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Breaking Bad News in Palliative Care: Literature Review

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Breaking Bad News in Palliative Care: Literature Review
Breaking Bad News in Palliative Care:
Literature Review
Res. Assistant Okan Anıl AYDIN1, Res. Assistant Çisem BAŞTARCAN2,
Prof. Dr. Ayşegül YILDIRIM KAPTANOĞLU3
1,2,3 Beykent University, School of Health Sciences
Abstract
Palliative care is a type of care that tries
to improve the patient's quality of life and
also involves the patient's family. But before
this stage, breaking bad news becomes im-
portant when informing about the disease.
Speaking badly to patients is a very difficult
situation for both the patient and patient’s
family. In this case, which may be destruc-
tive, both of them should be contacted more
carefully.
In the field of health, bad news is consid-
ered any information that negatively chang-
es the patient's view of the future. Usually,
when breaking bad news, the diagnosis is
shared with the patient; it may also include
a new chronic disease or information that
a chronic disease has worsened. Bad news
can be perceived personally, making it dif-
ficult to predict its individual effects and
consequences on the patient and patient’s
family.
Doctors, nurses and other health profes-
sionals on the palliative care team should
be trained in communication. Because an
important part of the work that is done also
passes through communication. In order
to be informed without disturbing the mo-
Introduction
Palliative medicine aims to alleviate or re-
lieve severe symptoms associated with
the disease, including weakening the pain
and death process associated with chron-
ic disease. The Center to Advance Palliative
rale of the patient and patient’s family, the
health professionals must speak with em-
pathy. The language the health profession-
als use when making statements should
be simple. The difficulty of communication
and the emotional intensity of breaking bad
news compels health professionals. In addi-
tion, poor or insensitive bad news can impair
the quality of life of a patient and patient's
families for the consequences of news giv-
en. The patient’s correct understanding
of the news may be very important for the
continuation of treatment. The culture, lan-
guage, religion of the patient and patient's
family should be taken into consideration.
Breaking bad news, first of all health pro-
fessionals need to work as a team and have
good communication skills. Because the
other party will be expected to accept what is
said and act according to this new situation.
In this study, we aimed to explain how health
professionals should tell the bad news and
the methods that they should use in doing
so with various aspects and perspectives.
Keywords: bad news, palliative care,
breaking bad news, delivering, true telling
Care (CAPC) defines palliative medicine is
as special medical care for people suffering
from serious illnesses. It focuses on provid-
ing relief from the symptoms and stress of
a serious illness. The aim is to improve the
19

quality of life for both the patient and the
family (Ruiz-Junco and Morrison, 2019;
CAPC, https://www.capc.org/about/pallia-
tive-care/).
According to the definition of World
Health Organization, palliative care relieves
pain and other disturbing symptoms, does
not accelerate death, but does not post-
pone it and sees it as a normal process.
Palliative care combines the psychological
and spiritual dimensions of patient care.
It provides a support system to help pa-
tients live as actively as possible until they
die and families to cope with the disease
and mourning process. Uses the necessary
team approach to respond to the needs of
the patient and family; it can also affect the
disease process positively by improving the
quality of life; it can be administered in the
early stage of the disease, together with
other treatments aimed at prolonging life,
such as chemotherapy or radiotherapy; it
includes research to better understand and
control painful clinical complications (WHO,
2018).
Diseases requiring palliative care; motor
neuron diseases such as Alzheimer's, heart,
lung, kidney etc. advanced organ failure,
cancers not responding to treatment, HIV /
AIDS, genetic / congenital progressive dis-
eases in children (Kivanc, 2017).
Bad news in terms of health is considered
to be any information that changes the pa-
tient's view of the future negatively. In gen-
eral, when breaking the bad news, the diag-
nosis is shared with the patient; however, it
may also include information about a new
chronic diagnosis or worsening of a chronic
disease. Breking bad news can be a person-
al perception, making it difficult to predict
the individual effects and consequences of
distressing information on the patient and
his or her family (Bumb et al., 2017).
20
Folia Palliatrica · 2020 · Volume I
It is difficult to communicate with the
stress-stricken patient and breaking bad
news. Health professionals experience se-
vere stress when they have to break bad
news. Patients' preferences should be
known and initiatives should be planned ac-
cordingly so that the communication with
patients to be effective . However, it is not
known exactly what patients' preferences
for breaking bad news are. This study, ad-
dresses the perceptions of the patient, the
patient's family and health professionals
about breaking bad news. In doing so, care
has been taken to address studies from dif-
ferent geographies and different cultures of
the world.
Breaking Bad News
Breaking bad news even at a normal time
will depress people. This will have a worse
effect when told for a medical condition.
In a medical setting, breaking bad news is
defined as “any news that drastically and
negatively alters the patient's view of his or
her future.". Perceiving bad news is like un-
derstanding from the eye of the person who
looks at it. One cannot comprehend the ef-
fect on the patient without understanding
his or her expectations (Parker et al., 2001).
Bad news is defined as the news of a sit-
uation where there is no hope and a threat
to a person's mental or physical well-being.
If bad news is given in a bad way, there may
be feelings of insecurity, anger, fear and
guilt. Bad news is more difficult when the
clinician has a long-standing relationship
with the patient, when the patient is young,
or when a successful outcome is expected
(Narayanan et al., 2010).
In another study bad news is defined as
any news that affects an individual's view of
the future negatively and seriously. Break-
ing bad news can affect both the family and
the patient very badly. Treatment will be
Breaking Bad News in Palliative Care: Literature Review

