 [PubMed]
- Vandekieft (2001) Am Fam Physician 64(12):1975-8 [PubMed]