Breaking Bad News Essay
Joined: 11 February 2010
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Topic: Breaking Bad News Essay
Posted: 14 February 2010 at 5:02pm
Heres a recent essay i wrote for a post reg Palliative Care Course. Its aprox 3500 words long and i got a 65% score.
Breaking bad news, or being present when bad news is given, is an integral part of a nurses role (Tobin & Begley 2008) and although a nurse may not always be involved directly in the giving of such news, Price (2006) suggests that it is an inescapable part of healthcare. The general feeling amongst nursing colleagues is that breaking bad news is carried out poorly and is probably one of the more difficult duties faced by the health care professional.
Bad news, simply defined, can be described as any information which is not welcome (Arber & Gallagher 2004), and will adversely alter a personâ€™s future expectations (Back 2005). Considering these definitions it can be said that bad news will have negative consequences for both the patient and their family and will alter their perceptions of the future. Randall & Wearn (2005) suggests that, in the context of healthcare, most often the term â€˜bad newsâ€™ is used for consultations focusing on the diagnosis of serious illness, a negative prognosis or recent death. However this can be expanded to include the discussion of disease progression, a negative or absent response to prescribed treatment or issues surrounding end of life care such as â€˜Do Not Resuscitateâ€™ orders and withdrawal of treatment. A diagnosis of Cancer is arguably the most feared in todayâ€™s society (Kalber 2009), and for the purposes of this essay the subject of bad news will focus on patients with this disease.
It can be assumed that receiving bad news has the potential to have an unfavourable effect on a personâ€™s quality of life, which will subsequently affect their ability to cope. Gowdy (2005) acknowledges that each person will be faced with this situation at some stage and each will receive and respond to this information in a unique way. Kaye (1996) explains that receiving such news alters a personâ€™s whole vision of the future which is why its delivery can come as a shock to the recipients. He compares breaking bad news to breaking an egg, a certain amount of skill being needed to avoid making a mess.
Buckman (1992) suggests that the effect of bad news does not wholly relate to the reaction of the news itself but also on the size of the knowledge gap between the patientâ€™s expectations and the medical reality. For example a patient may already have a suspicion of their diagnosis which may allow them to be more accepting of such news compared to someone who has not previously given any consideration to this.
The goal of breaking bad news is to do so in a way that facilitates understanding and reduces the risk of destructive responses (Watson 2006). This statement can apply to the perspective of both the receiver and giver of such news. From experience it has been noted that health care professionals tend to fear the blame that can be associated with breaking bad news. This could be due to the fact that the giver seemingly inflicts pain or distress on the patient, whereas usually they would be expected to alleviate these symptoms. The situation can also remind the giver of personal vulnerabilities; Buckman (1992) refers to this as sympathetic pain. It is suggested that the health care professional adopts an attitude that enables them to gain an understanding of the impact of the information received which helps avoid disparaging feelings of detachment. Psychological distress is a normal response to both giving and receiving such news and support during this time can avoid detrimental long term effects (Fukui 2009).
It has been established that breaking bad news is a difficult aspect of health care, yet it is debated as to who should communicate the news. Brewin (1998) proposes that serious bad news should be broken by medical rather than nursing staff as they are better equipped to perform the task. It is perhaps expected that a doctor be the person to give news such as a diagnosis or prognosis, however, traditionally nurses have been responsible for breaking bad news in situations where there has already been prior discussion with the medical team regarding these more serious issues. For example, informing the family of an expected deterioration, the death of their relative, news of a delay in discharge or treatment such as theatre being cancelled.
Buckman (1992) suggests that ultimately the responsibility of breaking bad news lies with the Consultant, but this could mean the Consultant making the decision to perform the task himself, or delegate to a more junior staff member. A doctor will have specific medical information to offer, whereas the nurse may be able to give more psycho-social support.
Farrell (2004) states that nurses tend to find the process more rewarding than doctors as they perceive it to strengthen their relationship with the patient and their family. This may be due to the nurse being able to take on a more supportive role during the process, assisting the patient and family to work through their emotions and fears. Lomas et al (2004) states that it is important where possible for the patient to be given the news by someone they know. Nurses have considerably more contact with patients and relatives and recognise emotional labour as an integral part of their role. They are therefore arguably better placed to deliver such news, albeit in the presence of a doctor.
