Giving sad and bad news

The Disclosure of Bad News Over the Phone vs. in Person and its Association with Psychological Distress: a Systematic Review and Meta-Analysis

BACKGROUND

Communicating bad news such as a new cancer diagnosis to patients may have a major impact on their well-being. We investigated differences in patients' psychological distress due to the disclosure of bad news by telephone compared to in person in a systematic review and meta-analysis.

METHODS

We included all studies that investigated anxiety, depressive or post-traumatic stress disorder (PTSD) symptoms in adult patients in whom bad news by telephone compared to in person were disclosed. We systematically searched PubMed, Embase, PsycINFO and CINAHL from the inception of each database to October 18, 2022. We included randomized and non-randomized trials.

RESULTS

We screened 5944 studies and included 11 studies in the qualitative analysis and 9 in the meta-analyses, including four randomized controlled trials. Overall, the quality of studies was moderate to good. There was no difference regarding psychological distress when bad news was disclosed by telephone compared to in person with similar symptom levels of anxiety (3 studies, 285 participants; standardized mean difference [SMD] 0.10 [95% CI -0.15 to 0.35]), depression (3 studies, 284 participants; SMD 0.10 [95% CI -0.30 to 0.49]), and PTSD (2 studies, 171 participants; SMD -0.01 [95% CI -0.48 to 0.36]). Results were similar for satisfaction with care.

DISCUSSION

This meta-analysis found no difference regarding psychological distress regardless if bad news were disclosed by telephone or in person, but there were overall only few and heterogeneous studies with a small number of eligible patients. The findings suggest that the modality of disclosure might play a secondary role and the way in which the bad news are communicated might be more important.

Training pharmacy students to deliver bad news using the SPIKES model

BACKGROUND AND PURPOSE

Delivery of bad news or negative health information is a complex skill critical to the provision of patient care. While counseling models with this focus exist within other health care professions, their use in pharmacy education is lacking. The purpose of this study is to assess pharmacy students' ability to deliver bad news with the implementation of a counseling model titled SPIKES (Setting, Perception, Invitation, Knowledge, Emotions with Empathy, and Strategy/Summary).

EDUCATIONAL ACTIVITY AND SETTING

First-year pharmacy students attended a one-hour training on the SPIKES model and completed three simulations with its application. Pre- and post-training surveys were administered to assess confidence, attitudes, and perceptions. Student performance during the simulations was evaluated by teaching assistants (TAs) as well as a self-assessment using the same grading rubric. A paired t-test was used to test for significant mean improvement in competency scores, confidence, attitudes, and perceptions from Week 1 to Week 3.

FINDINGS

One hundred and sixty-seven students were included in the analysis. There was a significant improvement in the student's self-assessment of their performance for each of the SPIKES components and summative scores. For the TA assessment, there was a significant mean improvement in the summative SPIKES score; however, within each component of SPIKES, only the knowledge component showed significant mean improvement. There was also a significant improvement in student confidence in the post-training surveys.

SUMMARY

Implementation of the SPIKES protocol in the pharmacy curriculum showed an overall improvement in students' self-assessed performance in delivering bad news.

Communicating Unexpected and Violent Death: The Experiences of Police Officers and Health Care Professionals

BACKGROUND

The notification of unexpected and violent death represents a challenging experience for police officers and health workers. These professionals are exposed to very intense emotions during this task.

AIM

We aimed to investigate the degree of preparation, and the emotions and attitudes of police officers and health professionals while communicating such a death.

METHOD

An ad hoc online questionnaire was created and disseminated through Qualtrics software. The participants were recruited through the institutional channels of Police, the College of Physicians, the ONG De Leo Fund and the Department of General Psychology of the University of Padua. In this qualitative study, thematic content analysis was used to examine the responses.

RESULTS

A total of 155 individuals participated in the study (44 females, 111 males): 102 individuals were police officers, 23 were doctors and were 30 nurses. Five main themes were identified: (1) how the communication took place; (2) the experiences during the communication; (3) the difficulties encountered; (4) coping strategies, and (5) forms of support. Most communications were performed in person, and most represented an intense emotional experience for the notifiers. There is a generalised lack of specific preparation and training for this practice. The recipient's characteristics (culture of origin, language, age, health conditions, psychological vulnerability) may add to the difficulties of the notification process. Professionals unload their tension by practicing sport, relying on their hobbies or interacting socially. The presence of other colleagues during and after the death notification is usually able to alleviate the burden of the communication.

CONCLUSIONS

Communication modalities can have a profound impact on the recipients and intensify the trauma of the loss; however, they also have the possibility of mitigating it. The notification of a violent and unexpected death remains a difficult and challenging task for the notifier, which is potentially stressful and emotionally charged. The topic is of great relevance and more research should be promoted in this area.

Receiving Notification of Unexpected and Violent Death: A Qualitative Study of Italian Survivors

(1) Background: The loss of a significant person can be especially traumatic when death comes without warning and is due to causes such as suicide, murder and accidents. The way an individual is informed about the loss can affect the way of adapting to the loss and the quality of life of survivors. Communication modalities of the notifier may deeply influence the bereavement process. Aim: The present investigation aimed to explore the experience of those who received communication of such a type of death by a professional figure. (2) Method: Snowball sampling was used to recruit the participants to this qualitative study. Social networks, word of mouth and researchers' acquaintances were used, including clients of the NGO De Leo Fund. A total of 52 Italian people (eight males and forty four females, mean age = 49.44; SD = 14.23) who received notification of the death of a loved one by police officers or by health professionals participated in the study. Deaths involved cases of suicide, murder, road accident and mountain accident. (3) Results: The following four key themes were identified: (a) how the communication took place; (b) reactions; (c) support; and (d) coping strategies. Only 22 participants reported having received clear information about the dynamics of what happened; the rest of the sample obtained only poor or ambiguous information. The majority of participants sought or received informal support from family and friends immediately after notification; however, some participants experienced a total lack of support. The opportunity to see the body of the loved one for the last farewell, when denied, caused discomfort in recipients of the news. (4) Conclusions: Even the impactful notification of a traumatic death such as suicide or road accident can be mitigated by the appropriate behaviour and attitude of notifiers, who should always avoid providing generic or ambiguous information about what happened. The notification process should not end with the simple transmission of the communication, but should also look at the following phases by including referral to supportive networks or bereavement services, aimed at assisting individuals in the immediate aftermath but also in the long term.

