Motivation and emotion/Book/2024/Breaking bad news

Breaking bad news:
How should bad news be shared to minimise emotional distress?

Multimedia presentation (3 min)

Overview

Figure1. Breaking bad news by health professionals. Case study On the 7th of October 2023, Israel and Hamas have been immersed in a horrific violence of war and over 1400 lives were lost, 240 people abducted, dozens missing and countless others left traumatised (Awwad-Tabry et al., 2024). The incident had left health and mental health professionals no choice but a daunting task of delivering distressing news to civilian families who have been impacted by the war and trauma (Awwad-Tabry et al., 2024). Traditionally, in Israel, it is the responsibility of the military to inform families about the loss or abduction of their loved ones (Awwad-Tabry et al., 2024).However due to the magnitude of casualties and abductions, breaking bad news extended beyond the military protocols (Awwad-Tabry et al., 2024). The daunting task of breaking bad news was given to a unique group of social workers in a particular city(Awwad-Tabry et al., 2024). Delivering negative news requires a unique skill sets such as balancing compassion, professionalism and psychological insight (Rosenzweig., 2012). For social workers, being met with such a difficult task has a profound effect on both sides of parties (Awwad-Tabry et al., 2024). The social workers who lack formal training on such areas of delivering negative news, were met with an extraordinary demand since the social workers were facing their own chaos and potential threats to their own families due to the catastrophic event(Awwad-Tabry et al., 2024). A qualitative case study design was conducted with the purpose of examining the intricacy of delivering bad news on a single entity (Awwad-Tabry et al., 2024). The finding showed that the magnitude and the complexity of the event made it challenging to deliver bitter news Irrespective of training, simulation and adequate preparation for such events, the task was alarming (Awwad-Tabry et al., 2024). The study suggested that delivering bad news in such events should be actioned by a formation of experienced and seasoned social workers. People who deliver bad news need to be fully prepared for the intense, difficult, painful and intimate moments for such cases (Awwad-Tabry et al., 2024).

Delivering negative news is an inevitable aspect of both professional and personal life, and doing so effectively requires sensitivity, clarity, and empathy (Ghanbari et al., 2023). Whether the person is informing the sad news to a team, friend, colleagues, or family, breaking bad news depends on how it is communicated (Ghanbari et al., 2023). The method of communicating bad news to a person or team can significantly impact the recipient's emotional response and future relationship (Ghanbari et al., 2023). The challenge lies in balancing honesty with compassion, ensuring that the recipient understands the gravity of the situation without feeling overwhelmed or demoralise (Ghanbari et al., 2023). This chapter investigates the best ways of breaking bad news. Such as preparation, selecting the correct environment, utilising empathetic language, and providing support for moving forward (Ghanbari et al., 2023). Following these principles enables a person to approach difficult conversations with confidence and foster an atmosphere of understanding and respect, even in challenging circumstances (Ghanbari et al., 2023).

Focus questions: What is bad news? How to deliver bad news empathically? What psychological theories frames breaking bad news?

What is bad news?

Figure 2. Image showing lab test analysis.

Diagnosis

Bad news is defined as information which is negative, unfavourable and distressing for individuals or groups that are receiving it (Abdel Wahab et al., 2022).This means that bad news can involve personal, social, economic or political situations (Awwad-Tabry., 2024). For instance, in medical field, delivering bad news can be health related issues, for example diagnosing a serious illness for a patient such as cancer (Abdel Wahab et al., 2022). An Oncologist would have to inform a patient about a negative test results from lab test or imaging which reveals an issue regarding an organ dysfunction or a present of a disease (Abdel Wahab et al., 2022). Informing a patient about a condition which is not getting better, Meaning the patient's current health problem has declined since the treatment is ineffective (Abdel Wahab et al., 2022).

Bad news can provoke a range of emotional responses which may include sadness, anxiety, anger and fear (Ghanbari et al., 2023). When individuals are faced with such problems it requires them to process the information and decide how to react and cope with the condition (Ghanbari et al., 2023). Hence, breaking bad news in the medical setting needs to be approached by sensitivity and compassion since it has a significant impact on a patient's psychological and emotional well-being (Ghanbari et al., 2023).

