Delivering bad news (8.38 mins)

Maria Cleary is a 45 year old secondary school teacher who has been referred to the Breast Clinic at the hospital with a breast lump. A biopsy was taken when Maria had a mammogram and ultrasound while attending her first appointment at the Breast Clinic. She is now attending a second appointment to receive the results of the biopsy. Watch this video to see how Dr Miriam O’Connor, medical oncologist uses good communication skills in her consultation with Maria.

Note on using this video

Read the background information to gain an understanding of the scenario context. On watching the video, you might feel that while many of the skills are good, perhaps there are some that you might do differently. To support your thinking on this, the communication skills sheet overleaf includes some examples of different wording.

As in any acted version of a healthcare conversation, you will notice that the video does not capture the full nuance of real-life communication. Instead, it highlights in a simplified, sometimes repeated manner, skills that are known to make healthcare conversations easier and more effective. The intention is not to teach skills ‘by rote’ and to learn wording by heart, but rather to help engage viewers in reflecting on what they communicate and how they do so.

The video includes multiple phases and skills. If you are using it in a teaching session, It can be useful to think in advance about particular skills you want learners to look out for. 


Supporting materials

Visit our webpage for supporting materials on communication skills for delivering bad news.

Click this link to download the Debrief in PDF format


Background

Maria Cleary is a 45 year old secondary school teacher who has been referred to the Breast Clinic at the hospital with a breast lump. In the video scenario she is returning to the clinic for a second time. At her first appointment, a biopsy had been taken and a mammogram and ultrasound conducted. In this second appointment she knows she will receive the results of the biopsy. In this video she meets Dr Miriam O’Connor, a medical oncologist who must tell Maria that her biopsy results show that she has breast cancer. ​


Clips

There are three clips in this scenario. 

FIRST CLIP
​INITIATE THE CONVERSATION
00:00 – 01:49

Miriam uses good communication skills to build rapport with Maria.

SECOND CLIP
​GIVE INFORMATION
01:50 – 8:00

Miriam delivers the unwelcome diagnosis in a step by step and sensitive way, conveys empathy, checks Maria’s understanding and perspectives, and begins to introduce what will happen next.

THIRD CLIP
​CLOSE THE CONVERSATION
08:01 – END

Miriam agrees next steps with Maria and emphasises support.

 


Communication Skills

FIRST CLIP
​INITIATE THE CONVERSATION
00:00 – 01:49
  • Miriam starts the conversation with a warm greeting (“Hi Mrs Cleary”), identifies herself by name and establishes her role (“My name is Dr Miriam O’Connor, I work with Dr Fraser and he’s asked me to meet with you today…”). 
  • Miriam checks the patient’s name (“Can I just check a few details to make sure I have the right Mrs Cleary?... So if you wouldn’t mind giving me your name and date of birth”). Explaining why she is asking for these details helps Maria understand why she is being asked (yet again) for them.  Maria confirms her name and says..(“It’s Maria Cleary”).
  • Miriam starts the conversation with a broad introductory question (“How are you today?”) and uses silence, verbal (“mm-mm”) and non-verbal encouragers (eye contact, nodding), giving Maria space to tell her story.
  • Miriam uses positive nonverbals to build rapport with Maria (eye contact, leaning, sitting at the same level, warm facial expression and gentle tone of voice). This helps to build rapport and trust and helps the rest of the conversation to flow more smoothly.
  • Miriam demonstrates that she has prepared for this meeting (“So I’ve looked over your notes and I can see that you came to see Dr Fraser a few weeks ago…”), this helps to build rapport and trust with Maria and Maria’s response helps Miriam to understand Maria’s understanding of the situation to this point, and her feelings (“I was quite worried about a lump that I’d found”).
  • Miriam continues to explore Maria’s understanding by inviting her to talk about her tests (“Talk me through the tests you’ve had done...”)
  • Miriam establishes what Maria already knows and what she might be expecting (“Did Dr Fraser talk about what it might be or what he was concerned it might be?”). Asking this kind of question – one that seeks Maria’s understanding and perspectives, and doing so fairly early in the conversation, is helpful in several ways. It means Miriam can find out how much of a surprise and shock the diagnosis might be, and she can find out the kind of terms and words Maria uses. Miriam can then fit what she says and how she says it to what Maria has said.
  • This question also gives Maria a clear opportunity to raise her concerns and present them in her own terms without steering from Miriam.
  • Miriam structures the conversation for Maria by sharing her thinking, giving Maria as much choice as possible and using signposting (“Before I go any further, it’s obvious you’ve come on your own today. Is that ok with you, or would you prefer to have had somebody with you?”). This emphasises Maria’s autonomy and promotes collaboration with her feeling partnership in the conversation with Miriam, (“If you did, we can change the appointment to another time”).​​

