How to cite this article: Muhammad Saaiq, Khaleeq-Uz-Zaman.

Breaking bad news

in emergency: How do we approach it ? Ann Pak Inst Med Sci 2006; 2(1): 72-4.

TITLE:
BREAKING BAD NEWS IN
EMERGENCY: HOW DO WE
APPROACH IT ?

AUTHORS:
MUHAMMAD SAAIQ* , KHALEEQ – UZ –ZAMAN**
ACCIDENT AND EMERGENCY DEPARTMENT,
PIMS, ISLAMABAD.
*Dr Muhammaad Saaiq, Medical officer , Department of Surgery, PIMS,
Islamabad.
**Prof. Khaleeq-uz-Zaman, Professor of Neurosurgery, PIMS, Islamabad.

CORRESPONDENCE:
Dr Muhammad Saaiq
Medical Officer,
Department of Surgery ,
Pakistan Institute of Medical Sciences (PIMS)
Islamabad.
e-mail : muhammadsaaiq5 @ gmail.com
 ABSTRACT

Breaking bad news has far reaching implications on the overall management

of the patient and his illness. It should not be taken casual and

must rather be respected as an indispensable component of health

care equivalent to other procedural sessions such as biopsy and

surgery. This realization will prompt application of the relevant

knowledge in clinical practice. In order to structure the process of

breaking bad news in emergency situations , the authors introduce

SAAIQ emergency approach that has five components. i.e. Setting the

scene as soon as possible, Assessing the understanding of the

news’ recipient , Alerting about the bad news, Informing clearly and

Quickly summarizing the communication with information based hope.

Adherence to this new approach ensures quick delivery of bad news

in an empathic , compassionate and tactful manner.

KEY WORDS: Breaking bad news , Communication skills , SAAIQ

emergency approach.

Page of 12 2
In this evidence based era it is imperative to redesign the entire health care delivery

from the patient’s perspective . Breaking bad news to patients or their relatives is one of

the most challenging aspects of medical practice. Effective communication skills hold

the key to solve such knotty issues of clinical practice as a well communicated

message though tragic, not only enhances the patient’s understanding of and adjustment

to his illness but also improves the overall satisfaction of both the patient as well as
1,2
the care giver.

Communication skills training programmes are becoming an integral part

of medical curriculum in UK and USA. Moreover there is growing concern

about the need for even training the experienced clinicians. 3

WHAT CONSTITUTES A BAD NEWS ?

Bad news is an upsetting information which drastically changes a person’s self

image and sense of interpersonal meaning. It is often associated with a terminal

diagnosis such as cancer. However bad news can come in many forms as for

example the diagnosis of a chronic illness like diabetes mellitus, loss of

function such as impotence , a treatment plan that is burdensome , painful

or costly, a pregnant lady’s ultrasound verifying a fetal demise , a

middle aged lady’s MRI scan confirming the clinical suspicion of

4
multiple sclerosis ; diagnosis of a potentially incurable illness such as AIDS ,

Page of 12 3
a disease that ultimately mutilates the body such as rheumatoid arthritis and

disabling treatment such as a permanent colostomy.

WHY TO WITHHOLD BAD NEWS FROM PATIENTS ?

We in Pakistan face similar situation as did Hippocrates5 and

Thomas Percival6 because we are forced by circumstances to

withhold the bad news.

In the last few decades , the traditional paternalistic model of patient

care has been replaced by one that emphasizes patient autonomy , empowerment

and full disclosure.. Many recent studies have found that majority of patients

want to know the truth about their illness.7 One review of studies on patient

preferences regarding disclosure of a terminal diagnosis found that

50-90 percent of the patients desired full disclosure.8 In fact honest

disclosure of diagnosis , prognosis and treatment options allows patients

to make informed health care decisions that are consistent with their goals

and values. A small percentage of patients still may not want full disclosure

and hence physicians need to ascertain the information needs of their

patients.9 The doctor has to adopt a sartorial approach and

individualize the manner and content of information according to the

needs of the patients. The unique situation in our set up arises when

the relatives request that the actual facts be withheld from the patient.
Page of 12 4
Such situations must be handled with great care and a tactful

approach would better serve neither to harm the patient nor his miserable

relatives.

WHY BREAKING BAD NEWS A DIFFICULT TASK?