Case study A mixed methods study design was conducted using a cross-sectional design to assess the training and practice of doctors in breaking bad news (BBN) (Abdullah et al., 2024).The study was carried out in five different hospitals, where data were collected in eight weeks (Abdullah et al., 2024) .The participants were selected through a simple random sampling which included medical personnel involved in the selected hospital (Abdullah et al., 2024). The data collection involved a 25-item self-administered questionnaire consisting of two main sections (Abdullah et al., 2024). The initial phase focused on recording participants demographic information (Age, gender, designation and specialty including the years of experience (Abdullah et al., 2024). The second phase contained questions regarding the healthcare worker familiarity with protocol concerning guidelines about BBN (Abdullah et al., 2024). The validity and reliability of the study was measured by administering a pilot study with ten work physicians in the general practice (Abdullah et al., 2024). The sample size was determined based on a 95% confidence level with an estimated population of 11% with a 5% margin error. Over all the population sample size was estimated to be 200, 000. It was estimated after using the design effect, the population size(N), the hypothesised Proportion (P), The margin Error (d) and the critical value (Z) (Abdullah et al., 2024). The study determined that the required sample size for the desired confidence level would approximately be 151 participants (Abdullah et al., 2024). After the data gathering, the information was analysed using SPSS version 22.0 descriptive statistics, frequencies table and percentages were computed to gain an insight about BBN (Abdullah et al., 2024). Qualitative data were collected through an in depth interview. The results of the demographic data revealed the participants out 151 to be 62.3% males than females. The overall outcome revealed that most health care workers rely on personal experience rather than formal training(Abdullah et al., 2024). It suggested the need for structuring educational programs in the guidelines in BBN (Abdullah et al., 2024).

It is recommended that healthcare providers communicate bad news clearly and supportively. This involves implementing strategies like the SPIKES protocol. The SPIKES protocol is a framework designed to guide practitioners on how to effectively discuss bad news with patients.

Table 1. A descriptive table for the SPIKES protocol by Baile & Buckman 2000.

Figure 3. A modified table explaining the SPIKES protocols, by Baile & Buckman 2000

The SPIKES protocol serves as a tool for breaking bad news in four components (Baile & Buckman 2000). Gathering details from patients, transmitting the medical information and providing support to the patient(Baile & Buckman 2000). Additionally, it elicits patient collaboration and develops a strategy and treatment for the future (Baile & Buckman 2000).

The evolutionary theory of Emotion, explained by  Charles Darwin and later scholars, suggests that emotions have evolved to facilitate social communication and survival (Shackelford et al., 2015). Emotions are seen as adaptive responses to environmental challenges, helping individuals navigate social interactions and threats (Shackelford et al., 2015).

How should bad news be delivered?

Private setting

Since breaking bad news is a sensitive and crucial task that can dramatically impact the emotional and cognitive well- being of a person, health professionals take great consideration on how and where such negative matter needs to be delivered effectively (Leoniuk & Sobczak., 2023). One of the components of delivering bad news is actioned in a private setting, a quiet space where the conversation can not be overheard by unwelcome bystanders (Leoniuk & Sobczak., 2023). It allows the patient to process the information in a manner which makes them feel unexposed but respected for their privacy (Leoniuk & Sobczak., 2023). The degree of comfort can be offered to a patient in comfortable environment such as a quiet room in a healthcare facility (Leoniuk & Sobczak., 2023). The space should provide a sense of safety and security. Furthermore, healthcare workers must think about time consideration to ensure that there is a sufficient duration for discussing the news without rushing (Leoniuk & Sobczak., 2023). It provides an open conversion where the patient can ask questions and express their emotions without being perceived as another statistical object on the topic.

Allow present support

Health professionals must listen to the wishes of the patient when breaking bad news, for example, allowing patients to have a present support, for instance allowing patients to have a family member or friend to be present during the conversation (Leoniuk & Sobczak., 2023). Having a present support can assist in enabling the patient to process the information without feeling isolated (Leoniuk & Sobczak., 2023). Healthcare workers need to be culturally sensitive when breaking bad news as some cultures may prefer to have a family member participating in the discussion. Lastly, a good healthcare professional must allocate an appropriate setting for follow-up discussion (Leoniuk & Sobczak., 2023). The consideration of where the follow up should take place and the type of follow-up matter whether it needs to be an ongoing conversation (Leoniuk & Sobczak., 2023). Ongoing conversation required a private setting to address treatment options, questions and emotional support. In total, breaking bad news, healthcare workers should constantly prioritise the patient’s emotional response and mental safety (Leoniuk & Sobczak., 2023). Ensuring a private, comfortable and supportive environment is provided for the patient. It facilitates a more compassionate and effective conversation for both parties (Leoniuk & Sobczak., 2023).