SECOND CLIP
​GIVE INFORMATION
01:50 – 8:00
  • Miriam structures the ‘giving information’ part of the conversation for Maria using signposting (“So Maria, this morning we had a meeting... with the people who look at those X-Rays, with the people who look at those biopsies”). This clarifies for Maria how the conversation will proceed and promotes collaboration with Maria feeling a partner in the conversation with Miriam.
  • Miriam uses a warning shot to indicate to Maria that she has to deliver bad news (“I am afraid the news is not what we were expecting or what you were hoping for”). Warning shots allow practitioners to forecast what is to come, this often works to lessen the degree of a patient’s shock on hearing the diagnosis. Practitioners’ warning shots enable patients to move more gradually from not knowing the news towards expecting what is to come, it is more gentle and lessens the likelihood of causing severe emotional shock than would simply delivering the diagnosis bluntly.
  • Miriam then gives the diagnosis using simple language and avoids euphemisms or medical jargon: “The result shows that you have breast cancer”.
  • When sharing information, Miriam uses appropriate pace and non-verbal behaviour. Her tone of voice demonstrates that she is taking the matter seriously.
  • After giving the diagnosis, Miriam pauses and waits for Maria to re-initiate the conversation.Clinicians often find it uncomfortable watching patients like this in silence but it is important to give the patient space to react.
  • Miriam conveys empathy and validates what Maria is feeling (“this is going to be a shock Maria…”), this skill enables her to convey that Maria’s concerns and feelings of worry in relation to her diagnosis are normal and reasonable and gives Maria permission to express her worries and concerns.
  • Miriam delivers the information in sizeable chunks, pausing between each chunk of information (this helps allow Maria to digest what she has heard). Miriam regularly checks Maria’s understanding. This can be done by watching Maria’s nonverbal responses (when she needs some time to take in information given so far) or asking Maria to restate key messages in her own words.
  • Miriam repeats key information, (“So the tests confirm that you have breast cancer Maria...”) using her name (“Maria”) to build connection.
  • Miriam supports and encourages Maria using positive nonverbals (eye contact, leaning, nodding, warm facial expression), and waits in silence, without interruption, giving Maria time and space to process the information (bad news) that she is receiving. Her facial expression implies a caring and compassionate approach.
  • Miriam responds to Maria’s question (“how can you be sure?”... “Dr Fraser said that for most people, it’s actually just these fatty, lumpy cysts”) with further information using slow pace, (“at our meeting this morning, they are certain... that lump you have in your breast is a breast cancer”). Miriam pauses again after repeating this key information to allow Maria time to digest what she has heard. This pause allows Maria time to articulate out loud what she is thinking... (“I don’t drink, I don’t smoke... so I just don’t see how I could possibly have cancer”).
  • Miriam responds with a wish statement (“I’d love to tell you that we have [made a mistake]”). This builds affiliation with Maria. Miriam then repeats key information regarding the multidisciplinary meeting, the tests and Maria’s diagnosis, (“At the meeting, we discuss each person’s case by case...the lump you have is a cancer Maria”) using her name to build connection.
  • Miriam empathises with Maria (“I can see that this is a big shock to you”). It is important in healthcare conversations to identify the feeling or emotion. Even if you initially get it wrong, this effort demonstrates to the person that you are trying to understand where they are coming from. In fact, because practitioners cannot know exactly what is going on in a patient’s feelings, it can be helpful to use alternative wording to what we see in this video, something like ‘I suspect/ imagine this is a big shock…’ or ‘women often find this a big shock’. By avoiding sounding like you definitely know what the patient is feeling, you show that you are trying to understand, but that you are not claiming you know precisely how the patient feels.
  • Miriam also sits with the emotion, and doesn’t try to fix it. By acknowledging and validating how Maria feels, Miriam builds connection with Maria and helps her to participate in the conversation by making her emotions feel less overwhelming. By talking about how Maria might be feeling, Miriam conveys her experience in giving bad news to patients in general, and conveys that she recognises that this is sensitive and bad news for Maria specifically.
