My Personal Experience with Breaking Bad News
I have often shared my experience of receiving bad news with my students. This story paints a powerful picture of how errors in communication can result in bad news being delivered insensitively. I also discuss my top tips on how this consultation could have been approached differently.
A bit about my Papa
This story dates back to 2018. My grandfather (or Papa, as I called him) was 99 years old at the time. He had been living in a nursing home for several years as his mobility had declined and care requirements increased. He had been in good health up until his mid-nineties; he was a man that took pride in his health and appearance (he even had his own set of teeth at 99!).
One morning, I got a call from my mum; she advised me that Papa had been taken to the hospital by ambulance as he was having difficulty breathing. She had been contacted by a hospital consultant, who explained that Papa's condition was serious and that the family should make their way there. I quickly left my house to go to the hospital.
Going to see Papa at the hospital
After a treacherous journey to the hospital (London transport does not deal well with snow!), I arrived at the hospital ward and saw my Papa. He looked incredibly frail, with all the colour drained from his cheeks. He was barely conscious.
I had seen patients looking like this whilst working in a hospice; this signalled to me that he was incredibly unwell, probably coming near the end of his life. At that moment, a physiotherapist came to talk to me and asked me about my grandad's baseline level of mobility. I sensed this was essentially so the team could start discharge planning. I felt confused; my grandad looked like he was on death's door, yet I was being asked about his mobility. I couldn’t make much sense of it but thought perhaps I was being overly cynical about Papa's state.
Finding the medical team and receiving the bad news
After a while, I went to see if I could speak to one of the medical team to get an update about Papa's condition. At the ward base near the ward entrance, I located a junior doctor; he was part of the team looking after Papa. He appeared tired and slightly dishevelled, unshaven, with his shirt untucked. I explained that I was the granddaughter of his patient and that I was also a doctor. I had also taken my aunt with me. I asked if we could have an update on how my Papa was doing.
#Error no 1: We stood in an open space in the middle of the ward base with no privacy. It was also a bustling and noisy area, hence not an ideal place to speak to relatives.
#Error no 2: We were all standing up. This was awkward and should be avoided when discussing bad news.
Leaning against a mobile computer stand, the doctor proceeded by telling me that my grandad was being treated for aspiration pneumonia. Bearing in mind that my aunt did not have a medical background, she did not know what this meant, nor was it explained to her. The doctor barely even made eye contact with her.
#Error no 3: There was no warning shot.
#Error no 4: Speaking using jargon.
#Error no 5: Failing to acknowledge the other relative.
He went on to say that my grandad was on IV antibiotics and that there was a 50:50 chance that he would survive. This was somewhat a bit of a shock bearing in mind the conversation I'd just had with the physiotherapist at the bedside. It felt like there was a real lack of communication and disparity between the team. The main message I took away from the doctor was that Papa's condition was critical and that the next 24 hours would determine the direction in which he was headed. In that sense, the information was clear. I thanked the doctor, and he went on his way. It felt like he was in a rush and had other things on his mind.
#Error no 6: The relatives had little opportunity to ask questions.
#Error no 7: There was no clear follow-up plan.
#Error no 8: The doctor appeared to be in a rush.
I never saw this doctor again, but he left an impression on me and still does to this day. This doctor had forgotten some fundamental principles when breaking bad news. Consider how you would like this type of news to be delivered if you were receiving it yourself, and use that sentiment to guide your discussions with patients and relatives.
My take on this scenario
I actually felt empathy for this doctor. I fully understood how overstretched the NHS can be. I knew he had probably not eaten in hours and had been overworked.
BUT this was MY PAPA, a man I'd lived with for most of my life, and I was being told in the middle of a ward base that he was probably dying. As much as I had encountered death in my job and clearly knew the day would also come for my Papa. I didn’t expect or think I would be told in such a cold and clinical way; I likened it to a medical handover. Even though I was a doctor, I wanted to be treated as the patient's relative and certainly not as a doctor in handover. This consultation lacked EMPATHY and missed several fundamental principles when discussing difficult news.
#Error no 9: No matter whether the patient's relative has a clinical background, treating them as a relative is essential.
What happened next ...
Later in the day, my family took turns sitting by Papa's bedside. Several of my relatives had gathered in the visitor's room on the ward. So, this large private room did actually exist on this ward; I wondered why the doctor hadn’t taken me there earlier. Around 10 of my relatives were in the room: my aunts, uncles, siblings and parents. They were all waiting eagerly to hear of any updates. I walked into the room and asked everyone to sit down.
Tip 1: The setting is key; find a quiet, private space.
I braced myself; I could see that my family was looking to me to give them any bit of positive news they could hold onto. I set the tone of the discussion using my body language and facial expressions. I told my family. “It’s not good news." This is what I refer to as an example of a warning shot.
Tip 2: It is always essential to prepare patients and relatives for bad news by using a warning shot.
I explained that Papa was critically unwell with a chest infection and was currently being treated with antibiotics through a drip. I explained that the next 24 hours would be critical in knowing whether the antibiotics would work and whether he would survive.
Tip 3: It is crucial to use language that supports the severity of the condition. Being honest is best. Avoid giving false reassurance.
At this point, my relatives were inconsolably upset. All I could do now was sit silently and allow them time to process the news. I looked with deep sadness as my family fell apart. I comforted, I consoled, and I cried.
Tip 4: Allow relatives time and space. This shows empathy.
I have since really pondered on this moment in my life. Yes, I was a doctor, but I never thought I would be the one delivering this news to my own family.
What happened to Papa?
The good news was that he did survive this illness. He lived on to celebrate his 100th birthday, where he was reunited with friends and family from all over the world. He died a happy man and even received a birthday card from the Queen.
What can you take away from this story?
Hopefully, you find this story helpful in unravelling some of the key concepts in breaking bad news. Remember that these moments will impact patients and their relatives for years to come, so we must do our best to get it right.
In essence, simple things go a long way. Here are my top tips:
- Be mentally prepared to give bad news.
- Find a quiet and private space.
- Give a clear warning shot.
- Give the news clearly and avoid giving false reassurance.
- Show an abundance of empathy by appropriately utilising pace, tone, silence and facial expressions.
New Course Now Available
If you found this post useful, you may like my Ultimate Guide to Breaking Bad News. It includes:
- An easy-to-follow 12-step process that will help you build confidence in breaking bad news.
- A handy mnemonic and detailed discussion on how to demonstrate clinical empathy.
- Advice on managing different types of emotional responses when breaking bad news.
- Discussions on how to tailor the delivery of bad news to different clinical scenarios.
- Lots of practical advice from me.
The Ultimate Guide to Breaking Bad News
Learn how to effectively break bad news to patients, taught by an expert.