Both the doctor and nurse can bring essential but varying skills to the â€˜breaking bad newsâ€™ meeting and although originating from separate standpoints, their perspectives are equally important. A collaborative approach between medical and nursing staff may be the most effective for all concerned. The presence of a nurse in the meeting will ensure ongoing support for the patient and family when the consultation is over thus minimizing feelings of abandonment. The professionals are also able to support each other during and after such meetings thereby reducing their own psychological distress. Emotional strain is easily felt when dealing with such psychological issues and professional burnout can be a side effect. Millington (2006) stresses the importance of gaining adequate emotional support by clinical supervision, in house counselling or simply by talking things through with colleagues and sharing the burden of breaking bad news as a collaborative procedure. Careful consideration needs to be undertaken to decide who is involved in the process but no matter who gives the news it should be done by someone with expertise and experience.
Receiving bad news is the first step of a journey for the patient and their family and it cannot be disputed that the family plays a significant role in such situations. The relationships within the context of receiving bad news can be viewed as a triangle which includes the clinician, patient and family member (Parpa 2005) and it is suggested that the dynamic within this triangle is affected by each member supporting the other two as required. Considering this structure it should imply that each person involved, is as equally important as another, however this does not appear to be the case when approaching from a moral or ethical standpoint. The patient should be allowed to make informed decisions on how much information they receive, control the timing of such information and who else that information is shared with.
Walker et al (2001) suggests that involving relatives in breaking bad news poses a number of difficulties for the health care professional. However, Brewin (1998) identifies that good communication with relatives not only provides information, but is also a powerful way of giving them courage and confidence. The patient should be consulted in the first instance to establish how much information they require and who they want involved within the process. The cliniciansâ€™ primary responsibility is for the patientsâ€™ welfare despite the familyâ€™s wishes, as there could be conflict between the rights of the patient and those of the family. The health care professional has an ethical and legal obligation to obtain patients consent, if mentally competent before sharing any information about the medical condition with family or friends.
Walker et al (2001) identifies the difficulty in finding ways of empowering patients when they are feeling so vulnerable but suggests that having an advocate such as a relative or close friend will assist in this aim. A key role for the family is supporting the patient through their disease, and involving them at an early stage will assist in the healing process.
Family and friends have high need for information and emotional support at the diagnosis stage as they may equally be feeling shocked frightened and confused (Royal Marsden 2008) Their reactions to bad news are noted to be similar to that of the patient, however the literature indicates that some reactions are unique to the family such as anticipatory grief, guilt and a wish to shield the patient from the situation. Kaye (1996) suggests that the reason families do not wish their loved ones to be told the news is due to their own distress together with an interest in protecting the patient. Many patients will somehow learn of their diagnosis despite efforts of family members and health care professionals to conceal this (Kendall 2005). This can lead to a feeling of mistrust between the patient, and family and the clinical team in a time when trust is paramount.
Buckman (1992) outlines two main objectives when dealing with relatives. Firstly, honouring the patients right to know their â€˜bad newsâ€™ and secondly, identifying and acknowledging the feelings and motives of the family. This will at least demonstrate to the family that whilst their wishes cannot be fully adhered to if the patient requests information, their opinions and viewpoint have been given consideration. Clear, honest communication will ensure that everyone shares the same objective.
The way bad news is given to patients can have a significant impact on their ability to cope with the subsequent issues involved with their treatment and disease. Lomas et al (2004) suggests that the level of skill with which the task is carried out will make a significant difference to the patientsâ€™ psychological adjustment and future compliance with medical management. Johnson (2008) states that empathy, efficiency coping and being knowledgeable are the key issues in effective bad news communication, but perhaps the most important factor of breaking bad news is tailoring the available information to the needs of the individual and allowing them to control the amount of detail given, together with the timing of its delivery. Each patient will have different needs and expectations and the assessment of these variables together with the application of an adopted strategy will determine an individualâ€™s skill at breaking bad news.
Research indicates that the teaching of communication skills is still of low priority despite government agencies outlining the expectation of all doctors to undertake such training (NHS Plan 2000, GMC 2002, NICE Guidelines 2004). Although standards are improving, Farrell (2004) suggests that the subject still receives scant attention during medical training. It appears that although a high standard of practical competency and an in-depth knowledge base is expected of a clinician, the same level of proficiency in interpersonal skills is not mandatory. Communication skills can be learned through a variety of mediums including role play and observation which can then be refined and practiced through experiential learning. It is no longer thought that learning these skills by experience alone is adequate.