difficult, especially because of the patient's
ideas for future negativity. Therefore, it is
necessary to be very careful when giving in-
formation. It should be said in a gentle and
far medical language, in a way that one can
easily understand. (Doyle and O'Connell,
1996).
If done incorrectly, breaking bad news
may also affect the patient's discontinua-
tion or continuation of medical treatment.
Approaching the patient with empathy, us-
ing the right language and involving the pa-
tient in the decision-making process are the
basic rules of establishing a proper relation-
ship between the doctor and the patient.
(Sobczak et al., 2018).
Breaking bad news is a difficult situa-
tion for both those who breaking bad news
and those who receive the bad news. The
health professional breaking bad news
should be able to communicate correctly
while performing this task. Because the
person in the face of this information will
give direction to the future and should be
able to cope with it. For this purpose, the
quality of the health care provided with
good communication will increase and the
patient will avoid misunderstandings and
will be treated accordingly (Dhage and
Wilkinson, 2017).
In palliative care, breaking bad news is as-
sociated with conditions such as cancer
diagnosis, survival, disease progression. In
these cases, the trust relationship between
the health professional and the patient is
very important for effective communication
(Mishelmovich et al., 2016).
In cases where the patient is unconscious
or unable to communicate independent-
ly, the focus is on the family of the patient
while breaking bad news. Health teams
should be aware that communication used
to help families cope in such situations is
difficult and complex (Bloomer et al., 2017).
Many studies emphasize the importance
of communication technique when breaking
bad news to the patient and patient's fam-
ily (Bousquet et al., 2015; Rao et al. 2016;
Richter et al., 2015). In the study of Paul et
al. (2009), training programs including com-
munication techniques used to breaking
bad news were evaluated. Many health pro-
fessional lack training in breaking bad news
to patients and patient's families.
If we know the mistakes made in deliver-
ing bad news, we will be able to overcome
this difficult situation more easily. These are
listed mistakes made while delivering bad
news. Identifying these errors is an impor-
tant step to correct.

Common Mistakes

• Being insensitive,
• Desperately giving bad news,
• Being unprepared to discuss the issue with the family/patient,
• Talking to one parent and not talking to the other,
• Being disrespectful,
• Using technical jargon,
• Delivering bad news at a time and place unsuitable for serious conversations,
• Only talking about illness and not talking about treatment,
• Giving wrong information,
• Being hasty.

Fig. 1: Mehta, P. N. (2008) Communication Skills–Breaking Bad News. Indian Pediatrics, Volume 45, pp. 839-841.
21
 Folia Palliatrica · 2020 · Volume I

