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Case History

image A 38-year-old woman accompanied by her partner attends her first appointment after completion of adjuvant chemoradiotherapy for breast cancer. She mentions vague nausea and abdominal pain, which she ascribes to residual side effects of treatment. Investigations in clinic reveal liver and lung metastases. Her treatment had delayed her wedding to her long-term partner, at which their daughters (4 and 6) were to be bridesmaids. Her partner does not get on with her parents, and has always wanted to protect her from bad news, seeing a positive approach as vital to her success in battling her cancer.

How will you approach the patient?

What should be the approach with the adult relatives?

How should the news be communicated to the patient's children?

How should the question of unfinished business be handled - how to maintain hope when time is limited?


image Breaking bad news is a complex communication task. It involves more than simply providing information to patient and relatives and requires other important skills. Some of the tasks the doctor will face are: responding to patients' emotional reactions; involving the patient in decision making; dealing with multiple family members; and the difficulty of maintaining hope in a situation with a bad prognosis.

How bad news is discussed can affect the patient's understanding of information and psychological adjustment. Poor communication can result in patients being unaware of their diagnosis, prognosis and the intent of any treatment.1 In an informal survey conducted at the 1998 annual meeting of the American Society of Clinical Oncology (ASCO) 55% of the participants identified 'being honest with the patient without destroying hope' as their most important difficulty when breaking bad news, followed by 'dealing with the patient's emotions' (25%). Only 26% of the participants had a consistent strategy when conveying bad news, 52% followed several techniques but no overall plan.2


How will you approach the patient?

image Undoubtedly this news will be a severe shock to the patient, as she is not prepared and attributes her symptoms to her recent chemotherapy. The necessary transition from adjuvant treatment aiming for cure to a limited prognosis and treatment with palliative intent can become overwhelming for both patient and doctor. Strong patient emotions often provoke equally strong feelings of sympathy, anxiety, guilt and failure in the doctor, who in response might give false hope, provide premature reassurance or prescribe unnecessary treatments.3 To avoid these pitfalls, doctors may find it helpful to reflect on their own feelings and work with 'guidelines' such as SPIKES (Table 51.1).4 This six step protocol for delivering bad news incorporates key communication techniques in a stepwise plan to achieve the four essential goals of disclosing bad news:

  1. determine the patient's understanding, expectations and readiness for the news by gathering information from the patient

  2. provide information according ...

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