There may have been times in your personal life when you have had to deliver some really bad news to someone; it is rarely an easy thing to do. In the context of seriously ill children at Great Ormond Street we can see that for the staff such difficult conversations about treatment that is not working or the likelihood that an illness is terminal are a frequently occurring part of their role.
Being able to do this well is a skill. In this short audio, taken from The Open University's Death and dying course, Fiona, a nurse in an accident and emergency department, reflects on her experience over number of years of having to tell relatives that someone has died. Listen and see if you can pick out what she believes are the necessary skills to do it well.
What is the skill?
It is clear that this is not just about learning the sorts of words to use but also developing communication skills such as empathy - trying to put herself in the shoes of the person on the receiving end. Fiona also says how important it is to ‘individualise’ families and not have a ‘stock’ response. It is both ‘what you say and how you are with them’ that can make such a huge difference.
How do you learn this skill?
Fiona’s experience was of a lack of formal guidance - more a case of just developing the skill as you go along – learning from experience and from seeing it done well by colleagues (and badly for example ‘hiding’ behind medical language). Training can help teach the basics though – see the box below.
What is the impact?
Although it is the relatives who are receiving the bad news, Fiona‘s reflections show how stressful the impact can also be to the news giver. She describes initially feeling helpless and wanting to say something that would make it all better as well as guilt.
Although in the end sensitive and skilful communication needs to be practiced in a real world setting, there is a lot that has been written about things to consider if you are a practitioner who will need to communicate difficult information for example.
Six steps for breaking bad news
- Get the physical context right. Make sure there are no interruptions, there is privacy and that the recipient of the bad news can stay there in order to compose themselves for whatever they need to do next, whether that be talking to other professionals or going home.
- Find out how much the recipient knows. Don’t assume, without first checking of what they know.
- Find out how much the recipient wants to know. This can range from very little to as much as you can tell them.
- Don’t overload them with information, however. It is likely they will not be able to take in everything that you say. They may have questions or ask for clarification, and you may have to repeat things more than once. Try to give the information in a sensitive manner and in non-technical, non-clinical language. Take your time in giving it; this cannot be rushed even if there are other priorities in your practice setting.
- Respond to the recipient’s feelings by acknowledging how hard this is for them, that their feelings are valid and that you empathise. If you find that you are unable to empathise, for whatever reason, it is worth considering whether you are the best person to be breaking this news. Perhaps it is a new situation for you; however, human emotions are universal and can be recognised and acknowledged as being valid and difficult.
- Make a plan together and follow through. The plan may just be as simple as agreeing between you to review the situation at an appointed time, to access further help, to refer the person to another service for support, or treatment, or to allow some thinking time to make a difficult decision. Do not expect the person to make decisions at the time, under pressure or without having the opportunity to discuss them with the significant people in their life. (Buckman 1998)
Fiona talks mainly about work with adults but the reluctance to break bad news might be felt to be even more difficult when talking to the parents of children or children themselves about their treatment. This may be because of a feeling that children should be protected as far as possible from some information - which may in turn depend on our view of childhood .
This is all the more difficult in settings like Great Ormond Street where the news might be that a child is likely to die. We have a common feeling in society that while any death is difficult and sad; the death of a child is ‘untimely’ and so even more sad, often described as tragic. Increasingly we have faith in medicine and technology to prevent such deaths but while these programmes show how far these advances have come they also show that there are still limits to what can be achieved.
The toll this takes on parents and professionals is clear in the programme. Dr Vas comments that every time a child dies the staff ‘lose a little bit of ourselves’.
Find out more about death and dying