Good communication skills are fundamental to giving bad news appropriately. When bad news is broken insensitively or inadequately the impact can be distressing for both giver and recipient, leaving lasting scars for the latter. Doctors should have a plan for this difficult process and learn how to cope with the recipient's reaction. Most of the circumstances described apply to unexpected death.
Some basic initial rules: H
• If relatives have to be contacted it is preferable for the doctor (if at all possible) or a sympathetic police officer to make the contact personally, rather than a relatively matter-of-fact telephone call from the hospital or elsewhere.
• If a telephone message is necessary it should be given by an experienced person.
• The relatives or close friends should not drive to the clinic alone.
The setting for the interview:
• Use a suitable quiet private room if possible.
• See the recipients of the news alone in the room.
• Advise that the meeting should be undisturbed.
Guidelines for the doctor
• Always ask those involved if they have heard any news or know the reasons for the consultation.
• Always assess their understanding.
• Give information in an unhurried, honest, balanced, empathic manner. 12
• Look directly at the person you are talking to, be honest and direct, and keep information simple (avoid technical language).
• The sad news must be accompanied by positive support, understanding and encouragement.
• Give recipients time to react (offer time and moments of silence to allow the facts to sink in) and opportunities to ask questions.
• Avoid false reassurance.
• Remember that relatives appreciate the truth and genuine empathy.
• In the event of death, relatives should be given a clear explanation of the cause of death.
A list of guidelines for the interview is summarised in Table 5.3 . 11
Table 5.3 Breaking bad news: Recommended actions during the interview
• opportunities to react
• free expression of emotions
• viewing of a dead or injured body Avoid
• withholding the truth
• protecting own inadequacies
• the notion 'nothing more can be done'
Source: After McLauchlan 11
Coping with patient responses
• The responses cover a wide range—stunned silence, disbelief, acute distress, anger, extreme guilt.
• Be prepared for any of these responses.
• Appropriate training using simulated patients, video replays and skilled feedback improves communication skills.
• Give permission and encouragement for reactions such as crying and screaming.
• Have a box of facial tissues available.
• A comforting hand on the shoulder or arm or holding a hand is an acceptable comfort zone.
• Offer a cup of tea or a cool drink if available.
• Ask the patients or relatives how they feel, what they would like to do and if they want you to contact anyone.
• Give appropriate patient education material.
• Provide information about support services.
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