Medical education typically offers little formal preparation for the task of breaking bad news despite the emphasis on the need for improvement in this area over the last ten years. It can be argued that nursing education deals more effectively with this type of tutoring as it teaches a problem solving approach. Towers (2007) highlights the benefit of this method, especially in dealing with the psychological impact of breaking bad news. For example, by working through problems as the patient perceives them, the individual is able to acknowledge their own feelings and seek help to work through specific issues. The comparison between medical and nursing education in this instance is an important one. It appears that general pre-registration communication skills within medicine are learned by a mechanical process which does not promote natural human interaction, whereas nurse education centers on the building and developing of a relationship with the patient and their family.
Higgins (2006) suggests that the most frequent dominating behavior within the breaking bad news interview is the giving of biomedical information. Some questions cannot be easily answered scientifically (Wilson 2006) and doctors may feel out of their depth if they have not received training in this area. Education should perhaps be inter-professional, giving both the doctor and nurse insight into each otherâ€™s perspective. Schildman (2005) emphasizes the need for task specific post graduate education on breaking bad news as a way of skill enhancement and continuity to ensure professional proficiency. The GMC as far back as 1993 indicated a particular need for it to be included in the medical curriculum. Not only is this of vital importance in giving the patient the best possible care and treatment but when working alongside a more junior member of the team, the clinician automatically becomes a role model, and therefore subsequent actions could influence otherâ€™s clinical practice, even if the clinician does not possess the correct skills himself.
It is widely accepted that breaking bad news effectively is not a natural gift and there are many different models and strategies developed to assist the clinician in its delivery. The use of a strategy helps steer the health care professional through the interview and subsequently guides the patient through their reaction and absorption of such news. Faulkner (1998) suggests two positive effects of using a structure; firstly it allows the health care professional to perform the task without causing psychological damage to the patient, secondly it leaves the patient in control of the rate at which they receive the news.
Interestingly, it appears that the models and strategies available, although well researched and used to effect, are based on the perspective of the clinician. The patientsâ€™ opinion on whatâ€™s important is rarely considered during their writing and research. This could be due to the difficulty in gaining consent from ethical committees for such research.
The goal of breaking bad news is always the same, to assist the patient in accepting the news and deal with it. However the way in which the strategy is used will always differ depending on the context of the news and the patientsâ€™ response to the information. Even when using a structure Buckman (1992) notes that the health care professional still requires skill to allow the patient to set the pace and to verbalize their reactions. Walker et al (2001) suggests that common sense and courtesy combined with some planning should be enough to ensure that no disasters occur and models are designed to ensure that such basic standards are maintained.
There are several barriers that are perceived to block good communication between health care professionals, patients and families. Research on common barriers focus not only on the limited training available, but also on issues related to the recognition of emotions from the perspectives of both patient and clinician.
Kelsey (2005) proposes that clinicians may distance themselves from the emotional nature of giving bad news in order to distance themselves from feelings of distress. However, in doing so, the patient and family could interpret this as a sign of uncaring. Distancing could be caused by an uncertainty in what to say and a fear of hostility as a result of raising difficult issues. A barrier indication could display as deliberate vagueness by the clinician, use of metaphors such as â€˜massâ€™ or â€˜growthâ€™ and medical jargon. Innes (2009) suggests that such barriers are triggered by unfamiliarity and uncertainty of the patientsâ€™ history and also concern that, due to the uniqueness of each personâ€™s illness trajectory, some information may be proven inaccurate. It has to be considered that the health care professional could also have an intrinsic fear of being the receiver of bad news or have experience as a family member of a similar encounter.
A barrier could be formed by the cliniciansâ€™ inability to manage the patientâ€™s response during an interview. This may result in inadequate or incomplete information giving which would subsequently affect the way in which the clinician deals with the patientsâ€™ emotional response. Joekes (2007) identifies the necessity to recognise these feelings and prevent them from obstructing the support of the patient and family. The emotional nature of such news can cause the patient to behave in a manner that is detrimental to their understanding and the absorption of the information being given. Evidence suggests that patients are more prone to misinterpretation of the given news and in their attempt to maintain hope, view the situation more positively than was intended. Innes (2009) implies that misinterpretation is enhanced by the use of medical terminology and lack of clarity in the information presented.
Joekes (2007) outlines factors such as age, gender, social status and race which can create barriers to communication. This could be extended to include issues related to hospital settings such as lack of privacy, time constraints and lack of team support. However Innes (2009) notes the importance of not making assumptions on the consideration of these factors, using them as excuses for poor delivery of information.
