Today’s workshop covers the Foundation Programme Curriculum on communication in challenging circumstances namely

  • Uses appropriate styles of communication
  • Seeks/provides additional support in situations where patient’s ability to communicate may be impaired
  • Breaks bad news compassionately and supportively
  • Manages consultation/communication in time limited environments e.g. outpatients, emergency departments
  • Manages consultation/communication when English is not a patient’s first language, including the appropriate use of an interpreter
  • Manages three-way consultations e.g. with an interpreter, using sign language, or with a child patient and their family/carers

The following is a summary of todays workshop

Learning objectives of the Breaking Bad News Workshop at NMUH

Develop an approach to breaking bad news

  • encouraging an individual response unique to the needs of each patient

Provide strategies

  • to help the patient identify and address those complex feelings, concerns, and fears created by bad news

Develop skills

  • in developing a plan that covers common ground
  • which incorporates clinical realities with the values of the patient

Use time effectively

  • to lead to a better understanding and improved patient care.

Increase confidence

  • in the ability to disclose unfavorable medical information to patients

Identify approaches which work well and gain awareness of some of the difficulties .

Review SPIKES and other systems for breaking bad news



In groups of two or three the following were discussed as an icebreaker

Q1. How do you feel about your own ability to break bad news?

Q2. Give examples of what Bad News you have seen or those you would include in the healthcare context. (include bad examples!)

Attendees were split into groups of three with role playing of a doctor, a relative and an observer with a scenario that the patient and relative had to discuss in 10 minutes. Following this the doctors relative and observers snowballed together for 5 minutes and fed back to the group.


“any information which adversely and seriously affects an individual’s view of his or her future”    Rob Buckman (1992).


S    Setting up an interview

P    Assessing patient’s perception

I     Obtaining the patients invitation

K    Giving knowledge

E    Addressing the patients emotions with empathetic response

S    Strategy and summary



 B – Background,

R-  Rapport,

E – Explore,

A – Announce

K –  Kindling

S – Summarize



A  – Advanced preparation

B  – Build a therapeutic relationship

C  – Communicate well

D  – Deal with patient and family reaction

E  –  Encourage and validate reaction

(all references below)

Common features of all

1.Be prepared

  • Read and understand the results
  • Talk to the clinician
    • performing the procedure
    • Or later involved with the case
  • Anticipate questions
    • “Are you certain”
    • “Might there be a mistake”
  • Find the answers


  1. Forecasting and delivering bad news
  • What is the patients level of understanding
  • Forecasting
    • “I am afraid I have some bad news to share with you”
  • Delivering bad news
    • Clarity by you will allow a realistic response from the patient
    • Be clear, brief with no jargon, no abbreviations
    • Avoid jargon that hides the truth.
    • Deliver if you can diagnosis and treatment.

3.Emotions, perspectives, agenda and the readiness to proceed of the patient

  • Silence
    • Non verbal communication
  • Acknowledge anticipated feelings
    • “I suspect that has been difficult to hear
    • “people often have strong feelings at times like this but not every patients feeling are the same. What are you experiencing?
  • Provide direction
    • “Before I tell you about this condition and this treatment I would like to pause and hear about you initial reaction to the news”
  • Use active listening
  • Elicit the patient’s experience and perspective
  • Determine the preference of how to proceed
    • Is there a readiness to proceed.
    • What additional information is needed
    • Who else should be present
    • What level of detail is required
  1. Delivering Detail
  • Establishing the agenda
  • Ask – tell – Ask
    • Ask what the patient knows
    • Tell the patient the details of the condition
    • Ask about what they understand of what has been shared


  • Address the patient’s initial feelings, ideas and expectations amd their preferences of how to proceed
  • Plan how ,when, where, and who
  • Forecast bad news
  • Short simple clear statements including what is bad
  • Determine what the patient knows or experienced before discussing the details of treatment

Reflect on all these points in your own time and ask yourself the following questions

  • What do I think this learning was about?
  • How can I apply it to my work ?
  • What barriers may there be for me and others ?
  • How will I manage these barriers ?
  • How will I know if I am doing things better ?
  • What keys skills should a healthcare professional demonstrate in giving bad news.

I recommend the on line BMJ e-learning Communication Skills

eBMJ Communication Skills

After completing and submitting a short reflection on one or more of these modules the certificate can be saved as a pdf file and upload to your NHS e-portfolio

References and sources including links


Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES – A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer.

The Oncologist 2000;5:302-311



Daily Telegraph article

How would you cope if you only have a few months to live

Examples from a previous group workshop

Went well

  • Private room…….. Good setting
  • Found out what they new…. Determining understanding
  • Warning shots
  • Left Doctors bleep
  • Used silence well
  • Sensitive but direct
  • Gauging how much they want to know

Didn’t go well

  • Warning shots after breaking bad news
  • Next steps
  • Finding the words
  • Skirting around the issue
  • Vague language

Examples from this workshop

Went well

  • Tone of voice
  • Setting the scene
  • Warning shots
  • Signposting
  • Offering time
  • Actively listened
  • Structured discussion
  • Responding to emotions
  • Checked understanding
  • Checked relatives home circumstances
  • Asked about prior knowledge
  • Asked if they wanted their family present
  • Good Physical contact
  • Offered support groups/ leaflets
  • Offeresd to speak to relatives
  • Offering water/tissues/tea
  • Empathy
  • “Did out level best”

Didn’t go well

  • Phone bleep going off
  • Lack of eye contact
  • Asked if wanted a viewing
  • Inappropriate contact
  • “offering a viewing”
  • “A bit of bad news”
  • Awareness of the next step
  • Lacked a diagnosis
  • Use of Jargon
  • Didn’t ask if wanted someone else present.
  • Stuttering
  • “We are rmoving the tubes”



Place the following into

Empathic statements

Exploratory questions

Validating responses


“I can see how upsetting this is to you.”
 “How do you mean?”
 “Many other patients have had a similar experience.”
“Could you explain what you mean?”
“Could you tell me what you’re worried about?”
“I can tell you weren’t expecting to hear this.”
“I can understand how you felt that way.”
“I guess anyone might have that same reaction.”
“I know this is not good news for you.”
“I was also hoping for a better result.”
“I’m sorry to have to tell you this.”
“It appears that you’ve thought things through very well.”
“Now, you said you were concerned about your children. Tell me more.”
“Tell me more about it.”
“This is very difficult for me also.”
“Yes, your understanding of the reason for the “tests” is very good.”
“You said it frightened you?”
“You were perfectly correct to think that way.”
“  I am afraid I have some bad news for you”
“I suspect that might have been difficult to hear”
“What do you understand?”