The ABCDE method, which is one of the
methods of breaking bad news, can provide
information to the family in a simple way and
help health workers. Information should be
provided in a quiet environment, for exam-
ple in an office and at the right time. It should
be spoken in sufficient time and explanatory
answers should be given to the questions to
be asked. Necessary preparations must be
made before breaking the bad news. Neces-
sary documents should be kept with the doc-
tor. If it is not kept, the questions asked by the
families cannot be given enough answers and
the reverse reactions can be taken. When giv-
ing bad information, empathy should be giv-
en and the condition of the patient and his /
her family should be taken into account. But
in another case, it is important not to create
a very pessimistic atmosphere while breaking
bad news (Mehta, 2008). ABCDE method in-
clude: Advance preparation, Build a therapeu-
tic environment/relationship, Communicate
well, Deal with patient and family reactions
and Encourage and validate emotions (reflect
back emotions) (Rabow and McPhee, 1999).
Breaking bad news can affect the patient's
quality of life. Especially when bad news is
given, it will cause anxiety both for the pa-
tient and his family, but it should still be said.
Because after bad news is given, it is easier
for the patient to act according to treatment,
while the family begins to prepare for the in-
evitable end.
In another study, the question of how
to tell bad news to the patient and his /
her family was answered according to the
SPIKES method;
There is another method for breaking bad
new - SPIKES. It includes six steps (Baile et al.,
2000);
STEP 1: SETTING UP the Interview
STEP 2: Assessing the Patient’s PERCEP-
TION
STEP 3: Obtaining the Patient’s INVITATION
STEP 4: Giving KNOWLEDGE and Informa-
tion to the Patient
STEP 5: Addressing the Patient’s EMOTIONS
(Empathic Response) with empathic responses
STEP 6: Strategy and SUMMARY

1.Setting: If possible, information should not be given when standing or on the phone. You should sit in an
office or in a quiet environment and have enough seats for participants. If it is switched on, the
phone and television must be switched off. Eye contact should be established while talking.

2.Perception: The patient and his / her family should tried to understand and get their information about
the condition of the disease.

3.Invitation: When giving information, it should be spoken slowly and without using technical language so
that the other person can understand it. If medical terms are to be used, they should be as
clear as possible.

4.Knowledge: It should be kept as quiet as possible and spoken in accordance with the tragic situation
when bad news is to be told. The patient and/or his / her family should be responded to with
empathy.
5.Empatice It should be kept as quiet as possible and spoken in accordance with the tragic situation
Response: when bad news is to be told. The patient and/or his / her family should be responded to with
empathy.

6.Summary: What is spoken should be summarized briefly. The date of the next meeting and the treat-
ment processes should be discussed.

Fig. 2: Reference: Hausdorff, J. (2017). Ask the Hematologist: SPIKES Protocol For Delivering
Bad News to Patients. The Hematolojist Ash News and Reports, Volume 14, Issue 4.

22
Breaking Bad News in Palliative Care: Literature Review
In a study, a brief review of the ABCDE and
SPIKES models, the two methods were used
to deliver bad news.
ABCDE and SPIKES models mix;
• Set up a meeting to tell the bad news,
• Prepare the environment,
• Learn the patient's knowledge,
perceptions and expectations,
• Speak clearly and directly to
the patient,
• Pay attention to the emotional
aspect of speech,
• Summarize before the end of the
conversation.
Patient’s Perspective
When we look at it from a patient’s point of
view, we see that everything is much more
painful. Therefore, in the event of breaking
bad news, the patient should be informed
first (Doyle and O'Connell, 1996). On the one
hand, when you give bad information, the
patient rejects that information and says,
" Why did it happen to me, how am I going
to get away with it?"such words can be ex-
pected. In situations like this, patients want
to know how much time they can spend
with their loved ones, but they can be dis-
appointed when doctors can't give enough
details (Ivan, 2005). The way it conveys the
breaking bad news certainly affects the pa-
tient's life, but it can also affect patient-doc-
tor relationships. Most patients want a full
explanation with empathy, kindness and
openness (Buckman, 2005).
Patients have some rights:
• Accurate and true information,
• Receive or not receive bad news,
• Decide how much information they want
or don't want,
• Decide who should be present during the
consultation, i.e. family members, including
children and / or other important persons,
• Decide who should be informed about
their diagnosis and what information they
should receive.
Reference: Singh, D. and Agarwal, D. (2018).
Breaking Bad News In Clinical Setting: A Sys-
tematic Review. Indian Journal Of Applied
Research, 7(12). Retrieved From Http://Wwjour-
nals.Com/İndex.Php/İjar/Article/View/122
In eastern and Asian countries, the word
“cancer” is perceived as incurable and fa-
tal disease and is a harbinger of fear, anxi-
ety and suffering for individuals. According-
ly, the findings of several studies in these
countries, including Iran, show that there is a
tendency among patients, their families and
members of the health team to avoid using
the word “cancer.” They prefer to tell news of
their cancer diagnosis indirectly and in less
negatively charged words, such as mass or
tumor. It is generally believed that their belief
reduces the distress caused by breaking bad
news and gives the patient a positive feeling
through the emotional support offered by
physicians and helps them move from health
to disease more easily (Tsoussis et al., 2013).
According to one study, the most accu-
rate way to tell the patient about his / her
disease is that the patient has the right to
know in the laws of the country. Because
the doctor will not be able to lie to the pa-
tient when it is in the law. Another problem
with breaking bad news is that health pro-
fessionals are not trained. (Khalil, 2013).
In a study conducted by Rozveh et al.
(2017) with cancer patients in Iran, it was
shown that approximately 40% of the pa-
tients did not know about their disease al-
tough many cancer patients in Iran prefer
to have information about their disease. In
another study conducted with cancer pa-
23