Barriers to effective disclosure of bad news include physician’s own

issues such as the fear of being blamed by the patient , of not knowing all

of the answers sought by the patient , of inflicting pain on the patient , and

even the physician’s own fear of illness and death. Many physicians have no

adequate training in how to break bad news and many perceive a lack of

time in which to present the news. Moreover patients may have multiple

physicians , making it unclear who should break the bad news. 10

Owing to the lack of adequate training , doctors and nurses fail to give

a crisp and clear message . There is lack of empathy and

professionalism in their approach which at times confuse the scenario

even more. They typically display blocking behaviours such as telling

patients that any distress is normal, switching the subject

to neutral topics, giving information and advice before patient’s concerns

have been identified, focusing only on physical aspects of the

condition and using leading , closed and multiple questions. This

has negative psychological consequences for patients as well as

Page of 12 5
anxiety and depression is more among patients who have unresolved

concerns about their condition.11

Objective evidence has proved the superiority of the proper communication

skills and there is growing recognition of the role of intradisciplinary

and multidisciplinary workshops in overcoming the communication

deficiencies of health care professionals .

WHAT MATTERS TO THE PATIENTS ?

Intensive patient satisfaction research is underway to explore what matters

to patients in an emotionally charged situation entailing breaking bad

news.
12
Parker PA et al found that physician’s competence , honesty and attention ,

the time allowed for questions , a straightforward and understandable diagnosis ,

and the use of clear language are the factors which matter to the patients in

breaking bad news. Jurkovich GT et al13 worked on how family members

evaluate delivery of bad news and found that privacy, physician’s attitude,

competence , clarity of the message and time for questions were the top

rated areas.

Page of 12 6
HOW TO TACKLE THE ISSUE OF BAD NEWS
DELIVERY ?
Bad news delivery in a proper way is a relatively new area of

communication skills and is literally still in its infancy. Several professional

groups have published consensus guidelines on how to discuss bad news ,

however few of those guidelines are evidence based.1 The clinical efficacy

of many standard recommendations has not been empirically

2
demonstrated Majority of articles on breaking bad news are rather

opinions and reviews by physicians.1,2 and fewer than 25 percent of

publications on breaking bad news are based on studies reporting original

data and those studies commonly have methodological limitations. 4

For effective delivery of bad news various authorities have

attempted to devise comprehensive models of their own.

14
Girgis A et al undertook pioneering work and published guidelines

on how to convey bad news to patients. They placed special emphasis

on ensuring privacy and allowing adequate time , assessing patient’s

understanding , giving simple and honest account of diagnosis and

prognosis , avoiding euphemisms, encouraging patients to express feelings,

Page of 12 7
being empathic, giving a broad but realistic time-frame concerning

prognosis and arranging a review .

15
Rabow and Mc Phee devised ABCDE mnemonic for breaking

bad news. i.e. Advance preparation, Build a therapeutic environment / relationship,

Communicate well, Deal with patient and family reactions,

Encourage and validate emotions. This mnemonic has been expanded

by adding F for follow-up plan and hence ABCDEF.16

7
Baile WF et al devised the mnemonic SPIKES for bad news

delivery i.e. : Setting up , patient’ s Perceptions, Invitation to break bad

news , Knowledge, Emotions, Strategy and summary. This approach

aims to enable physicians break bad news in a straightforward

and empathic manner .

The authors have enjoyed working at the busy Accident and emergency

department of Pakistan Institute of Medical Sciences (PIMS) , Islamabad

for quite some time. PIMS is a premier medical institution of the country

and its catchment area not only includes the twin cities of Islamabad

and Rawalpindi but also Northern Areas , North West Frontier

Province (NWFP), Azad Jammu Kashmir and upper Punjab. In emergency

situations bad news often must be delivered in an entirely different context.

Here neither the settings are conducive to intimate conversations nor the

situation permits adequate forewarning. Obviously the information

Page of 12 8
can’t be furnished in small chunks and usually the swiftly changing

clinical scenario rather warrants it to be delivered in heavy bolus doses.

There is often hectic pace of clinical activity and yet the doctor

has to pay attention to administrative responsibilities as well. Mostly

the patient himself is critical and bad news must often be conveyed

to the emotionally charged relatives. In such a touchy situation even

words can easily shift the balance of the situation in any direction.

