Breaking Bad News

This is from Dr. R. Buckman's book How to Break Bad News, UofT Press,
1992 and only represents a small portion of his work.

Summary of 6 Steps Protocol in Breaking Bad News

Step 1: Starting off well

Step 2: Find out how much the patient knows

Step 3: Find out how much the patient wants to know

Step 4: Share the information (Aligning and Educating)
Aligning = starting from the patient's starting point
Educating = tips below

Step 5: Respond to the patients feelings

Step 6: Planning and follow through

1)   Always try to get the physical setting right.  Establish a private location.  Decide who should be there and confirm the patient's wishes. Attend to the normal courtesies of introduction and an opening question "How do you feel"

2)  Establish the level of knowledge the patient has so far with respect to: 1) understanding 2) style of statements 3) emotional content which may be verbal an non-verbal

3)   This is a critical step.   The question is not in whether to disclose but At what level that the patient wants the knowledge in.  Reinforce that further information is available at any visit. Caveat: Buckman is a proponent of denial as a coping mechanism.

4) This step is the nitty-gritty of the situation with the following recommendations:
a) decide on your objectives (diagnosis/ treatment plan/ prognosis/ support) - you should have an agenda
b) give information in small chunks; the "Warning shot" in cases of serious info. Discrepancy
c) Avoid medical lingo
d) Check reception frequently allowing the patient to exert control, speak, and shows caring
e) Reinforce and clarify the information frequently - repeat yourself, consider written information
f) Check your communication level
g) Listen for the patient's agenda
h) Try to incorporate your agenda with the patient's

6) Organizing and planning including a contract and follow-through distinguishes your professional role from that of a friend/family.  Allow for questions at this time and set a clear future plan whether you are following up or not.  Clarify your availability.

"...an essential component of human nature, amplified during illness, that everybody wants to be considered as special to some extent... and everyone dreads being ignored." - Buckman, p. 96

Buckman, R, How to Break Bad News: A Guide for Health Care Professionals, 1992