'It was like being hit with a brick': a qualitative study on the effect of clinicians' delivery of a diagnosis of eye disease for patients in primary and secondary care

OBJECTIVES

To explore patients' experiences of getting a diagnosis of eye disease, the psychological impact of this and how this could be improved.

DESIGN

An exploratory qualitative interview study using a narrative approach and inductive methods.

SETTING

This study was conducted with patients who had attended ophthalmic appointments in primary and secondary care and in opticians located in the South of England.

PARTICIPANTS

18 people diagnosed with eye disease in England.

RESULTS

Four themes were identified: the convoluted process of being diagnosed, the impact of clinicians' words, the search for information and reflections on what could be improved. The prolonged wait for a definitive diagnosis was a source of frustration and anxiety for many patients. Professionals' words and tone when delivering a diagnosis sometimes affected a patient's view of their diagnosis and their later ability to come to terms with it. Patients were desperate for information, but many felt they were not provided with sufficient information at the time of diagnosis and did not know whether to trust information found online. Participants felt the provision of a hospital liaison service and/or counselling could mitigate the impact on patients and families.

CONCLUSIONS

Interactions with clinicians can have a lasting impact on how a diagnosis is experienced and how well the patient is able to come to terms with their visual impairment. Receiving little or no information left patients feeling lost and unsupported. This led them to search for information from less reliable sources. Clinicians should consider how they communicate a diagnosis to patients, how and when they offer information about diagnosis and prognosis and where possible signpost patients to additional support systems and counselling services as early as possible.

Developing a question prompt list for the oncology setting: A scoping review

OBJECTIVE

The purpose of this study was to provide an overview of existing methods used to develop a Question Prompt List (QPL) for an oncology setting.

METHODS

We conducted a search of the literature published between 1999 and 2019 in five online databases followed by a hand search, and extracted data on the methods used to develop a QPL.

RESULTS

A total of 21 studies were included. The review shows differences in the development of older QPLs (1999-2009) and current QPLs (2010-2019). However, most QPLs were developed using interviews or focus groups with patients and an expert session to review or adapt the QPL. Health professionals, patients, and researchers were included in nearly all the studies.

CONCLUSION

To develop a QPL, it is important to combine several information sources and at least to involve health professionals, patients, and researchers in the development process. Review or evaluation steps can improve the appropriateness and acceptance of a QPL.

PRACTICE IMPLICATIONS

Further research is needed to define the type of target population for new QPLs and to develop a framework for their development.

The experience of pre-hospital emergency personnel in breaking death news: a phenomenological study

BACKGROUND

Today, breaking the death of patients to their families has become one of the challenges for medical staff. Considering the lack of study in the pre-hospital emergency, the present study aimed to explore the experience of pre-hospital emergency personnel regarding the breaking death news to families.

METHOD

In this qualitative study with a descriptive phenomenological method, data were collected by purposeful sampling method through in-depth interviews with thirteen pre-hospital emergency personnel in Kermanshah and Kurdistan provinces. After recording and writing the interviews, the data were managed by MAQUDA-10 software and analyzed using the Collaizi approach.

RESULTS

Of 13 participants, five from Kermanshah, eight from Kurdistan, and 12 (92%) were married. The mean age and work experience were 34.38 and 10.38 years, respectively. Five main extracted themes were 1) perceived stress, 2) challenge factors of breaking death news, 3) unnecessary actions, 4) death breaking precautions, and 5) BDN requirements. They were covered fifteen sub-themes.

CONCLUSION

In this study, emergency medical employees were always faced with stress and challenges to announce the patient's death to families, including the stress of violence against employees. Hereof, personnel had to take unnecessary care actions such as slow resuscitation to transfer the patient to the hospital.

Prognostic disclosure in oncology - current communication models: a scoping review

BACKGROUND

Prognostic disclosure is essential to informed decision making in oncology, yet many oncologists are unsure how to successfully facilitate this discussion. This scoping review determines what prognostic communication models exist, compares and contrasts these models, and explores the supporting evidence.

METHOD

A protocol was created for this study using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols extension for Scoping Reviews. Comprehensive literature searches of electronic databases MEDLINE, EMBASE, PsycINFO and Cochrane CENTRAL were executed to identify relevant publications between 1971 and 2020.

RESULTS

In total, 1532 articles were identified, of which 78 met inclusion criteria and contained 5 communication models. Three of these have been validated in randomised controlled trials (the Serious Illness Conversation Guide, the Four Habits Model and the ADAPT acronym) and have demonstrated improved objective communication measures and patient reported outcomes. All three models emphasise the importance of exploring patients' illness understanding and treatment preferences, communicating prognosis and responding to emotion.

CONCLUSION

Communicating prognostic estimates is a core competency skill in advanced cancer care. This scoping review highlights available communication models and identifies areas in need of further assessment. Such areas include how to maintain learnt communication skills for lifelong practice, how to assess patient and caregiver understanding during and after these conversations, and how to best scale these protocols at the institutional and national levels.

Art of breaking bad news: A qualitative study in Indian healthcare perspective

BACKGROUND

Health-care communication is essential for amiable provider-recipient relationship. This study explored various health-care experiences and expectations of service recipients and providers in private clinical establishments of West Bengal, India, while breaking difficult news, bad news, and death.

AIM

The current study was framed with the following research question: What are the varying perceptions, experiences, and expectations of healthcare recipients and their providers while seeking/delivering support in situations of breaking bad news and communications on death?

MATERIALS AND METHODS

The data were collected through individual in-depth interviews-31 respondents that included 16 patients and their families (recipient) and 15 medical practitioners (provider). Inductive thematic analysis was used.

RESULTS

Three main themes and nine sub-themes were identified highlighting livid experiences and perceptions of respondents. The findings suggest that interpersonal communications involve language barriers, health literacy and COVID-19 pandemic, situations of sudden unexplained death, perceptual negativity surrounding healthcare, empathy as well as emotions and multiple affiliations leading to ethical moral conflicts to influence individual perception. Regarding treatment attributes, factors of inaccessibility misconceived as incompetence and waiting and contact time are involved. The behavior and personality dimensions include attitude and robustness of the patient party and capability to handle emotions that affect provider-recipient relationship during communications of bad news and death.

CONCLUSION

This study provided a local perspective about the experiences and expectations of healthcare recipients and their providers. Understanding this critical realm shall help in bridging the gap between recipient expectations and provider practices. It will also attempt towards possible alignment to improve patient satisfaction.

