How to Use the BREAKS Framework for Delivering Bad or Life-Altering News.
Introduction
Delivering bad or unfortunate news to patients is part of the medical profession; after all, medicine is about looking after sick people. Bad news can be broadly categorized as diseases that may be chronic or lifelong, life-altering illness, diseases that significantly shorten life expectancy, and injuries that may persist or being seasonal.
Delivering bad news can be difficult and challenging for any physicians, and special care should be taken to learn these crucial skills. Patients will distinctively remember the day when bad news was delivered to them, and in a way, the physician becomes part of that moment. Having bad news being delivered inadequately can make a patient resentful and may always be bitter towards the healthcare team, which may impede on their health journey, whether palliative or not.
It is found that patients like to be with the physician when they hear the bad news to answer any questions, if they wish to ask. The physician needs to make sure that the language used is clear and easy to understand as well as an environment that reflects calmness, privacy and a safe space. Interestingly, patients have different ways of coping and receiving information, such that some patients want to know everything and others want to know the bare minimum. This behaviour is influenced by different cultures, age, education, gender and so on. Delivering bad news can also put a lot of pressure on the healthcare staff, and it has been found that some physicians are scared of causing a huge emotional reaction and being blamed for the patient’s unfortunate outcome. Some physicians may over-express themselves or too little or be too afraid in sharing their emotions in some instances. Being overly optimistic or withholding information may also damage the relationship between patients and the healthcare staff. Delivering bad news can be very tough, especially when the estimated prognosis has a broad time frame. Hence several frameworks enable bad news to be delivered correctly, in the best possible way and decreases the amount of stress on the patient and the physician.
BREAKS framework
Before setting up and getting the environment ready, it is essential to “fire warning shots” at the patient that needs a discussion. This includes asking the patient to come back so that results can be discussed and, if possible, to bring a family member with them. Warning shots are vital as it infers that there is bad news and may not be as shocking as if the patient had no warning shots. Imagine a situation where a patient arrives with no knowledge of anything serious going on, only to be told that they have cancer that has spread (or even worse with a poor 5 years prognosis such as lung cancer). We want to avoid the 0 to 100 escalation in terms of bad news. Warning shots help the patient ease into the bad news and acknowledging it.
B - Background
Before seeing the patient, make sure to read up on the patient’s case and clinical history and mentally rehearse for the upcoming meeting. Familiar yourself with the clinical information and results.
Know the family or support person.
Have an understanding of the patient’s education level, support system, coping skills and emotional status.
Set up and plan ahead that the environment is private and comfortable. Arrange an adequate time for the meeting and let the staff know that you need to be undisturbed. Switch anything that may be a distraction off, such as pagers and cellphones.
Have tissues or water available.
If the physician is not ready, postpone the interview.
R - Rapport
Building rapport is critical and understand the patient’s concerns.
Introduce yourself and your role, and get to know everybody that is present and their relationship with the patient.
Sit down with the patient if they wish to do so (provide the option). It may be appropriate to be in touching distance if the patient allows it. Let the patient be as comfortable as possible.
Do not show any hostile or condescending attitude, and a hurried meeting is almost always disastrous.
E - Explore
What is the patient’s perception, knowledge or what do they suspect? Use open-ended questions to assess their perception of the situation. Perception is helpful in seeing the patient’s level of comprehension and if there are any misunderstanding or misinformation.
Find out how much the patient would like to know about their diagnosis and prognosis. This can be a very challenging question and moment in the interview. Ask permission, such as ask the patient if they want their results. This helps the patient be in charge and control the moment and wait for someone before hearing the news. If the patient declines, ask for another time or date so that results can be discussed. Encourage them if they want to bring their families or friends.
A - Announce
Foreshadow the news or fire a warning shot.
Patients have the right to know as much as the right to refrain from knowing. Get consent.
Being straightforward, honest, and compassionate has shown better outcome in terms of how patients hear bad news for the first time. Avoid medical jargon or euphemism. Avoid inappropriate humour or flippant comment. If you know the patient well enough, discreet humour may be used. Assess the situation first.
Maintain eye contact (do not look away or chart around).
After hearing bad news, patients will most likely be shocked and enter fight/flight mode. From there, memory retention is poor as survival instincts take over; hence, be sure to repeat, speak slowly and use sketches to present information. A general rule of thumb is to give three pieces of news at a time.
It is essential to hear what the patient understands from the news. In this way, information can be clarified and prevent confusion. Encouraging questions is crucial.
If the prognosis is poor, do not end on “there is nothing else we can do”. There are always things that can be done, such as palliative care and increase the quality of life, pain control, legal advice and so on.
If the disease is incurable, mention the positive aspects of treatment and ways to increase the quality of life. Do not use the word “cure” but “treat” when speaking about an incurable disease.
After each visit, summarise the treatments plan and how it is going, and set up the next goal.
K - Kindle
Assess the emotions of the patient and empathize. You may see shock, disbelief, denial, blame, acceptance, an outburst of emotions, crying, shouting/howling and so on. Silence and crying might occur as a natural reaction; wait for the moment to pass and do not talk to fill the silence. Let the patient take the pace.
Actively listen and be aware of denial. Validate how they feel and respond to their emotions.
Notice their body language.
Be empathetic and be aware of your emotions. Do not become emotional due to personal experience and similarities. Mirroring the patient’s emotions to a degree can be appropriate.
Give the patient some time.
At each visit, recall their emotions and compare how they are doing. Be aware of suicidal idealization.
Do not engage in confrontations, arguments and criticize colleagues of the medical profession.
S - Summarise
Correct any misinformation, summarise the bad news and explore the patient’s outcome.
A written summary is very beneficial.
Offer realistic hope but do not create unrealistic optimism.
Use interdisciplinary resources as follow-ups. This can be the physiotherapist, nurse, dietician, psychologist, social worker, pharmacist, occupational therapist, palliative team, specialist and so on.
Most importantly, let the patient know that they are not alone, schedule a follow-up appointment, and mention that you are available. Provide instructions on how to contact the staff.
Look after your patient’s safety, especially in the most vulnerable time of their life.
Published 15th March 2021. Last reviewed 1st December 2021.
Reference
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. Oncologist. 2000;5(4):302-11. doi: 10.1634/theoncologist.5-4-302.
Berkey FJ, Wiedemer JP, ND Vithalani. Delivering Bad or Life-Altering News. Am Fam Physician. 2018;98(2):99-104.
Buckman, R. Breaking bad news: the S-P-I-K-E-S strategy. Community Oncology. 2005;2:183-142.
Monden KR, Gentry L, Cox TR. Delivering bad news to patients. Proc (Bayl Univ Med Cent). 2016;29(1):101-102. doi:10.1080/08998280.2016.11929380
Narayanan V, Bista B, Koshy C. 'BREAKS' Protocol for Breaking Bad News. Indian J Palliat Care. 2010;16(2):61-65. DOI:10.4103/0973-1075.68401
Vandekieft GK. Breaking Bad News. Am Fam Physician. 2001;64(12):1975-1979.
