Intended for healthcare professionals

Careers

How can I break bad news remotely?

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1876 (Published 12 May 2020) Cite this as: BMJ 2020;369:m1876

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  1. Abi Rimmer
  1. The BMJ

Covid-19 has made breaking bad news harder than ever. Doctors share their advice on how to speak to patients and their families when you can’t see them face-to-face with Abi Rimmer

Prepare as if you were meeting in person

Rachel Heard, specialty trainee year 5 in general surgery, Northwest, says, “Breaking bad news is a challenging part of being a doctor. Many people use a system, such as the SPIKES six step protocol,1 to guide these conversations. Such systems emphasise the physical situation in which these conversations take place and talk about things like making eye contact, sitting in a quiet room, and having relatives present. So how can we adapt to break bad news sensitively by telephone?

“Firstly, apologise for the remote nature of the consultation and explain why it’s happening over the phone. In general, try to keep the structure of the conversation similar to a face-to-face consultation. Indeed, any change in delivery style may make the conversation more difficult for you and the patient.

“Prepare in the same way you would if you were relaying the information in person. Try to have someone the patient has previously met to break the news. Make sure you and the patient are both in quiet rooms and unlikely to be interrupted. If possible, ensure they have somebody with them. Consider having the conversation by videocall, so you can assess and respond to non-verbal cues, and talk to the patient and their significant others concurrently.

“Afterwards, have a robust follow-up plan, preferably with a named person contacting the patient later that day. Let them know when any team meetings or investigations are likely to be and who’ll contact them with the results. Finally, give the patient a contact phone number should they need additional support.”

Make use of video if you can

Emma Vardy, consultant geriatrician, Salford Royal NHS Foundation Trust, says, “I can say from experience that when it’s done with honesty, empathy, and humanity, breaking bad news by telephone isn’t always as bad as you might anticipate. Making a few simple adjustments to your preferred method is the best way to go about it.

“Being able to see the person you’re delivering the news to may be helpful—NHSX has provided guidance2 around information governance and allowed the use of apps such as WhatsApp, FaceTime, and Skype. The caveat is to be cautious if using personal devices and make sure that you approach safeguarding personal and confidential information in the same way you would any other consultation.

“Virtual consultation tools may also be used. Some require organisational instalment, others are free to use with an NHS email address. AccuRx is a tool that seems to be helpful and is used by many primary care colleagues. A freely available tool that can be set up using an NHS email address is www.myclinic.com. This allows the patient or relative to access a virtual clinic room through use of a patient password. Of course, always check with organisational digital leads that any software or app is approved for use.

“Remember these are far from ideal circumstances. In most cases our patients and their relatives will understand the efforts we are making under challenging conditions.”

Self-reflection is important

Kathryn Mannix, consultant in palliative medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, says, “Perhaps the most daunting of all medical tasks is giving the news that someone is dying, or has already died, to their dear ones. This task seems ill suited to a phone call. Yet, with care, we can offer compassionate support. An evidence based framework for unwelcome news conversations, devised for the covid-19 pandemic,3 has several recommendations.

“Firstly, prepare by defining the key message of the conversation: centre on your compassion and remember that you speak on behalf of your team. Begin the call by establishing names and identities—yours and the person you are speaking to—and ascertain that they’re in a safe place for a conversation.

“Progress a conversation about worsening illness by asking the other person to describe what they already know: this helps them to recognise the pattern of events as they describe it and allows you to pick up the story to add further details. For announcing a death, simply express sorrow—a warning shot—before giving the news.

“Tone of voice and empathic language are important: bad news is best told in simple, non-ambiguous words. Listening is as important as speaking: allow silences, acknowledge emotions, and reassure that weeping is acceptable.

“Finally, closure is reached by offering to answer further questions, helping the person to plan what they will do next, clarifying arrangements for next steps like when there will be more news or how to collect a death certificate, and always restating empathy.

“After writing up the conversation, taking a moment for self-care and reflection is important.”

Consider tone of voice

Beth Walker, medicolegal consultant at the Medical Protection Society, says, “Before telephoning, ensure you are well prepared and, ideally, call from a quiet setting where you won’t be disturbed. Check the relative is prepared to have the conversation at this time—are they somewhere they can talk, and do they wish to have someone else with them?

“Speak clearly, introduce yourself and your role. Begin by exploring what the relative knows about the situation so far, allowing you to gauge their understanding and concerns. Before conveying bad news, try to prepare the relative in a compassionate manner, for example, ‘I’m sorry, I have some serious news to discuss with you.’

“The tone of your voice becomes even more important when unable to use non-verbal communication. Give the news simply and honestly with empathy, using silence to allow the relative to react to, and process, each part of your discussion.

“Avoid using medical jargon or ambiguous terms. If they’re distressed, acknowledge this sensitively and give time and support before carrying on. Before closing the conversation, check whether the relative has any further questions and summarise what they may expect to happen next.

“Document your conversation clearly in the medical records and try to take a moment for yourself after these discussions: you may also wish to debrief with a colleague.

“There is no single right way to do this: you can only do your best from a place of kindness.”

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