Communicating bad news of COVID-19: An empirical study of patients' preferences in India

The study aims to assess patients' preferences regarding physicians communicating bad news of COVID-19. Based on the data collected from 74 patients with COVID-19 in India, this study assesses "how" patients want bad news to be delivered. Key aspects of the physician-patient interaction were identified from the literature. Regression tests proved that three main constructs contribute significantly toward patient outcomes. Content of the message and facilitation were most crucial, however too much emotional support was not desirable by patients. Also, the patient's gender and educational background should be considered before breaking bad news . Thus, to increase patient compliance full disclosure and patient-centered methods of communication can be used.

The Impact of Police Behavior During Death Notifications on Mental Health of the Bereaved: A Cross-Sectional Study

The delivery of death notifications may affect the mental health of bereaved individuals. Police officers are often the first people with whom the bereaved have contact in this exceptional situation. Therefore, it is essential to assess the behavior of police officers and the impact on the bereaved. We examined the experiences of 86 individuals who received the notification through the police and assessed symptoms of prolonged grief, depression, and posttraumatic stress symptoms. The interaction with police was associated with posttraumatic avoidance behavior and the presence of another supporting person was associated with higher scores of depression. Handing out information material and staying with the bereaved was related to a positive evaluation of police behavior. It appears important to identify helpful and problematic behavior for a better understanding and for an adaptation of existing guidelines.

A study of Chinese medical students' communication pattern in delivering bad news: an ethnographic discourse analysis approach

BACKGROUND

Breaking bad news is inevitable for prospective doctors, it is important for medical students to learn how to humanely communicate devastating news to patients. This study explores the discourse strategies used by Chinese medical students when conducting critical conversations via role-play scenarios.

METHODS

Fifty Year-6 medical students attending the 'Serious Illness Communication Module' were recruited from a local medical school in Hong Kong. They were asked to participate voluntarily in two role-play scenarios requiring them to break bad news to a simulated patient in Cantonese. The verbal interactions were video-recorded and analysed using an ethnographic discourse approach to unpack the quality of the observed interaction sequences and identify the discourse strategies strategically used by the medical students to overcome any communication breakdowns (e.g. linguistic expressions conveying diagnoses) and show empathy to patients.

RESULTS

Six discourse strategies for delivering bad news were identified in the Chinese context: (1) placing great emphasis on patients' emotional needs; (2) informing patients with a balanced focus on medical and emotional needs; (3) directing patients' attention to treatment options; (4) acknowledging concerns about dying patients' physical discomfort and wishes; (5) directing bad news disclosure to patients; and (6) addressing the family expectations of patients. The majority of the Chinese medical students in this study used a patient-oriented approach to cater to the patients' emotional and physical needs. They also often informed and acknowledged the patients' family members.

CONCLUSIONS

When delivering bad news, medical students should be equipped with discourse strategies that effectively balance interpersonal communication with the communication of medical expertise, which is integral to ensuring patients' participation, their understanding and satisfaction with their clinicians. This is in accordance with the existing communication frameworks for critical conversation and demonstrates awareness of the needs in the Chinese context. However, some students demonstrated poor sensitivity to non-verbal cues, such as tone, manners and attitude. Thus, more training using a culturally appropriate model of   communication for critical conversation should be promoted.

[Heidelberg Milestones Communication (HeiMeKOM) - Experiences, Best Practice Examples and Recommendations from the Final Symposium on January 30 and 31 in 2020]

The National Cancer Plan emphasises the importance of medical communication and calls for its integration into medical education and training. In this context, the Milestone Communication Approach meets the communicative challenges in dealing with lung cancer patients. Interprofessional tandems, consisting of doctors and nurses, conduct structured conversations at defined moments with patients and their relatives. The concept aims at shared decision making, continuity in the care of lung cancer patients and the early integration of palliative care. During the symposium on the Heidelberg Milestone Communication in January 2020, recommendations on the care situation of lung cancer patients in advanced stages were developed. In addition, the further adaptability of HeiMeKOM to other settings and hospitals and to other diseases was discussed as well as the possibility of implementing such a concept in standard care. This article presents the experiences, best practice examples and recommendations discussed during the symposium in order to enable their extrapolation to other similarly oriented projects. The long-term goal is to transfer the milestone concept to other hospital, primarily certified lung cancer centers, and to ensure permanent funding. For further dissemination of the concept and, above all, to have it established in standard care, health policy awareness and support are required in addition to the integration of the concept in competence catalogues of continuing medical and nursing education.

Indigenous perspectives on breaking bad news: ethical considerations for healthcare providers

Most healthcare providers (HCPs) work from ethical principles based on a Western model of practice that may not adhere to the cultural values intrinsic to Indigenous peoples. Breaking bad news (BBN) is an important topic of ethical concern in health research. While much has been documented on BBN globally, the ethical implications of receiving bad news, from an Indigenous patient perspective in particular, is an area that requires further inquiry. This article discusses the experiences of Māori (Indigenous peoples of New Zealand) lung cancer patients and their families, in order to investigate the ethical implications of receiving bad news. Data collection occurred through 23 semistructured interviews and nine focus groups with Māori lung cancer patients and their families in four districts in the Midland Region of New Zealand: Waikato, Bay of Plenty, Lakes and Tairāwhiti. The findings of this study were categorised into two key themes: communication and context. Avenues for best practice include understanding the centrality of the HCP-patient relationship and family ties in the healthcare journey, and providing patients with the full range of viable treatment options including hope, clear advice and guidance when the situation calls for it. Overall, the findings of this study hold implications for providing culturally safe and humanistic cancer care when BBN to Māori and Indigenous patients.

Breaking Bad News, a Pertinent Yet Still an Overlooked Skill: An International Survey Study

Delivering bad news to patients is a challenging yet impactful everyday task in clinical practice. Ideally, healthcare practitioners should receive formal training in implementing these protocols, practice in simulation environments, and real-time supervision with feedback. We aimed to investigate whether healthcare providers involved in delivering bad news have indeed received formal training to do so. We conducted a cross-sectional survey study that targeted all healthcare providers in the intensive care units of 174 institutions in 40 different countries. Participants included physicians, nurses, medical students, nursing students, pharmacists, respiratory technicians, and others. The survey tool was created, validated, and translated to the primary languages of these countries to overcome language barriers. A total of 10,106 surveys were collected. Only one third of participants indicated that they had received a formal training. Providers who had received formal training were more likely to deliver bad news than those who had not. Younger and less experienced providers tend to deliver bad news more than older, more experienced providers. The percentage of medical students who claimed they deliver bad news was comparable to that of physicians. Medical schools and post-graduate training programs are strongly encouraged to tackle this gap in medical education.