  • Miriam asks a question that seeks Maria’s understanding, perspective, and starting point before giving her information about breast cancer by asking her what she already knows, “What do you know about breast cancer?” When she has established what Maria knows and wants to know, she is then able to fit what she says to Maria’s understanding and perspective.
  • Miriam supports and encourages Maria using positive nonverbals (eye contact, leaning, nodding, warm facial expression), and listening in silence, without interruption, giving Maria time and space to share her understanding and knowledge of breast cancer.
  • Miriam continues to deliver the information in sizeable chunks, (“at the meeting, there was a discussion about the treatments for you... we are going to be recommending that the first treatment for you is surgery”), pausing between each chunk of information (to allow Maria to digest what she has heard) and regularly checks Maria’s understanding. This can be done by watching Maria’s nonverbal responses (when she needs time to take in the information).
  • Another way of checking Maria’s understanding, not shown in this particular video, would be for Miriam to say something like “I’ve given you quite a bit of information today, and I might not have explained it clearly enough, so would you mind telling me what you have understood so far from what I have said?”. This way of checking understanding is an especially useful one compared to just asking the patient to repeat what you have told them – doing so can make patients feel they are being tested. Also, this way of checking understanding means that if the patient has not taken in every point, and you need to go over some information again, the patient is not made to feel like it is their fault that they have not understood everything.
  • Miriam again validates what Maria is feeling (“You’re right Maria, it is hard to take it all in…”), this skill enables her to convey that Maria’s concerns and feelings of worry in relation to her diagnosis are understandable, and and it encourages Maria to express her worries and concerns.
  • Miriam then signposts the next steps for Maria’s treatment, (“I am going to introduce you to Carolina”), summarising and repeating key information, (“you have a breast cancer...the treatment... which is surgery”).
  • Miriam then pauses, using positive nonverbals which encourage Maria to share her concerns, (“Could this have spread anywhere else?”).
  • Miriam validates Maria’s concern (“That’s a really common question, Maria and it’s a really good question…”), this skill enables her to convey that Maria’s concerns and feelings of worry in relation to her diagnosis are normal, giving Maria permission to express her worries and concerns. It also means that Miriam subtly reassures Maria that she is clinically experienced in these situations.
  • She answers Maria’s concerns, clearly, using small chunks and no obscure jargon (“it hasn’t travelled anywhere else”).
  • In the video, Miriam repeats the term ‘shocking news’, however, there may be times when repeating – having already acknowledged shock – that news is ‘shocking’ might prompt the patient to become more distressed. Alternatives include ‘difficult’ or ‘unwelcome’,
  • Miriam signposts what will happen next today (“The next step today is to meet the nurse that works with me…”). She listens to Maria’s emerging thoughts about how she will manage work and home in the future, and brings the conversation back to next steps, pausing while Maria nods to confirm her understanding of the next steps. Alternatively, Miriam could have spent time acknowledging Maria’s concerns about her work and home life, and could have said that the team, including the breast care nurse, would support her to think these through and work out how best to manage them.
  • Miriam puts a safety net in place (“The breast care nurse will give you her contact details”).

THIRD CLIP
​CLOSE THE CONVERSATION
08:01 – END
  • In this clip, Miriam checks that Maria is comfortable with the next steps and that she can close the conversation.
  • Miriam invites Maria to ask any questions (“...can I ask, have you any other questions today?”) and uses silence and non-verbal encouragers (eye contact, nodding), giving Maria space to speak and showing that she is listening. Whilst you may yourself have been taught to use the word ‘any’ in this sort of screening question, we now know that using other terms such as ‘some’ works better at encouraging positive responses from patients about other concerns and questions, so an alternative Miriam could have used would be ‘Can I ask, do you have some more questions or more things you want to raise at the moment?’.
  • In closing, having clearly explained what will happen next, Miriam reaches a shared understanding and agreement with Maria that they can leave the conversation and pick it up again together at another time.