Time is probably the most significant institutional barrier in relation to psychological care. Schofield et al (2006) identifies that when other responsibilities are competing for attention, â€˜sitting downâ€™ and â€˜talkingâ€™ may not be considered as important or valid as physical care, especially in an acute or busy clinical area. This would not occur in any other aspect of patient care, for example, a complex wound dressing may be equally as time consuming but rarely neglected. Therefore a potentially long consultation should be identified and planned where possible, in order to adjust the workload accordingly.
By acknowledging such barriers as areas of weakness, the health care professional can work to improve both their ability and confidence within their clinical practice.
The impact of bad news can have a long term effect on both the patient and the family. Towers (2007) suggests that the way in which a person deals with this impact could be seen as either detrimental or therapeutic. Support and guidance following bad news will help to minimize distress and assist the patient and family to work through their feelings, concluding in an adjustment to their situation (Davidson 2005).
There is a significant difference in the type of anxiety felt by the patient to that of the family in this instance. Fitzsimons (2007) suggests that the patientsâ€™ main concern lies with the uncertainty of their future and their pending deterioration in health, whereas family members are troubled initially with the distress caused by the bad news and later, the potential of unresolved symptoms and a fear of seeing their loved one suffering. The patient may view their journey as leading down a path to decreased independence, social isolation and family burden; other stress factors may include fears about the dying process itself. However the literature suggests that the level of distress experienced will depend on personality and coping ability as well as social support and current health status (Taylor & Ashelford 2008).
Throughout the patients disease trajectory it is important that they do not lose hope. Parpa (2008) explains that despite the inevitability of eventual death, a patient's hope can shift during their journey through the illness. For example, hope may shift from the hope of a cure and hope for a prolonged life to the hope for dying well. It is important for the health care professional not to give false hope when answering questions and giving information, but continue to support and inform the patient when required.
A support network for the long term is paramount for both the patient and family, and the provision of information is perhaps the key to such support. From the familyâ€™s perspective the situation not only involves â€˜caring aboutâ€™ a person but also â€˜caring forâ€™ that person. This shift in perspective can cause considerable stress, however it is evident that in most research studies to date, the family conveyed their willingness to look after the patient despite the difficulties they encountered (Fitzsimons 2007).
The patientâ€™s perspective and understanding of the situation will obviously influence their adjustment to the news and use of subsequent coping mechanisms. Support networks should be identified and made available to the patient and their family to assist in the acceptance of their circumstances.
It is accepted that breaking bad news is difficult for health care professionals but learning the skills to perform the task well will greatly enhance the clinicians experience and obviously benefit the patient and their family. From the authors experience bad news is seldom broken effectively and following an examination of the available literature areas for improvement have been identified, namely education and collaboration together with an awareness of personal and institutional constraints. Breaking bad news is not a â€˜one offâ€™ event within the patientâ€™s disease trajectory. News needs to be digested, with time given to think of further questions, and further opportunities offered to address them.
All health care professionals should provide ongoing support to patientâ€™s families and each other. The notion of teamwork is central to an effective bad news interview and a collaborative approach will ensure all parties are satisfied with their particular role within the team and avoid burnout. By using a structure to break bad news the stress of the process will be decreased. The health care professional needs to explore their own feelings in order to empathize with others and be more supportive.
People always remember being given bad news, no matter how well it is delivered (McCulloch 2004) . Health-care professionals have a responsibility to minimize the trauma of this experience by being well prepared. Timmings (2004) recognizes that it may not always be possible to achieve best practice within the clinical setting but suggests that the quality of breaking bad news practice should be assessed and monitored at regular intervals. Competent and caring communication in a cancer diagnosis is an essential part of the patient's trajectory along the cancer journey (DoH 2001). If dealt with properly, it can aid the patient's progress towards adjustment.
Joined: 11 February 2010
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|Quote Reply Posted: 14 February 2010 at 5:05pm|
Forgot to add the reference list:
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Joined: 15 March 2006
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|Quote Reply Posted: 15 February 2010 at 11:18am|
Thank you so much for posting it and well done!
Joined: 07 December 2009
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|Quote Reply Posted: 21 October 2010 at 3:33am|
Consider what the bad news is. How bad is it? Are you trying to tell someone that their cat died, or that you lost your job? Has a family member or close friend died? If the bad news relates to you (such as you lost your job) the effects will be different than if the problem relates to them (their cat died).
I read this topic at : http://www.wikihow.com/Break-Bad-News.
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