"What's Going on With My Ears?": Some Reflections on Managing Uncertainty in the Audiology Consultation

Purpose Feedback sessions after audiology consultations predominantly involve information counseling or patient education, where the patient is informed about their hearing status and possible management options. Effective communication is vital to ensure that information about the hearing impairment, recommendations, and/or management options is appropriately provided and understood by patients and that patient needs and expectations from the session are met. This research note reports on an exploratory study that sought to describe communication in follow-up audiological consultations within a context where ototoxicity monitoring is routine practice. Method Six interactions between patients and audiologists were video-recorded at an in-patient treatment facility for drug-resistant tuberculosis in Johannesburg and analyzed using a sociolinguistic approach. Semistructured interviews were also conducted with participants and analyzed using content analysis. Results These interactions differed considerably to other audiology consultations we have analyzed in terms of aspects such as the length of the interaction and the type of information given to patients. We observed a substantial amount of mitigative, vague, and exaggerated language in these interactions. Conclusions In this research note, we offer some reflections on this data set using a lens of uncertainty management theory and explore factors within the broader context that may contribute to the interactional features observed in the current study. Overall findings suggest the need for clinicians to be trained to embrace and address uncertainty rather than avoid it within challenging clinical encounters.

Mixed-Reality Simulation for a Pediatric Transport Team: A Pilot Study

OBJECTIVE

Transport medicine requires a complex set of skills including fast-paced medical decision making, in-depth medical knowledge, procedural competence, interpersonal and communication skills, leadership, and professionalism. There has been a call for more training in these areas. Simulation-based training can be a way to acquire these necessary skills and bridge the gap to higher-quality transport care. The purpose of this study was to develop a novel mixed-reality simulation program to enhance medical and communication skills for a pediatric transport team.

METHODS

A mixed-reality simulation program using standardized patients portraying family members and high-fidelity manikins to simulate a medical emergency was developed and implemented for a pediatric transport team. Ten nurses, 9 respiratory therapists, and 8 emergency medical technicians participated. Pre-post self-perceptions of skill and program quality were assessed prospectively.

RESULTS

Team members rated the overall program quality highly, with a median 5 on a 5-point Likert scale. There was a statistically significant change in pre- versus postprogram self-perceptions of skill in the areas of communication (premedian = 3 vs. postmedian = 4, 5-point Likert scale, P < .001).

CONCLUSION

Mixed-reality simulation programs can enhance standard technical skills training by providing an additional relational element. Such programs are translatable to other institutions.

Evaluation of medical ethics competencies in rheumatology: local experience during national accreditation process

INTRODUCTION

Rheumatologists are the primary healthcare professionals responsible for patients with rheumatic diseases and should acquire medical ethical competencies, such as the informed consent process (ICP). The objective clinical structured examination is a valuable tool for assessing clinical competencies. We report the performance of 90 rheumatologist trainees participating in a station designed to evaluate the ICP during the 2018 and 2019 national accreditations.

METHODS

The station was validated and represented a medical encounter in which the rheumatologist informed a patient with systemic lupus erythematosus with clinically active nephritis about renal biopsy. A trained patient-actor and an evaluator were instructed to assess ICP skills (with a focus on kidney biopsy benefits, how the biopsy is done and potential complications) in obtaining formal informed consent, delivering bad news and overall communication with patients. The evaluator used a tailored checklist and form.

RESULTS

Candidate performance varied with ICP content and was superior for potential benefit information (achieved by 98.9% of the candidates) but significantly reduced for potential complications (37.8%) and biopsy description (42.2%). Only 17.8% of the candidates mentioned the legal perspective of ICP. Death (as a potential complication) was omitted by the majority of the candidates (93.3%); after the patient-actor challenged candidates, only 57.1% of them gave a clear and positive answer. Evaluators frequently rated candidate communications skills as superior (≥80%), but ≥1 negative aspect was identified in 69% of the candidates.

CONCLUSIONS

Ethical competencies are mandatory for professional rheumatologists. It seems necessary to include an ethics competency framework in the curriculum throughout the rheumatology residency.

The role of hope for health professionals in rehabilitation: A qualitative study on unfavorable prognosis communication

BACKGROUND

The communication of prognosis represents an ethical and clinical challenge in medical practice due to the inherent uncertain character of prognostic projections. The literature has stressed that the mode of communicating prognoses has an impact on patients' hope, which is considered to play a major role in adapting to illness and disability. In light of this, this study aims to explore health professionals' (HPs) perceptions of the role of hope in rehabilitation and to examine if and how they use strategies to maintain hope when discussing prognostic information with patients.

METHODS

Eleven qualitative semi-structured interviews with a purposive sample of HPs were conducted at two rehabilitation clinics in the Canton of Ticino, Switzerland. The interviews were analyzed using thematic analysis.

RESULTS

The HPs perceive hope in rehabilitation as a double-edged sword. Three main strategies were identified to maintain hope while avoiding false hope: 1) giving space for self-evaluation; 2) tailoring the communication of prognostic information; and 3) supporting the patient in dealing with the prognosis. These strategies are particularly suitable when HPs consider that patients might not be ready to accept the prognosis, due to their expectations for recovery.

CONCLUSIONS

The strategies identified here support a person-centered approach to the communication of prognosis and are in line with existing protocols for the communication of unfavorable medical information. The findings emphasize the need for strengthening communication and inter-professional collaboration skills of rehabilitation HPs.

Is there a Relationship between Psychological Well-Being and Patient-Carers Consensus? A Clinical Pilot Study

Does communication with terminal cancer patients about their disease influence their psychological well-being? The degree of patient-carer consensus about the disease was compared to psychological well-being related to acceptance of the disease, emotional state, and hope. These were evaluated and scored from 6 (good) to 0 (poor) through a semi-structured interview of 10 open-ended questions. Nineteen palliative care patients were studied, 18 of whom were suffering from advanced cancer. Overall, 57 interviews were conducted with the patients, staff nurses, and medical doctors. The answers of the carers (staff nurses and doctors) were compared to the patients’ answers to determine the degree of consensus in terms of communication about disease, aim of treatment, and ultimate objective of hospitalization. The consensus between patients and carers was scored from 6 (satisfactory) to 0 (unsatisfactory). A significant positive correlation between the scores of consensus and those of psychological well-being ( r=0.90, p<0.001) was found. These results suggest that good and truthful communication may improve patients’ psychological well-being.

