I always think back to my particular nursing speciality which is Palliative Care and think of the many conversations I have had with patients and their loved ones during the period up to the patient's death and afterwards. Of course, bad news does not always relate to death and dying. The other area which springs to mind is dementia and the grieving which surrounds the diagnosis.
I used to teach a Communications in Nursing course to nursing students in Australia and always asked students at the end of the course what type of conversations they felt they would have the most difficulty with. The answer was invariably 'Talking to a patient who is dying'. Death and dying is still viewed by many as a taboo subject which makes learning the skills needed to communicate effectively at this time very difficult.
If I take 'Breaking bad news in Palliative Care' as a sub-heading, these are the communication skills I feel are necessary to develop:
Active Listening - (to the patient and relatives) - often a greater use of appropriate non-verbal skills (nodding the head, avoiding communication barriers, placing yourself within a comfortable personal space (often culturally determined) ,use of phrases to indicate you are still listening
Empathetic openers and lead-ins - setting the scene, avoiding interruptions, respecting privacy and dignity, negotiating a time when you will be free to talk uninterrupted, gentle openers which lead onto the bad news
Breaking the news into chunks which can be more easily taken in, use of silence to allow information to sink in, giving simple explanations about the likely outcome or likely plan of treatment
Understanding of cultural factors which may affect the way a patient receives information or responds to the information
Expressing empathy , judicious use of therapeutic touch
Checking patient's understanding, clarifying information, offering to clarify later when the patient is more able to take in information
The breaking of bad news may change the relationship a doctor or nurse has with a patient. It may be the beginning of long-term treatments where the patient is seen for blood tests, chemotherapy,radiotherapy and/or inpatient care for opportunistic infections. Staff often become very close to patients and their relatives and develop a more personal relationship than they would do in the case of a day-stay surgical patient for example. It can be difficult to balance the personal with the professional and certainly when the time comes to give news that there is no more to be done, this can be very difficult.
As the Palliative Care and hospice movement developed , there was quite a lot of research done into what patients want with regards to information about their condition. The days of keeping information from the patient and encouraging them to 'keep up their spirits' are long gone. What is generally wanted is an honest conversation about their prognosis; without clichés or platitudes. Whilst some people may feel that it is not a good idea to teach what NOT to do, I feel that it is helpful especially as a discussion topic. Medical English students should discuss the feelings they might have if they were told :