tients, 90.8% wanted to know the disease
in the first stage of the cancer, while 60.5%
wanted to know the disease in the last stage
(Jiang et al., (2007).
Tse et al. (2003), their work dealt with the
view of Chinese philosophers and the peo-
ple, especially the rural part, to death. Phi-
losophers handle death as a natural condi-
tion like living, and this is also observed in
the public. For example, elderly people in ru-
ral areas begin preparing for funerals before
they die.
Ishaque et al. (2010), in a study conducted
with 400 patients in Pakistan, tried to reveal
the expectations and perceptions of pa-
tients from doctors saying bad news. 33.5%
of the participants of the study wanted to
hear the bad news immediately, and 47.5%
wanted to learn it later. 57% of the patients
want to learn the disease at home, while
58% want to learn with their family. 63.5% of
the patients want the doctor to ask for per-
mission before giving any information about
the treatment.
Patient’s Family Perspective
Giving the priority of the principle of respect
for “autonomy” in Western societies, it is not
common to consider the views of relatives
in the protocols and guidelines developed
in these countries. However in Asia and
the Middle East, the principle of “harmless-
ness” is superior to the principle of respect
for “autonomy” and the family plays a very
important role in deciding whether or not to
inform the patient. Therefore, it is very im-
portant to consider the opinions of the fam-
ily members of the patients when breaking
bad news (Abazari et al., 2017).
In studies in China, doctors talk to their
family before telling the patient the bad
news. If the family wants the disease to be
told to the patient, it is said (Wang et al.,
2018; Hahne et al., (2019). In another study,
24
Folia Palliatrica · 2020 · Volume I
69.9% of families wanted to tell their pa-
tients about the disease in the first stage of
cancer, while in the last stage this rate falls
to 34.4% (Jiang et al., (2007).
When examined in his study on bad news
to patients in China, it is observed that pa-
tient’s families there interact directly with
patient-related situations. Even in most
cases of cancer and other fatal cases the
doctor is forced to lie when the patient
wants to know the bad news. The family's
view of this issue is to protect the patient
and other members of the family from this
painful news and prevent them from getting
worse (Tse et al., 2003).
Health Professional’s Perspective
Healt professionals have trouble with how
to support the patient while breaking bad
news. An average of 117 million people in the
United States are diagnosed with chron-
ic diseases such as cancer, diabetes, heart
disease and arthritis (Centers for Disease
Control and Prevention, 2017). Doctors may
have to break bad news to their patients
about 20,000 times during their careers.
Clinicians have different attitudes about
breaking bad news. (De Valck et al., (2001).
Regarding the importance and necessity
of breaking bad news, many researchers are
now looking for models that will help them
implement this task correctly and scien-
tifically and have the least emotional and
psychological impact on patients and their
families. Adopting a systematic strategy to
breaking bad news is a challenging task.
The lack of such a strategy or roadmap to
control patients' reactions to bad news may
cause physicians to not explain all aspects
of the news and give patients false hope.
This will reduce patients' confidence in doc-
tors and make them unwilling to partici-
pate in clinical decisions (Buckman, 2005).
Although such protocols and guidelines
Breaking Bad News in Palliative Care: Literature Review
have long been used in Western countries
to train healthcare teams in reporting bad
news, many Asian countries do not have
such a protocol. It would be appropriate for
each country to develop a local protocol, as
breaking bad news or telling the truth is a
purely cultural matter based on the values
and beliefs of each community (O’Kelly et al.,
2011; Labaf et al., 2015; Abazari et al., 2017).
In Muslim countries it is not possible to
deny the positive effects of spiritual and
religious beliefs on the psychological con-
dition of individuals during difficult mo-
ments of life, including the crisis following
a cancer diagnosis. It is therefore recom-
mended that physicians and nurses try to
take advantage of these beliefs even in the
context of positive and optimistic sentenc-
es such as "everything is in the hands of
th Lord" and "The Lord is merciful" when
speaking the facts (Salem and Salem, 2013;
Abazari et al., 2017). Protocols in Western
countries, however, do not recommend the
use of religious statements to explain the
news, although it is important to investi-
gate the patient's personal, cultural or re-
ligious background before delivering the
bad news (Labaf et al., 2015).
In a study conducted by Borjalili et al
(2018) with 207 Iranian clinicians, 58% of
respondents stated that they had breaking
bad news to 5 cancer patients in the past
3 months. The results showed that only 24
doctors received special training in break-
ing bad news, while 82% said they needed
a guide to breaking bad news to patients.
58% of respondents prefer the breaking bad
news to patients when a definitive diagnosis
is made.
Hahne et al. (2019), doctors reported that
they had some fears before giving the bad
news to the patients. These fears were that
patients are vulnerable to bad news and
cannot afford to remove it; the other is the
possibility of conflict between the patient's
family and himself. Although some doctors
think that the patient has the right to know,
they do not do much in practice.
In one study, it was studied how to tell
the truth to cancer patients according to
Chinese and American culture. In America,
doctors give accurate information to pa-
tients with cancer because of the patient's
right to self-care and right to information.
In this country, the main topic of discussion
is not to give information, but how to best
express this bad news to the patient and his
family. But in China, most patients are still
unaware of their disease even when they
come to the last stage of cancer. Because
in China, if family members do not want the
patient to know, even if the doctor wants to
give information, they usually do not. Belief
differences between these two countries
are also effective in saying bad. Because in
Christianity, the view of illness is not seen as
a punishment, but according to Buddhism
and Confucianism in China, it is the price
of what we do in the world. In China, doc-
tors often do not tell the patient the truth
because they want to help the family, and
even when patients reach the final stage of
cancer, they say to themselves, "Why do I die
from pneumonia?" (Dong et al., 2011).
Martis and Westhues (2015) conducted a
study of patients' spiritual perceptions for
bad news with 27 doctors in India. In the
study, it is stated that when patients want to
be given bad news, it is necessary to make
decisions and explain them by taking into
account not only the patient's health history
but also the culture, religion, psychological
state, mental state and many other aspects.
The study also identified 10 characteristics
that doctors pay attention to in the patient
when explaining bad news. These are age,
25
 Folia Palliatrica · 2020 · Volume I