Development of a Web-Based Formative Self-Assessment Tool for Physicians to Practice Breaking Bad News (BRADNET)

BACKGROUND

Although most physicians in medical settings have to deliver bad news, the skills of delivering bad news to patients have been given insufficient attention. Delivering bad news is a complex communication task that includes verbal and nonverbal skills, the ability to recognize and respond to patients' emotions and the importance of considering the patient's environment such as culture and social status. How bad news is delivered can have consequences that may affect patients, sometimes over the long term.

OBJECTIVE

This project aimed to develop a Web-based formative self-assessment tool for physicians to practice delivering bad news to minimize the deleterious effects of poor way of breaking bad news about a disease, whatever the disease.

METHODS

BReaking bAD NEws Tool (BRADNET) items were developed by reviewing existing protocols and recommendations for delivering bad news. We also examined instruments for assessing patient-physician communications and conducted semistructured interviews with patients and physicians. From this step, we selected specific themes and then pooled these themes before consensus was achieved on a good practices communication framework list. Items were then created from this list. To ensure that physicians found BRADNET acceptable, understandable, and relevant to their patients' condition, the tool was refined by a working group of clinicians familiar with delivering bad news. The think-aloud approach was used to explore the impact of the items and messages and why and how these messages could change physicians' relations with patients or how to deliver bad news. Finally, formative self-assessment sessions were constructed according to a double perspective of progression: a chronological progression of the disclosure of the bad news and the growing difficulty of items (difficulty concerning the expected level of self-reflection).

RESULTS

The good practices communication framework list comprised 70 specific issues related to breaking bad news pooled into 8 main domains: opening, preparing for the delivery of bad news, communication techniques, consultation content, attention, physician emotional management, shared decision making, and the relationship between the physician and the medical team. After constructing the items from this list, the items were extensively refined to make them more useful to the target audience, and one item was added. BRADNET contains 71 items, each including a question, response options, and a corresponding message, which were divided into 8 domains and assessed with 12 self-assessment sessions. The BRADNET Web-based platform was developed according to the cognitive load theory and the cognitive theory of multimedia learning.

CONCLUSIONS

The objective of this Web-based assessment tool was to create a "space" for reflection. It contained items leading to self-reflection and messages that introduced recommended communication behaviors. Our approach was innovative as it provided an inexpensive distance-learning self-assessment tool that was manageable and less time-consuming for physicians with often overwhelming schedules.

Review of the Ethical Issues of a Biomarker-Based Diagnoses in the Early Stage of Alzheimer's Disease

BACKGROUND

Today, many healthcare or dementia organizations, clinicians, and companies emphasize the importance of detection of Alzheimer's disease in an early phase. This idea has gained considerable momentum due to the development of biomarkers, the recent FDA and EMA approval of three amyloid tracers, and the failure of a number of recent therapeutic trials conducted in the early dementia phase. On the one hand, an early etiological diagnosis can lead to early and more efficacious intervention. On the other hand, it is questioned how early an etiological diagnosis is beneficial to the patient. Here we consider ethical issues related to the process of biomarker testing and the impact on the diagnostic disclosure to patients with mild cognitive impairment due to prodromal Alzheimer's disease.

METHODS

A systematic review of the theoretical bioethics literature was performed by using electronic databases. The review was limited to articles published in English between 2003 and 2016.

RESULTS

A total of twenty articles were included in our effort to make an analysis of the ethical challenges. One of the biggest challenges was the uncertainty and the predictive value of the biomarker-based diagnosis where patients can be amyloid positive without full certainty whether or when they will develop symptomatic decline due to Alzheimer's disease. Another challenge was the tension between the right to know versus the wish not to know, the limited efficacy of currently available treatment options, and the opportunities and consequences after receiving such an early diagnosis.

CONCLUSION

Based on the results and the additional comments in the discussion, several unanswered questions emerged. Therefore, careful consideration of all these ethical issues is required before the disclosure of a biomarker-based diagnosis to the patient with mild cognitive impairment due to Alzheimer's disease.

Effect of Breaking Bad News on Patients’ Perceptions of Doctors

The breaking of bad news is a routine but difficult task for many health professionals. There are numerous anecdotes of insensitive practice but the subject has attracted little systematic research. We therefore interviewed 106 patients with advanced cancer (from an original sample of 195) to assess their perceptions of the doctors involved in their care. Aspects of the ‘breaking bad news’ event were recorded during discussion of the illness history and were subsequently rated. Participants were also asked to nominate doctors under the headings ‘most helpful’ and ‘less helpful’, and completed standardized psychological screening questionnaires.

In 94 of the 106 cases the bad news had been given by a doctor, usually a surgeon. Of the 13 doctors categorized as ‘most helpful’ when breaking bad news, 8 were general practitioners; of the 7 categorized as ‘less helpful’ all were surgeons. 69% of patients were neutral or positive about the bad-news consultation, but 20% were negative and 6% very negative. Doctors in surgical specialties were significantly more likely to be rated poorly than non-surgical specialists or general practitioners.

Surgeons were the group of doctors most likely to break bad news, but non-surgical doctors were rated more positively in performance of the task. This finding has implications for training.

Physicians' psychophysiological stress reaction in medical communication of bad news: A critical literature review

INTRODUCTION

Stress is a common phenomenon in medical professions. Breaking bad news (BBN) is reported to be a particularly distressing activity for physicians. Traditionally, the stress experienced by physicians when BBN was assessed exclusively using self-reporting. Only recently, the field of difficult physician-patient communication has used physiological assessments to better understand physicians' stress reactions.

METHOD

This paper's goals are to (a) review current knowledge about the physicians' psychophysiological stress reactions in BBN situations, (b) discuss methodological aspects of these studies and (c) suggest directions for future research.

RESULTS

The seven studies identified all used scenarios with simulated patients but were heterogeneous with regard to other methodological aspects, such as the psychophysiological parameters, time points and durations assessed, comparative settings, and operationalisation of the communication scenarios. Despite this heterogeneity, all the papers reported increases in psychological and/or physiological activation when breaking bad news in comparison to control conditions, such as history taking or breaking good news.

CONCLUSION

Taken together, the studies reviewed support the hypothesis that BBN is a psychophysiologically arousing and stressful task for medical professionals. However, much remains to be done. We suggest several future directions to advance the field. These include (a) expanding and refining the conceptual framework, (b) extending assessments to include more diverse physiological parameters, (c) exploring the modulatory effects of physicians' personal characteristics (e.g. level of experience), (d) comparing simulated and real-life physician-patient encounters and (e) combining physiological assessment with a discourse analysis of physician-patient communication.