Case study In the article titled Delivering bad news to patient, Cox et al., 2016). it examines the importance of healthcare professionals, chiefly physicians, being equipped with the necessary training when tasked with the unenviable role of telling an individual life altering news. In the study,(Cox et al., 2016), implemented a questionnaire at the Baylor University Medical Centre to deduce if an educational intervention should be undertaken at the facility. (Cox et al., 2016) the theorised based on their research that a patient centred approach was the ideal, highlighting the SPIKES protocol (Setting, Perception, Invitation, Knowledge, Empathy & Staggery) and the ABCDE approach (Advanced preparation, Build a rapport, Communicate, Deal with reaction & Encourage and validate emotions). They concluded that while there was an abundance of online resources at a physician’s fingertips there was no certainty that those at the university medical centre were actively seeking them out and implementing them (Cox et al., 2016). A questionnaire was undertaken involving fifty-four participants (Cox et al., 2016). The results yielded that an overwhelming 93% of the sample size believed the ability to effectively deliver bad news was essential, however only 43% believed they presently had adequate training to perform such a task with 85% conceding they felt they required additional training (Cox et al., 2016). It was concluded that a follow up study would be undertaken to gauge the effectiveness of the aforementioned ABCDE approach by using simulated patients and three altering bad news scenarios that would be filmed and feedback provided (Cox et al., 2016). If this further study proved fruitful, (Cox et al., 2016) determined it would become a staple method of training moving forward at the university.

How to deliver bad news empathically

Figure 3. Graphic image of Person-Centred Approach, Carl Rogers.

Preparation

Empathy is an essential skill for a health practitioner to contain in order to deliver bad news with soft impact and making the discussion session more constructive (Aoun & Breen., 2020). In order to enhance empathy, the medical practitioner would need to prepare themselves before breaking bad news to patients (Aoun & Breen., 2020). Taking a moment to gather their thoughts, understand the facts clearly and anticipate the emotional reactions which may arise is an important step for health workers to consider before breaking bad news. Patients will have emotional reactions when responding to bad news delivered to them (Aoun & Breen., 2020). For instance, experiencing silent shock, substantial crying and sobbing.

A relevant theory that is planted in the area of empathy when breaking bad news is the person-centred therapy or the client-centred therapy (Aoun & Breen., 2020). The theory of Person-centred therapy was established by an influential American psychologist and the founders of the humanistic approach to psychology Carl rogers (Dulmen et al., 2015). He developed several concepts and practices that have had a significant impact on therapy and counselling (Dulmen et al., 2015).

These emotional responses can create a potentially awkward moment for the health practitioner but can be diminished through engaging in an empathetic communication (Aoun & Breen., 2020). For example, empathy can be revealed by acknowledging the impact of the news through phrases. “ I can imagine how difficult it is for you,” or “ I’m really sorry to break this horrific news for you.’ The usage of simple and clear language can help the process of breaking bad news to be less complicated (Aoun & Breen., 2020). Being direct and honest ensures understanding and can avoid beating around the bush to minimise confusion and frustration (Aoun & Breen., 2020).

Active listening

Another valuable component of revealing empathy is being an active listener. Medical workers should listen to the patient's emotional and general response during such times (Aoun & Breen., 2020). Encourage them to express their feelings and validate their emotions. Utilise phrases such as “ I understand this is a lot to take in and it's okay to be upset.”  Offer them support and solutions by providing options and resources which might be healthy to cope with the negative situation (Aoun & Breen., 2020). For instance, directing them to see a psychologist and notify them that you will be there to support them. Finally a health practitioner should reflect on the experience. After the discussion, it is a positive practice to take time to reflect on how it went and how it can be improved next time. The habitat of reflection can help to develop the skills in delivering difficult news empathetically (Aoun & Breen., 2020). Being compassionate and thoughtful can assist in mitigating the distress that comes with breaking bad news. It fosters a supportive relationship and maintaining trust moving onward.

The Facial Feedback, this theory suggests that facial expressions can influence emotional experiences (Coles & Lench., 2019). For instance, smiling can make a person feel happier, while frowning may lead to feelings of sadness.The idea is that feedback from facial expressions can increase or decrease emotional experiences (Coles & Lench., 2019).