In order to overcome these challenges and yet convey bad news in an

empathic, compassionate and tactful manner, the authors devised the

mnemonic SAAIQ for breaking bad news in emergency. (The

mnemonic uses the name of the first author)

SAAIQ emergency approach of breaking bad news is

summarized as under :

• Set the scene as soon as possible.

Review the case in detail so that all the necessary information is at hand..
Arrange privacy .Our emergency department now has a room for
counseling the relatives of serious patients.
Prepare to act naturally
Introduce yourself

• Assess the understanding of the attendant / news’ recipient.

Assess what he knows and how much further he wants to know. This can be
elicited by a probing question such as What do you know about the critical condition
of your patient .Also inquire as to whether he wants to know all the details or may

Page of 12 9
 simply be given a broad picture of the situation.. This helps to tailor the subsequent
transfer of information . .

• Alert them that I have bad news .

There is no need to display misleading optimism.

• Inform in clear and understandable words about the serious state / demise etc.

• Quickly repeat summary of the communication with information based

realistic hope..

This SAAIQ emergency approach has been of great help not only for us

but was also found very helpful by our colleagues . This new approach is

being scientifically validated in a prospective study on critically ill patients

presenting as acute emergencies and the results will be published as soon as

the study completes.

CONCLUSION:

Breaking bad news has far reaching implications on the overall

management of the patient and his illness .It should not be taken

casual and must rather be respected as an indispensable component

of health care equivalent to other procedural sessions such as biopsy

and surgery. This realization will prompt application of the relevant

knowledge in clinical practice.

Page of 12 10
REFRENCES:

1) Girgis A, Sanson –Fisher RW. Breaking bad news I : current best

advice for clinicians. Behav Med 1998 ;24 (2) : 53-9.

2) Walsh RA , Girgis A , Sanson – Fisher RW. Breaking bad news 2 : What

evidence is available to guide clinicians ? Behav Med 1998 : 24 (2) : 61-72.

3) Hulsman RL, Ros WJG, Winnubst JAM , Bensing JM. Teaching clinically

experienced physicians communication skills. A review of evaluation studies.

Med Edu 1999 ; 33 : 655-68.

4) Vandekieft GK Breaking bad news. Am Fam Physician 2001: 64 (12) : 1975-8.

5) Hipporcates . Decorum, XVI. In : Jones WH , Hippocrates with an English

Translation. Vol 2. London : Heinemann , 1923.

6) Percival T. Medical ethics : or , A code of institutes and precepts, adapted to the

professional conduct of physicians and surgeons. Manchester, England : S.

Russel , 1803 : 166.

7) Baile WF, Buckman R, Lenzi R . SPIKES ----A six step protocol for delivering bad

news : application to the patient with cancer . Oncologist 2000 ; 5 (4) : 302-11.

8) Ley P. Giving information to patients . In : Eiser JR ed . Social

psychology and behavioral medicine . New York : Wiley, 1982 : 353.

9) Kutner JS, Steiner JF, Corbett KK, Jahnigen DW, Barton PL. Information

needs in terminal illness. Soc Sci Med 1999 ; 48 : 1341-52.

Page of 12 11
10) Buckman R. Breaking bad news : Why is it so difficult ? Br Med J 1984 : 288

(6430) : 1597-9.

11) Maguire GP. Breaking bad news : explaining cancer diagnosis and

prognosis. MJA 1999 ; 171 : 288-89.

12) Parker PA , Baile WF , de Moor C. Breaking bad news about cancer

: patients ’preferences for communication. J Clin Oncol 2001 : 19 (7) : 2049-56.

13) Jurkovich GJ, Pierce B, Pananen L, Rivara FP. Giving bad news : the family

perspective . J Trauma 2000 ; 48 : 865-70.

14) Girgis A, Sanson-Fisher RW. Breaking bad news : consensus guidelines for

medical practitioners. J Clin Oncol 1995; 13 : 2449-56.

15) Rabow MW, McPhee SJ. Beyond breaking bad news : how to help patients who

suffer . West J Med 1999 ; 171 : 260-3.

16) Moses S . Breaking bad news . Family Practice Notebook : 2004.

(Serial online ) : (Cited 2004 Feb 2 ) : (3 screens ) : Available from : URL :

www.fpnotebook.com/HEM 209.htm.22 k

Page of 12 12