Breaking bad news to patients with cancer: A randomized control trial of a brief communication skills training module incorporating the stories and preferences of actual patients

OBJECTIVE

This study tested the effectiveness of a brief, learner-centered, breaking bad news (BBN) communication skills training module using objective evaluation measures.

METHODS

This randomized control study (N=66) compared intervention and control groups of students (n=28) and residents' (n=38) objective structured clinical examination (OSCE) performance of communication skills using Common Ground Assessment and Breaking Bad News measures.

RESULTS

Follow-up performance scores of intervention group students improved significantly regarding BBN (colon cancer (CC), p=0.007, r=-0.47; breast cancer (BC), p=0.003, r=-0.53), attention to patient responses after BBN (CC, p<0.001, r=-0.74; BC, p=0.001, r=-0.65), and addressing feelings (BC, p=0.006, r=-0.48). At CC follow-up assessment, performance scores of intervention group residents improved significantly regarding BBN (p=0.004, r=-0.43), communication related to emotions (p=0.034, r=-0.30), determining patient's readiness to proceed after BBN and communication preferences (p=0.041, r=-0.28), active listening (p=0.011, r=-0.37), addressing feelings (p<0.001, r=-0.65), and global interview performance (p=0.001, r=-0.51).

CONCLUSION

This brief BBN training module is an effective method of improving BBN communication skills among medical students and residents.

PRACTICE IMPLICATIONS

Implementation of this brief individualized training module within health education programs could lead to improved communication skills and patient care.

Innovative patient-centered skills training addressing challenging issues in cancer communications: Using patient's stories that teach

This workshop demonstrated the utility of a patient-centered web-based/digital Breaking Bad News communication training module designed to educate learners of various levels and disciplines. This training module is designed for independent, self-directed learning as well as group instruction. These interactive educational interventions are based upon video-recorded patient stories. Curriculum development was the result of an interdisciplinary, collaborative effort involving faculty from the East Tennessee State University (ETSU) Graduate Storytelling Program and the departments of Family and Internal Medicine at the James H. Quillen College of Medicine. The specific goals of the BBN training module are to assist learners in: (1) understanding a five-step patient-centered model that is based upon needs, preferences, and expectations of patients with cancer and (2) individualizing communication that is consistent with patient preferences in discussing emotions, informational detail, prognosis and timeline, and whether or not to discuss end-of-life issues. The pedagogical approach to the training module is to cycle through Emotional Engagement, Data, Modeled Practices, Adaptation Opportunities, and Feedback. The communication skills addressed are rooted in concepts found within the Reaching Common Ground communication training. A randomized control study investigating the effectiveness of the Breaking Bad News module found that medical students as well as resident physicians improved their communication skills as measured by an Objective Structured Clinical Examination. Four other similarly designed modules were also created: Living Through Treatment, Transitions: From Curable to Treatable/From Treatable to End-of-Life, Spirituality, and Family.

Sharing news of a lung cancer diagnosis with adult family members and friends: a qualitative study to inform a supportive intervention

OBJECTIVE

Extensive research exists on breaking bad news by clinicians. This study examines perspectives of patients and those accompanying them at diagnosis-giving of subsequently sharing news of lung cancer with adult family/friends, and views of healthcare professionals, to inform development of a supportive intervention.

METHODS

Qualitative interviews with 20 patients, 17 accompanying persons; focus groups and interviews with 27 healthcare professionals from four Thoracic Oncology Units. Intervention development workshops with 24 healthcare professionals and six service users with experience of sharing a cancer diagnosis. Framework thematic analysis.

RESULTS

Patients and accompanying persons shared news of lung cancer whilst coming to terms with the diagnosis. They recalled general support from healthcare professionals but not support with sharing bad news. Six elements were identified providing a framework for a potential intervention: 1-people to be told, 2-information to be shared, 3-timing of sharing, 4-responsibility for sharing, 5-methods of telling others and 6-reactions of those told.

CONCLUSION

This study identifies the challenge of sharing bad news and a potential framework to guide delivery of a supportive intervention tailored to individual needs of patients.

PRACTICE IMPLICATIONS

The identified framework could extend the portfolio of guidance on communication in cancer and potentially in other life-limiting conditions.

Delivering bad news to patients

When physicians lack proper training, breaking bad news can lead to negative consequences for patients, families, and physicians. A questionnaire was used to determine whether a didactic program on delivering bad news was needed at our institution. Results revealed that 91% of respondents perceived delivering bad news as a very important skill, but only 40% felt they had the training to effectively deliver such news. We provide a brief review of different approaches to delivering bad news and advocate for training physicians in a comprehensive, structured model.

Osteoarthritis medical labelling and health-related quality of life in the general population

Background

Osteoarthritis is the most common chronic joint disease. In the absence of an effective medical treatment and due to the chronic nature of this condition, an osteoarthritis medical diagnosis may finally result in decreased health-related quality of life. Therefore, the aim of this study was to measure the impact of the osteoarthritis medical labelling on physical and mental health-related quality of life.

Methods

Subjects (n = 1132, 58.7% women) were approached as participants of an urban population-based cohort (EPIPorto). Self-reported information on previous diagnosis of knee, hip or hand osteoarthritis was obtained and rheumatologists established knee, hip or hand osteoarthritis clinical diagnosis in symptomatic individuals. Physical and mental dimensions of health-related quality of life were evaluated using the self-administered Medical Outcomes Study: 36-Item Short Form Survey. Crude and adjusted linear regression coefficients (beta) and the corresponding 95% confidence intervals (95% CI) were computed to estimate the associations between being labelled as an osteoarthritis case and health-related quality of life.

Results

Regardless of disease medical labelling, individuals with osteoarthritis scored significantly lower physical health-related quality of life when compared to those without joint disease (knee_unexposed: beta = −5.3, 95% CI: −7.6, −3.1; knee_exposed: beta = −6.0, 95% CI: −8.4, −3.7; hip_unexposed: beta = −6.0, 95% CI: −9.8, −2.3; hip_exposed: beta = −11.0, 95% CI: −15.6, −6.4; hand_unexposed: beta = −4.3, 95% CI: −6.5, −2.0; hand_exposed: beta = −4.3, 95% CI: −6.6, −2.1). The same was not observed regarding mental health-related quality of life. Among subjects with clinically confirmed osteoarthritis, the medical labelling of this joint disease was not significantly associated to health-related quality of life.

