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1. Reporting bad news
Palliative care
Lior 1852

2.  Bad news is “any news that adversely and seriously affects an individual’s
view of his or her future”
 Bad news is therefore the gap between the patient's expectation and the
reality of the patient's medical condition

3.  Delivering bad news is one of the most daunting tasks faced by physicians. For
many, their first experience involves patients they have known only a few
hours. Additionally, they are called upon to deliver the news with little
planning or training . Given the critical nature of bad news, that is, “any
news that drastically and negatively alters the patient's view of her or his
future” , this is hardly a recipe for success.

4.  The fears doctors 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 physicians to become emotionally disengaged from their patients.
 Additionally, bad news delivered inadequately or insensitively can impair
patients' and relatives' long-term adjustments to the consequences of that
news.

5. Breaking bad news models
 NON-DISCLOSURE model
 FULL DISCLOSURE model
 INDIVIDUALIZED DISCLOSURE model

6. NON-DISCLOSURE MODEL
 Less used
 This model is used when the physician or the patient relatives fear about the
actions of the patient when he will hear the “bad news” about his illness, the
“physician is decides what is the best for the patient”
 Also occur when the patient has no interest to here about the bad news.
 Either way the patient not informed, can make him less cooperative

7. Full - Disclosure
 In this model the patient is informed about anything regarding his illness,
including small details and unimportant for his understanding of the illness.
 Done due the presumption that patient need to know about his illness and
adapt to the new situation

8. Individualized disclosure
 Usually the prefer one
 In this mode the physician take into consideration that every patient is
different by his perception of getting the bad news, and is individualized
during the conversation with the patient, if the patient need more detailed or
want less to hear about that.
 Has the Advantage of building collaboration of relationship between the
physician and the patient

9.  There are 6 steps protocol for communicating of bad news – SPIKES
 S – SETTING UP – preparation
 P – PERCEPTION – what does the patient knows
 I – INVITATION – how much does the patient want to know
 K – KNOWLEDGE – giving information
 E – EMPATHY – responding to emotions
 S – SUMMARY AND STRATTEGY – summary and planning

10. SETTING UP
 Setting up discussion and confirmation of medical facts.
 Create an environment, leading to effective communication: arrange for
privacy, comfortable and quiet environment, without the risk to be disturbed.
 Ensuring confidentiality and preventing interruptions.
 Allot adequate time for the discussion.
 Determine who else the patient would like to have present for the discussion
(family members, friends, interdisciplinary team members, others)

11. PERCEPTION
 Determine the patient’s understanding and expectations of the situation.
 Start the discussion collecting anamnesis and establish what and how much
does the patient knows or suspects (or his/her family) about the patient’s
state of health.
 The questions will be open:
- “What do you understand about your illness/what is happening?”
 Occasionally the patient can remain silent and seems completely unprepared
or incapable of responding.
 To ease the situation and facilitate discussion, try to clarify what does the
patient understand about his/her medical status and recently underwent
investigations.

12. INVITATION
 Obtain the patient’s permission to disclose the news and what level of detail
is desired.
 People manage information in different way depending on ethnic, cultural,
religious aspects and social-economic status.
 Each person has the right to refuse, to receive the medical information and
has the right to appoint someone else in his/her place.
 Check if more information is wanted and at what level
 Find out from the patient if he or she want to know the details of the medical
conditions and or treatment.

13. KNOWLEDGE
 Share the information in small pieces without medical jargon, allowing time
to process. Assess the patient’s understanding. Be clear and simple, avoiding
medical jargon.
 Use silence and body language as tools to facilitate the discussion.
 You might choose to break bad news by using language like:
” I'm afraid the news is bad. The biopsy shows … that you have ... colon
cancer....”
 The phrase ”I’m sorry” can be interpreted by patient that the physician is
responsible for situation. If you still use this phrase, try adjusting it to better
show empathy.

14. EMPATHY
 Acknowledge the patient’s emotions, and provide opportunity to express
them. Listen and offer empathetic responses.
 Patients and families respond to bad news in a variety of ways.
 Outburst of strong emotions make many physicians uncomfortable.
 Give the patient and family time to react. Remind patients and families that
their responses are normal.
 Encourage the patient to express his/her feelings.

15. SUMMARY AND STRATTEGY
 Summaries what has been said, emphasizing the positive.
 Establish a plan for the next steps, using written or printed material if
possible. This may include gathering additional information or performing
further tests.
 Treat the present symptoms and discuss the treatment plan.
 Discuss about the potential sources of psycho-emotional, social, spiritual
support (e.g., family members, social worker, support groups, psychologist
etc.)
 Keep hope, but do not provide early assurances.
 Provide the availability for the future and establish a follow-up appointment.
 At the next meeting many of the patients and their families need to resume
bad news for a complete understanding of the medical situation.

16. CONCLUSIONS
 Communicating the diagnosis is a requiring process.
 It requires certain skills and techniques that can and must be taught.
 Patients have the right but not the obligation to find out about their
diagnosis and prognosis.
 Patients need honesty, clarity, time, interest, information adaptation and
fidelity.

17.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4677873/
 https://www.investopedia.com/terms/n/nda.asp
 Buckman R, How to break bad news: A guide for health professionals.
Baltimore, MD, John Hopkins Press, 1992.