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Breaking Bad News


Breaking Bad News


The MRCGP course organisers have written some quick reference tools to help you pass your MRCGP CSA exam and aid you in your consultation skills. We recommend using and adapting them into your daily consultations to improve your communication skills. All the articles and headings below are covered on the MRCGP course in detail and role-played in the group



  • General principles with breaking bad news
    • Allow the patient as much time as they need and do not make them feel rushed.
    • Facts – Ensure that you have access to all the facts when you see the patient and think through what needs to be communicated before you see the patient.
    • Rapport – Establish rapport and try and use appropriate eye contact. 
    • Manner – Look calm, using an appropriately slowed down tone and pace of voice when speaking to the patient.
    • Pauses – Use pauses effectively and give the patient plenty of time to digest what you are telling them.
    • Warning Shot – Try and drop a warning shot that the news you have today for the patient is not all good.
    • Empathy – Display sympathy and empathy to the patient even if it not your naturally disposition not to do so.
  • Avoid 
    • Overloading  Avoid overloading the patient with excessive facts and figures that they may not be able to retain or understand.
    • False Promises  Avoid giving false hopes to the patient and similarly avoid painting a bleaker picture than what the results indicate. 
    • Evasive  Do not be evasive to their questions instead try and answer them as honestly as possible however awkward. 
    • Rushed – Avoid trying to turf out the patient once you have handed over the news

  • Setting the Scene
    • Before you even see the patient, ensure that you have read the case notes clearly and formulated a plan about how you wish to convey the news. 
    • If the candidate brief is not comprehensive, offer to take a very brief history from the patient about what has happened up until that point
      • Thanks for coming in today. As we have not met before, can I just ask you a few questions before we speak about the test results today?
    • Try and establish the patient’s understanding about why they were sent for the test and what the doctor or health professional had communicated to them about what it was looking for.
      • With your symptoms going on for such a long time, did you think about what may be causing it?
      • Was there anything playing on your mind that worried you about your symptoms?
    • Try and find out whether the patient attended the appointment on their own or whether someone came with them.  Establish who is at home with them and whether they have any social support from a partner, friends or children. 

  • Fire a warning shot
    • Ensure that before you break the bad news you do not do it all in one go, but rather perform it in stages and fire a warning shot suggesting that some unpleasant news may follow
      • Unfortunately, I have some difficult news I have to tell you… 
      • The results are a little more serious that we had hoped…
  • Breaking the news
    • Ensure that before you break the bad news you do not do it all in one go, but rather perform it in stages and fire a warning shot suggesting that some unpleasant news may follow
      • Unfortunately, I have some difficult news I have to tell you… 
    • Provide an honest and clear explanation about what the results show. Repeat important information if need be. 
      • The results show some changes in your scan results. Although this may be caused by infection or inflammation, sadly at this stage we cannot exclude cancer as a possible cause.

  • Await the patient’s response
    • Patients may respond a number of ways when hearing the news. Give them the space and time to respond how they feel appropriate.
      • I am sorry that you were not expecting this news…  
    • If the patient cries, offer tissues or if you feel appropriate, a gentle touch on the shoulder or lower thigh to give reassurance and show empathy.
      • If the patient goes into shock and does not respond then give them the space to do so. Do not disengage with the patient and offer them all the time they need
        • Please take you time… I know it is a lot to take in… 
        • I am happy to wait until you are ready to do so…

    • Offer a management plan
      • Explain to the patient what will happen next.
        • I am taking your results seriously and will be referring you to see a specialist within 2 weeks… 
        • They will assess you and carry out some more tests. After this, they should be in a better position to tell you what is actually going on…

    • Closing the consultation
      • Do not make the patient feel rushed that they have to leave your room.
      • Offer to contact a friend or family member to come and pick up the patient if they have attended alone.
      • Offer to call a receptionist or nurse to stay with the patient in a quiet room before they have to go home.
      • Offer an open appointment so the patient can return when they are more comfortable.
        • There has been a lot spoken today. I am sure you will have many questions and will have more questions when you go home. I am happy to see you in a few days time to talk these through with you…


    SET THE SCENE
    Thank you for coming today. Before we begin can I just check if you came with someone or came alone?
    We have not met previously. Before we speak about the results, can you tell me a bit more about your symptoms?


    BREAKING THE BAD NEWS
    I am sorry but I have some difficult news to tell you…
    Although your results could be due to infection or inflammation, we cannot exclude cancer as a possibility…


    CONCLUDING THE CONSULTATION
    I can imagine that it must have been quite difficult for you…
    I would like to get the receptionist or nurse to make you a cup of tea and take you to a quiet room before you go home…
    I am sure you have a lot going through your mind and I would like to see you again in a few days time to discuss this… is that ok?


    By Nazmul Akunjee & Muhammed Akunjee
    03.05.2014