Conclusions

The labelling of knee, hip and hand osteoarthritis diagnosis may not add specific benefit to osteoarthritis patients in terms of its capability to improve health-related quality of life.

The reliability of a modified Kalamazoo Consensus Statement Checklist for assessing the communication skills of multidisciplinary clinicians in the simulated environment

OBJECTIVE

With increased recognition of the importance of sound communication skills and communication skills education, reliable assessment tools are essential. This study reports on the psychometric properties of an assessment tool based on the Kalamazoo Consensus Statement Essential Elements Communication Checklist.

METHODS

The Gap-Kalamazoo Communication Skills Assessment Form (GKCSAF), a modified version of an existing communication skills assessment tool, the Kalamazoo Essential Elements Communication Checklist-Adapted, was used to assess learners in a multidisciplinary, simulation-based communication skills educational program using multiple raters. 118 simulated conversations were available for analysis. Internal consistency and inter-rater reliability were determined by calculating a Cronbach's alpha score and intra-class correlation coefficients (ICC), respectively.

RESULTS

The GKCSAF demonstrated high internal consistency with a Cronbach's alpha score of 0.844 (faculty raters) and 0.880 (peer observer raters), and high inter-rater reliability with an ICC of 0.830 (faculty raters) and 0.89 (peer observer raters).

CONCLUSION

The Gap-Kalamazoo Communication Skills Assessment Form is a reliable method of assessing the communication skills of multidisciplinary learners using multi-rater methods within the learning environment.

PRACTICE IMPLICATIONS

The Gap-Kalamazoo Communication Skills Assessment Form can be used by educational programs that wish to implement a reliable assessment and feedback system for a variety of learners.

Meanings of existential uncertainty and certainty for people diagnosed with cancer and receiving palliative treatment: a life-world phenomenological study

BACKGROUND

Many people around the world are getting cancer and living longer with the disease. Thanks to improved treatment options in healthcare, patients diagnosed with advanced gastrointestinal cancer can increasingly live for longer. Living with cancer creates existential uncertainty, but what does this situation mean for the individual? The purpose of the study is to interpret meanings of existential uncertainty and certainty for people diagnosed with advanced gastrointestinal cancer and receiving palliative treatment.

METHODS

This study is part of a larger project in which 7 men and 7 women aged between 49 and 79 participated in a study of information and communication for people with advanced gastrointestinal cancer. A total of 66 interviews were conducted with participants who were followed up over time. The narrative interviews were transcribed verbatim and the texts were analysed in three steps: naive reading, structural analysis and interpreted whole by utilizing a phenomenological life-world approach.

RESULTS

THIS STUDY HAS IDENTIFIED DIFFERENT SPHERES IN WHICH PEOPLE DIAGNOSED WITH ADVANCED GASTROINTESTINAL CANCER VACILLATE BETWEEN EXISTENTIAL UNCERTAINTY AND CERTAINTY: bodily changes, everyday situations, companionship with others, healthcare situations and the natural environment. Existing in the move between existential uncertainty and certainty appears to change people's lives in a decisive manner. The interview transcripts reveal aspects that both create existential certainty and counteract uncertainty. They also reveal that participants appear to start reflecting on how the new and uncertain aspects of their lives will manifest themselves -a new experience that lays the foundation for development of knowledge, personal learning and growth.

CONCLUSIONS

People diagnosed with advanced gastrointestinal cancer and receiving palliative care expressed thoughts about personal learning initiated by the struggle of living with an uncertain future despite their efforts to live in the present. Their personal learning was experienced through a changed life for themselves and having to confront their own pending death and develop self-insight regarding finality of life. Healthcare professionals can try to support people receiving palliative treatment for cancer by diversifying avenues for their personal growth, thus helping them manage their existential uncertainty and gravitate towards greater existential certainty.

Information perception, wishes, and satisfaction in ambulatory cancer patients under active treatment: patient-reported outcomes with QLQ-INFO25

Background

Information is vital to cancer patients. Physician–patient communication in oncology presents specific challenges. The aim of this study was to evaluate self-reported information of cancer patients in ambulatory care at a comprehensive cancer centre and examine its possible association with patients’ demographic and clinical characteristics.

Patients and methods

This study included adult patients with solid tumours undergoing chemotherapy at the Institute Jules Bordet’s Day Hospital over a ten-day period. EORTC QLQ-C30 and QLQ-INFO25 questionnaires were administered. Demographic and clinical data were collected. Descriptive and inferential statistics were used.

Results

101 (99%) fully completed the questionnaires. They were mostly Belgian (74.3%), female (78.2%), with a mean age of 56.9 ± 12.8 years. The most frequent tumour was breast cancer (58.4%). Patients were well-informed about the disease and treatments, but presented unmet information domains. The Jules Bordet patients desired more information on treatment side effects, long-term outcome, nutrition, and recurrence symptoms. Patients on clinical trials reported having received less information about their disease and less written information than patients outside clinical trials. Higher information levels were associated with higher quality of life (QoL) scores and higher patient satisfaction.

Conclusion

Patients were satisfied with the information they received and this correlated with higher QoL, but they still expressed unmet information wishes. Additional studies are required to investigate the quality of the information received by patients enrolled in clinical trials.

A Structured End-of-Life Curriculum for Neonatal-Perinatal Postdoctoral Fellows

Death in tertiary care neonatal intensive care units is a common occurrence. Despite recent advances in pediatric palliative education, evidence indicates that physicians are poorly prepared to care for dying infants and their families. Numerous organizations recommend increased training in palliative and end-of-life care for pediatric physicians. The purpose of this study is to develop a structured end-of-life curriculum for neonatal-perinatal postdoctoral fellows based on previously established principles and curricular guidelines on end-of-life care in the pediatric setting. Results demonstrate statistically significant curriculum effectiveness in increasing fellow knowledge regarding patient qualification for comfort care and withdrawal of support (P = .03). Although not statistically significant, results suggest the curriculum may have improved fellows' knowledge of appropriate end-of-life medical management, comfort with addressing the family, and patient pain assessment and control.

To tell or not to tell? Revealing the diagnosis in multiple sclerosis

We review briefly (1) the history of patient-physician relationship and its evolution from a physician-centered to patient-centered model; (2) the impact of the McDonald Criteria for Multiple Sclerosis (MS); (3) why it is important to tell patients of their diagnosis; (4) how physicians should disclose the diagnosis to patients; (5) dealing with suspected MS; and (6) prognosis and treatment. For the majority of clinically definite MS patients we advocate disclosure, identify steps for physicians to communicate the diagnosis and propose a framework to follow when revealing a diagnosis of MS.