Quizzes

1 What framework is often use in guiding healthcare professionals in breaking bad news? SMILE CARE SPIKE RELAX 2 Breaking bad news can be a daunting task for most healthcare practitioner True False 3 What actions should healthcare worker do if a person reacts very emotional to bad news? Get frustrated and leave Validate their feelings and offer support Minimize their emotions Change the topic

Conclusion

This chapter focused on exploring the best ways of breaking bad news. Breaking bad news to patients requires the skills of being empathetic, having safe space and providing support. Health practitioners are recommended to have strong knowledge of the SPIKES protocols when breaking bad news to clients. Compassion and empathetic are highly regarded to facilitate and support relationships and maintain trust when breaking bad news.

See also

• Empathy versus sympathy (Book chapter 2024)
• Emotional self-care (Book chapter 2024)
• Empathy-altruism hypothesis (Book chapter 2021)

References

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Abdullah, M. A., Khan, K. R., Shaikh, B. T., & Yasin, M. A. (2024). Breaking bad news: A mixed methods study reporting the need for improving communication skills among doctors in Pakistan. BMC Health Services Research, 24(1), 588–588. https://doi.org/10.1186/s12913-024-11056-2

Aoun, S., & Breen, L. (2020). A person-centred approach to breaking bad news.http://hdl.handle.net/20.500.11937/9107

Awwad-Tabry, S. , Elyoseph, Z., Levkovich, I. , & Weisman-Moschkovich, M.(2024). Breaking Bad News: A Case Study of Social Workers Communicating Bereavement and Distressing News in the Aftermath of Hamas Attack in Israel. Psychology, 15, 915-923. doi: 10.4236/psych.2024.156054.

Barclay, L. J., Breitsohl, H. & Kitz, C. C. (2023). The delivery of bad news: An integrative review and path forward. Human Resource Management Review, 33(3), 100971-. https://doi.org/10.1016/j.hrmr.2023.100971

Coles, N. A., Larsen, J. T., & Lench, H. C. (2019). A Meta-Analysis of the Facial Feedback Literature: Effects of Facial Feedback on Emotional Experience Are Small and Variable. Psychological Bulletin, 145(6), 610–651. https://doi.org/10.1037/bul0000194​

Cox, T. R., Gentry, L., & Monden, K. R . (2016). Delivering bad news to patients. Proceedings (Baylor University. Medical Center), 29(1), 101–102. https://doi.org/10.1080/08998280.2016.11929380

Dulmen, S. A., Lukersmith, S., Muxlow, J., Santa Mina, E., Nijhuis‐van der Sanden, M. W. G., & Wees, P. J. (2015). Supporting a person‐centred approach in clinical guidelines. A position paper of the Allied Health Community – Guidelines International Network (G‐I‐N). Health Expectations : An International Journal of Public Participation in Health Care and Health Policy, 18(5), 1543–1558. https://doi.org/10.1111/hex.12144

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Ghanbari Jolfaei, A., Mansoursamaei, A., Mansoursamaei, M., Salehian,R., & Zandi, M.(2023). Self-assessment of residents in breaking bad news; skills and barriers. BMC Medical Education, 23(1), 1–740. https://doi.org/10.1186/s12909-023-04720-4

Healthcare professionals: Hone your advance care planning skills. (n.d.). VITAS Healthcare. https://www.vitas.com/about-us/newsroom/webinar-spikes-protocol-for-national-healthcare-decisions-day-2020​

Leoniuk, K. & Sobczak, K. (2023.Doctors’ attitudes in the situation of delivering bad news: patients’ experience and expectations. Archives of Medical Science, 19(4), 921–929. https://doi.org/10.5114/aoms/112756

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Shackelford, T. K., Welling, L. L. M., & Zeigler-Hill, V., (2015). Evolutionary perspectives on social psychology. Springer. https://doi.org/10.1007/978-3-319-12697-5

External links

• Breaking Bad News Demonstration ( YouTube video)
• Breaking Bad News - SPIKES Overview -OSCE Guide ( YouTube Video)
• How Do I Break Bad News (Hospice friendly Hospitals Book)
• Empathy (very well Mind)
• Procedures explaining Breaking Bad News (Life in the Fastlane)
• Top Tips for Difficult Conversation (South Tees Hospitals)