Breaking Bad News In Emergency: How Do We Approach It?

Muhammad Saaiq and Khaleeq-Uz-Zaman

Medical Ethics In Debate

Muhammad Saaiq*
Breaking Bad News In Emergency: Khaleeq-Uz-Zaman**

How Do We Approach It? *Medical officer, Department of

Surgery, PIMS, Islamabad.
**Professor of Neurosurgery,
PIMS, Islamabad
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 Correspondence:
biopsy and surgery. This realization will prompt application of the relevant knowledge in Dr Muhammad Saaiq
clinical practice. In order to structure the process of breaking bad news in emergency Medical Officer,
situations , the authors introduce SAAIQ emergency approach that has five components. Department of Surgery,
i.e. Setting the scene as soon as possible, Assessing the understanding of the Pakistan Institute of Medical
news’ recipient, Alerting about the bad news, Informing clearly and Quickly summarizing Sciences (PIMS)
the communication with information based hope. Adherence to this new approach ensures Islamabad.
quick delivery of bad news in an empathic, compassionate and tactful manner. e-mail: muhammadsaaiq5 @
KEY WORDS: Breaking bad news , Communication skills , SAAIQ emergency approach. gmail.com

In this evidence based era it is imperative to redesign Why to withhold bad news from
the entire health care delivery from the patient’s
perspective. Breaking bad news to patients or their patients ?
relatives is one of the most challenging aspects of
medical practice. Effective communication skills hold the We in Pakistan face similar situation as did Hippocrates5
key to solve such knotty issues of clinical practice as a and Thomas Percival6 because we are forced by
well communicated message though tragic, not only circumstances to withhold the bad news.
enhances the patient’s understanding of and adjustment
to his illness but also improves the overall satisfaction In the last few decades, the traditional paternalistic
of both the patient as well as the care giver.1,2 model of patient care has been replaced by one that
Communication skills training programmes are emphasizes patient autonomy, empowerment
becoming an integral part of medical curriculum in UK and full disclosure. Many recent studies have found
and USA. Moreover there is growing concern about the that majority of patients want to know the truth about
need for even training the experienced clinicians. 3 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
What constitutes a bad news? disclosure.8 In fact honest disclosure of diagnosis ,
prognosis and treatment options allows patients
Bad news is an upsetting information which drastically to make informed health care decisions that are
changes a person’s self-image and sense of consistent with their goals and values. A small
interpersonal meaning. It is often associated with a percentage of patients still may not want full disclosure
terminal diagnosis such as cancer. However bad news and hence physicians need to ascertain the
can come in many forms as for example the diagnosis information needs of their patients.9 The doctor has to
of a chronic illness like diabetes mellitus, loss of adopt a sartorial approach and
function such as impotence, a treatment plan that is individualize the manner and content of information
burdensome, painful or costly, a pregnant lady’s according to the needs of the patients. The unique
ultrasound verifying a fetal demise, a situation in our set up arises when
middle aged lady’s MRI scan confirming the clinical the relatives request that the actual facts be withheld
suspicion of multiple sclerosis4; diagnosis of a from the patient. Such situations must be handled with
potentially incurable illness such as AIDS, a great care and a tactful
disease that ultimately mutilates the body such as approach would better serve neither to harm the patient
rheumatoid arthritis and disabling treatment such nor his miserable relatives.
as a permanent colostomy.

Ann. Pak. Inst. Med. Sci. 2006; 2(1): 72-74 72

Breaking Bad News In Emergency: How Do We Approach It? Muhammad Saaiq and Khaleeq-Uz-Zaman

Why breaking bad news a How to tackle the issue of bad

difficult task? news delivery?
Bad news delivery in a proper way is a relatively new
Barriers to effective disclosure of bad news area of communication skills and is literally still in its
include physician’s own issues such as the fear of infancy. Several professional groups have published
being blamed by the patient, of not knowing all consensus guidelines on how to discuss bad news ,
of the answers sought by the patient , of inflicting pain however few of those guidelines are evidence based.1
on the patient , and even the physician’s own fear of The clinical efficacy of many standard recommendations
illness and death. Many physicians have no has not been empirically
adequate training in how to break bad news and many demonstrated 2 Majority of articles on breaking bad
perceive a lack of time in which to present the news. news are rather opinions and reviews by physicians.1,2
Moreover patients may have multiple and fewer than 25 percent of publications on breaking
physicians , making it unclear who should break bad news are based on studies reporting original
the bad news. 10 data and those studies commonly have
Owing to the lack of adequate training, doctors and methodological limitations. 4
nurses fail to give a crisp and clear message . There For effective delivery of bad news various authorities
is lack of empathy and professionalism in their approach have attempted to devise comprehensive models
which at times confuse the scenario of their own. Girgis A et al 14 undertook pioneering
even more. They typically display blocking behaviours work and published guidelines on how to convey bad
such as telling patients that any distress is normal, news to patients. They placed special emphasis on
switching the subject ensuring privacy and allowing adequate time,
to neutral topics, giving information and advice before assessing patient’s understanding , giving simple and
patient’s concerns have been identified, focusing only honest account of diagnosis and prognosis, avoiding
on physical aspects of the euphemisms, encouraging patients to express feelings,
condition and using leading, closed and multiple being empathic, giving a broad but realistic time-
questions. This as negative psychological frame concerning prognosis and arranging a
consequences for patients as well as anxiety and review.
depression is more among patients who have Rabow and Mc Phee devised ABCDE mnemonic 15
unresolved for breaking bad news. i.e. Advance preparation, Build
Objective evidence has proved the superiority of the a therapeutic environment / relationship, Communicate
proper communication skills and there is growing well, Deal with patient and family reactions,
recognition of the role of intradisciplinary Encourage and validate emotions. This mnemonic has
and multidisciplinary workshops in overcoming the been expanded by adding F for follow-up plan and
communication deficiencies of health care hence ABCDEF.16 Baile WF et al 7 devised the
professionals. 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
What matters to the patients? break bad news in a straightforward and
empathic manner.
Intensive patient satisfaction research is underway to The authors have enjoyed working at the busy Accident
explore what matters to patients in an emotionally and emergency department of Pakistan Institute of
charged situation entailing breaking bad news. Medical Sciences (PIMS), Islamabad
Parker PA et al 12 found that physician’s competence, for quite some time. PIMS is a premier medical
honesty and attention, the time allowed for institution of the country and its catchment area not
questions, a straightforward and understandable only includes the twin cities of Islamabad and
diagnosis, and the use of clear language are the factors Rawalpindi but also Northern Areas , North West
which matter to the patients in breaking bad news. Frontier Province (NWFP), Azad Jammu Kashmir and
Jurkovich GT et al13 worked on how family members upper Punjab. In emergency situations bad news often
evaluate delivery of bad news and found that privacy, must be delivered in an entirely different context.
physician’s attitude, competence, clarity of the message Here neither the settings are conducive to intimate
and time for questions were the top rated areas. neither conversations nor the situation permits adequate
forewarning. Obviously the information 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

Ann. Pak. Inst. Med. Sci. 2006; 2(1): 72-74 73

Breaking Bad News In Emergency: How Do We Approach It?
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 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.
Ann. Pak. Inst. Med. Sci. 2006; 2(1): 72-74
Muhammad Saaiq and Khaleeq-Uz-Zaman
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.
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