gender, educational level, cognitive capaci-
ty, will, economic status, social role, disease
type, social support and religion / spiritual
practices. According to the doctors they
say that the elderly accept bad news much
more easily. Because elderly people say that
they could live enough and spend time with
their loved ones.
In a study of 217 physicians in Kuwait,
67.3% of physicians report their patients di-
rectly because they think that patients have
the right to know. On the other hand, 32.7%
of the doctors stated that they did not pro-
vide accurate information to the patients
based on their past experience (Qasemet et
al., 2002).
Khalil (2013) examined accurate telling
to patients with cancer by taking into ac-
count attitudes, beliefs and perceptions in
countries in the Middle East. Looking at the
family structures here, unlike the west, the
social structure is family-based, not individ-
ual-based. Generally, doctors in this area first
give bad news to the patient's family. Ac-
cording to the study, the real quality of com-
munication is a reflection of the education
received in medical schools. Israel, Iran and
Lebanon are examples of these countries.

Conclusion
In this study, we have compiled practic-
es on breaking bad news in palliative care in
different cultures of the world. According to
these reviews, Asian and Eastern countries
do not show the same sensitivity to break-
ing bad news as in the Western countries.
However, considering the fact that this pe-
riod constitutes a life crisis will facilitate the
cooperation between patients, familys and
health professionals, the importance of fo-
cusing to this field can be understood. In
this regard, training to improve the commu-
nication skills of health professionals and to
review the difficulties they face in their re-
lationship with their patients will help them
to breaking bad news. This will contribute to
the realization of a health service not only
for the health worker but also for the pa-
tient and patient's family. While taking these
trainings, methods of breaking bad news
should be emphasized. Because if breaking
bad news is not done well, it will have dev-
astating effects for the patient and patient's
family. In cases where a fatal disease or
cancer diagnosis is in question, new studies
are needed to lead to understanding, dis-
cussing and increasing the sensitivity of the
breaking bad news method for the benefit of
the patient and the health professional and
to eliminate the deficiencies in determining
the path to be followed in this field.

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