Author: Charlotte Davies / Editor: Liz Herrieven / Codes: SLO7 / Published: 03/09/2024

This blog will aim to introduce some concepts around bad or difficult news, link to some structures for delivering bad news, and hopefully stimulate some further thoughts and discussions. 

So firstly… what is bad news and is it the same as difficult news? I’ve been caught out many times when delivering bad news because I didn’t anticipate that the patient would feel it was bad. Generally, imminent death is accepted to be “bad” by the deliverer and the recipient – but is a broken leg bad news? A heart attack? A need for an operation? Not being able to drive? I’ve found it’s best not to assume the news will be “ok”, and to prepare for the majority of conversations as if they will be received as bad news. The way you approach this in “real life” may be very different to the way you might approach it in an exam situation.

DNA CPR and Treatment Escalation has been discussed in our other blog here along with the need to accurately identify dying covered originally here, and then here, so this will not be re-visited.

Communication Strategies

1. Avoid self-fulfilling prophecies and Nocebo.

Nocebo: A harmless thing that causes harm because you believe it’s harmful.

Reframe “If you don’t stop drinking, you’ll die soon” to “The health effects of stopping drinking will be more evident every day”.

2. Consider the environment

We know the environment in Emergency Department (ED) is challenging, and if the environment is sub-optimal, I consider this my “warning shot” as I say “I’m sorry it’s so noisy in here, as I’ve got difficult information to give you”.

3. Prepare yourself

Start with the basics – phone on silent, and bleep elsewhere. Make sure your tummy won’t start grumbling, and you’re well hydrated. Ensure you’re toileted. Do you need someone (usually a nurse who is involved in the patient’s care) with you? Then, ground yourself to reduce anxiety and make sure you are feeling kind and ready to go – patients notice if you seem nervous.

4. Deliver the message

  • Consider a pre-planned script e.g. “Mr X, we’ve noticed that you’ve been to ED three times in the last six months with chest infections. Although you got better last time, I’m worried you won’t get better next time.”
  • Pause for at least ten seconds
  • Check understanding with closed loop communication
  • Ask “What questions do you have for me?” as acknowledging that there will be questions and giving permission to ask them is likely to get you more response than “Do you have any questions?”.
  • Actively listen to the questions, and any comments you get.

It’s worth watching and listening to how others break bad news. There will be good and not-so-good points for you to learn from. It might feel intrusive to tag along when someone is delivering bad news, so judge each situation before diving in. Often it’s useful for the person delivering the news to have another member of staff present, to pass tissues, watch for signs of someone not understanding, or to go back and answer questions later if the lead clinician is busy. This is often a member of the nursing team, but doesn’t have to be. Equally, if you’re delivering the news, could a junior colleague come along to provide support and to learn?

Bad News Structures

I love this approach from LITFL, as I think it allows for a sliver of optimism, whilst still maintaining realism. I often say, the best case is, the two week wait referral will show there’s nothing wrong. Worst case, they’ll identify a cancer and give you a chance to ask questions about treatment options.

  • Spikes

I don’t use SPIKES in ED, as I don’t always find it very useful, but it is a good reminder and a helpful strategy for exams. We’ve already talked about setting up and considering the environment – these are essential. Perception can be useful to ascertain as often patients are more aware than we give them credit for. Invitation can be useful – do we need to go ahead without an invitation? Knowledge is very important. Exploring and displaying empathy should be integral to everything we do. Summaries are always VERY important. 

  • GRIEV_ING is great, but I find it too complicated to remember!

SAGE & THYME is a commonly used strategy, and I like the empowerment aspect of it – “What do you think would help?”. This approach seems more focussed on exploring concerns rather than communicating difficult news.

This is all summarised by St. Emlyn’s.

Hopefully this has been a useful introduction to some of the strategies you can use. This is a real life situation we all approach regularly, as well as being an easy topic to examine in OSCEs (see St Emlyns). 

Consolidate your knowledge by thinking what approach you’d take in these scenarios:

  • A single parent with no family support needs admitting with a broken femur after falling down the stairs.
  • A high profile lawyer has a massively raised troponin, and needs admitting for cardiology review the day before their case comes to trial.

References

  1. Edwards S. Dying Matters in the ED. RCEMLearning, 2020.
  2. Nickson C. Best Case/Worst Case – a communication tool. Life In The Fast Lane (LITFL), 2023.
  3. Minhas H, Davies C. Hypnosis and EM. RCEMLearning, 2021.
  4. Nasser L. Breaking Bad News. CanadiEM, 2020.
  5. Nickson C. Breaking Bad News to Patients and Relatives. Life In The Fast Lane (LITFL), 2022.
  6. Sanders S, Gebhardt K (2016, August 2). The GRIEV_ING MNEMONIC: A Simple Approach To Death Notification In The ED [NUEM Blog. Expert Commentary by Neely K].
  7. Morgenstern J. Breaking Bad News: Notifying family members of a death in the emergency department. First 10EM. 2015, Updated in 2019.
  8. Sidhu S, Cheese F. Breaking Bad News – OSCE Guide. Geeky Medics, 2023.
  9. Back AL, Curtis JR. Communicating bad news. West J Med. 2002 May;176(3):177-80.
  10. Davies, C. Nocebo. RCEMLearning, 2015.
  11. Davies, C. Communicate, communicate, communicate. RCEMLearning, 2020.