II. Indications

  1. Telling patient about a terminal illness, serious chronic disease (HIV, MS) or life altering change (e.g. amputation)

III. Precautions

  1. Breaking Bad News impacts medical provider stress regardless of years of experience
  2. Medical providers are often fearful of Breaking Bad News, being blamed for bad outcomes, expressing emotions

IV. Efficacy

  1. Planful End-Of-Life Care (e.g. Hospice, Palliative Care) results in improved quality of life, and longer survival

V. Approach: General

  1. Overall Approach (Mnemonic: ABCDEF) - see below
    1. Advanced Preparation
    2. Build a therapeutic environment
    3. Communicate well
    4. Deal with reactions of patient and their family
    5. Encourage and validate emotions
    6. Follow-up plan
    7. References
      1. Rabow (1999) West J Med 171:261 [PubMed]
      2. Vandekieft (2001) Am Fam Physician 64(12):1975-8 [PubMed]
  2. Other mnemonics (nearly identical approach to the ABCDEF Protocol)
    1. BREAKS Protocol
      1. Steps: Background, Rapport, Explore, Announce, Kindle, Summarize
      2. Narayanan (2010) J Palliat Care 16(2): 61-5 [PubMed]
    2. SPIKES Protocol
      1. Steps: Setting, Perception, Invitation, Knowledge, Emotions, Strategy and Summary
      2. Balle (2000) Oncologist 5(4): 302-11 [PubMed]

VI. Approach: Step 1 - Advanced Preparation

  1. Assign clinician responsible for telling the patient
  2. Review patient's case and therapeutic options
  3. Rehearse your plan to deliver the bad news
  4. 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

  1. Allocate adequate time in suitable, quiet environment
  2. Invite participants patient would like present
  3. Participants introduce themselves
  4. Foreshadow the bad news (e.g. I have bad news)
  5. Be sensitive to patient's preferences (touch, humor)

VIII. Approach: Step 3 - Communicate well

  1. Patient has right to accurate information
    1. Ask what the patient already knows
    2. Determine how much the patient wishes to know
    3. Some patient groups tend to want more detailed information
      1. Younger patients
      2. Female patients
      3. Higher education levels
  2. Speak slowly, pause and repeat important points
  3. Express information clearly so patient understands
    1. Speak simply and honestly
    2. Express compassion (e.g. I am sorry)
    3. Avoid euphemisms (e.g. use words such as death)
    4. Implications clearly laid out
    5. Avoid medical jargon and technical language
    6. Avoid overwhelming with too much information
    7. Avoid witholding key information or overestimating survival
  4. When treatment options are discussed, intent of treatment should be made clear
    1. Is the treatment intent cure or palliative?
  5. Assume time for patient to assimilate information
    1. Encourage questions
    2. Write down summary of information on paper
  6. Some racial and ethnic groups are more family centered in their decision making, while other more individual centered
    1. Family-centered decision making: Mexican American, Korean American
    2. Individual-centered decision making: African American, European American
  7. Be aware of preconceived expectations and beliefs that patients and their families may hold
    1. Compared with TV and movies, CPR fails far more to achieve ROSC (let alone intact function)
    2. Beliefs about the afterlife vary widely by culture and religion

IX. Approach: Step 4 - Deal with reactions of patient and their family

  1. Be aware of body language
  2. Stop and address emotions as they arise
  3. Understand coping mechanisms of meeting participants
  4. Avoid arguments and defensiveness

X. Approach: Step 5 - Encourage and validate emotions

  1. Understand how patient feels about the news
  2. Offer realistic hope
    1. Describe prognosis generally (e.g. weeks to months)
    2. Emphasize what can be done (e.g. comfort)

XI. Approach: Step 6 - Follow-up plan

  1. Summarize the bad news and the patient's concerns
  2. Schedule follow-up meetings
  3. Establish community support services (e.g. Hospice)

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