Is breaking of bad news indeed unacceptable to native Africans? A cross-sectional survey of patients in a Nigerian neurosurgical service

OBJECTIVES

Breaking of bad news is anecdotally deemed to be culturally unacceptable, even intolerable, to native Africans. We sought whether this hypothesis could be formulated among a cohort of patients who had difficult diagnoses given them in a Nigerian neurosurgical service.

MATERIALS AND METHODS

A semi-structured, interviewer-administered questionnaire was used in a cross-sectional survey among a consecutive cohort of patients on their opinion and preferences regarding the full disclosure of the grave prognoses of their difficult neurosurgical diagnoses.

RESULTS

A total of 109 patients, 74 (67.9%) males, were sampled over a one-and-half-year period. They were mainly young adults, mean age of 40.2 (SD 14.2) years; more than half of them, 56%, had only basic literacy education, but the majority, 99.1%, declared themselves to have serious religious commitments. Less than 3% of the study participants chose not to receive their medical bad news whilst the majority who preferred to have the full disclosure of their medical diagnosis wanted their relations around during the process in 88%, and indeed, 91% would not be happy to be kept in the dark by their knowing relations. Finally, whilst the majority (98%) did not see the prospects of getting any governmental support, hope in God (88%) and family support (40%) were the means by which they expected to cope with the realities of their new futures.

CONCLUSIONS

This data-driven study showed that contrary to anecdotal belief breaking bad news was not intolerable to a cohort of native Nigerian-African patients in a neurosurgical practice.

Medical students' skills and needs for training in breaking bad news

This study assessed medical students' perception of individual vs. group training in breaking bad news (BBN) and explored training needs in BBN. Master-level students (N = 124) were randomised to group training (GT)-where only one or two students per group conducted a simulated patient (SP) interview, which was discussed collectively with the faculty-or individual training (IT)-where each student conducted an SP interview, which was discussed during individual supervision. Training evaluation was based on questionnaires, and the videotaped interviews were rated using the Roter Interaction Analysis System. Students were globally satisfied with the training. Still, there were noticeable differences between students performing an interview (GT/IT) and students observing interviews (GT). The analysis of the interviews showed significant differences according to scenarios and to gender. Active involvement through SP interviews seems required for students to feel able to reach training objectives. The evaluation of communication skills, revealing a baseline heterogeneity, supports individualised training.

A simulation-based curriculum to address relational crises in medicine

INTRODUCTION

Preparing health care professionals for challenging communication tasks such as delivering bad news to patients and families is an area where a need for improved teaching has been identified.

OBJECTIVES

We developed a simulation-based curriculum to enhance the skills of health care professionals, with an emphasis on the communication of difficult or bad news, which we termed relational crises.

METHODS

Our approach was based on a review of existing simulation-based curricula, with the addition of unique features, including a learner-focused needs assessment to shape curriculum development, use of 360-degree evaluations, and provision of written feedback. Development and implementation of our curriculum occurred in 3 phases. Phase I involved a multidisciplinary needs assessment, creation of a clinical scenario based on needs assessment results, and training of standardized patients. In Phase II we implemented the curriculum with 36 pediatric and internal medicine-pediatrics residents, 20 nurses, and 1 chaplain. Phase III consisted of the provision of written feedback for learners, created from the 360-degree evaluations compiled from participants, observers, faculty, and standardized patients.

RESULTS

Participants felt the scenarios were realistic (average rating of 4.7 on a 5-point Likert scale) and improved their practice and preparedness for these situations (average rating, 4.75/5 and 4.18/5, respectively). Our curriculum produced a statistically significant change in participants' pre- and postcurriculum self-reported perceptions of skill (2.42/5 vs. 3.23/5, respectively, P < .001) and level of preparedness (2.91/5 vs. 3.72/5, respectively, P < .001).

DISCUSSION

A simulation-based curriculum using standardized patients, learner-identified needs, 360-degree evaluations, and written feedback demonstrated a statistically significant change in participants' self-perceived skills and preparedness for communicating difficult news in pediatrics.

‘What matters to me’: an international online survey of people treating, affected by and living with lung cancer

Aim: Lung cancer is a common malignancy that occurs worldwide and generally has a poor prognosis. Its diagnosis presents significant physical and emotional challenges for patients and their family, friends and caregivers (FFCs). This study aimed to gain insights into patients’ and FFCs’ perspectives regarding lung cancer and its treatment, as well as physicians’ perceptions of patients’ thoughts about their illness. Patients & methods: An international online survey was conducted, assessing 113 patients diagnosed with non-small-cell lung cancer, 70 corresponding FFCs and 188 treating physicians. Data were collected using an interactive internet-based tool, in order to establish respondents’ priorities. Results: Interesting differences between patients’, FFCs’ and physicians’ perspectives on lung cancer were revealed. For all respondents, the primary feeling about lung cancer was described as “sadness”. Patients were more likely to express a determination to be positive, whereas fear was a common response for FFCs and was a perspective also reported by physicians. Physicians’ views on how they had communicated disease information were more positive than those of the patients, with many patients detecting physician hesitancy to communicate negative news. Conclusion: This study provides important insights into the self-reported thoughts and feelings of patients with lung cancer, their personal networks of FFCs and the physicians who care for them.

'BREAKS' Protocol for Breaking Bad News

Information that drastically alters the life world of the patient is termed as bad news. Conveying bad news is a skilled communication, and not at all easy. The amount of truth to be disclosed is subjective. A properly structured and well-orchestrated communication has a positive therapeutic effect. This is a process of negotiation between patient and physician, but physicians often find it difficult due to many reasons. They feel incompetent and are afraid of unleashing a negative reaction from the patient or their relatives. The physician is reminded of his or her own vulnerability to terminal illness, and find themselves powerless over emotional distress. Lack of sufficient training in breaking bad news is a handicap to most physicians and health care workers. Adherence to the principles of client-centered counseling is helpful in attaining this skill. Fundamental insight of the patient is exploited and the bad news is delivered in a structured manner, because the patient is the one who knows what is hurting him most and he is the one who knows how to move forward. Six-step SPIKES protocol is widely used for breaking bad news. In this paper, we put forward another six-step protocol, the BREAKS protocol as a systematic and easy communication strategy for breaking bad news. Development of competence in dealing with difficult situations has positive therapeutic outcome and is a professionally satisfying one.