Buckman R. Breaking bad news: a guide for health care professionals. Baltimore: Johns Hopkins University Press, 1992:15
Clinicians regularly share with patients bad news ranging from the catastrophic (“You have a terminal illness” or “There has been a death in the family”) or serious (“You have an ulcer” or “You should take medicine regularly for your blood pressure”) to the merely inconvenient (“No heavy lifting for a week” or “With this chest infection it will probably be at least a few more days before you start to feel better”). Patients frequently harbor stories about physicians who deliver unpleasant information in a fashion that seems uncaring or unnecessarily frank. We know how our patients dread hearing bad news from us, at times even avoiding us or concealing information that might suggest a serious diagnosis. Anyone who doubts the importance in the public’s mind of the sharing of such bad news need only monitor how frequently television programs and movies portray these doctor-patient communications as riveting moments.
Although physicians have become dramatically more frank over the past 30 years in talking to patients about terminal illness and other major diagnoses, they have received little guidance on how to convey information sensitively and effectively. The art of sharing bad news is rarely studied or taught, despite its obvious importance. Thus, clinicians may approach the sharing of bad news with discomfort, vaguely recognizing the difficulty of the task and their lack of training and confidence in carrying it out. Clinicians in training are infrequently supervised in this task. Medical students anticipate their initiation as bearers of bad news with dread and fascination. Medical records almost never document details of this important procedure.
In his fine book, Robert Buckman, a medical oncologist, presents a well-organized, thoughtful, and readily assimilated approach to breaking bad news. His method was developed as part of an interviewing-skills course at the University of Toronto. He begins with a discussion of why the sharing of unpleasant information is difficult. Included is a particularly important section on doctors’ factors, such as fear of being blamed for the bad news, fear of arousing strong emotions or causing pain, uneasiness with their inability to make the disease go away or to answer all the patient’s questions, difficulty in facing death, and discomfort arising from the fact that they simply do not know how to carry out the task well. Next, wisely recognizing that the sharing of bad news cannot be discussed independently of a basic approach to clinical interviewing, Buckman presents a concise but useful primer on communication skills. The format here and in later sections includes brief “ground rules” and “practice points” that summarize key propositions, as well as clinical vignettes and scenarios that nicely illustrate different ways to respond to patients, demonstrating both ineffective and more therapeutic interventions.
The author then introduces the centerpiece of the book, a six-step protocol for breaking bad news: making introductions and establishing a setting conducive to discussion; clarifying what the patient already knows and believes; finding out what the patient wants to know; sharing information, a process that begins with the clinician “aligning” his or her perspective with that of the patient, and one that requires careful attention to educational principles; responding to the patient’s feelings; and planning for the future, including arranging for support and ensuring appropriate follow-up. Although these steps are not necessarily carried out in order, they encompass the essential elements of sensitive and effective communication. In two final sections, Buckman describes how patients, family, and friends respond to hearing unwanted news; here he provides a basic review of psychological coping and defenses, while also mentioning the importance of cultural issues. The reactions of health care professionals, including avoidance and withdrawal, are also addressed.
Although he focuses on patients with terminal illnesses, Buckman’s general approach applies well to everyday, less dramatic instances involving the breaking of disagreeable news. The book also addresses a variety of familiar but rarely discussed situations: the family that insists on not sharing the truth with the patient, the patient who asks awkward questions about prognosis and what death will be like, and the dilemma faced by the junior clinician when a senior physician does not want the patient told the truth. The attention to clinicians’ feelings and responses is most welcome. The book would benefit from more discussion about the pros and cons of truth telling, how to deal with uncertainty (for example, in explaining the importance of a “suspicious” mammogram), the nature of hope, and our natural reluctance to be frank and our wish to soften harsh facts. I would also have appreciated increased emphasis on the fact that good communication requires time, which many clinicians believe they lack. Although we may break bad news in one clinical encounter, the development of a therapeutic relationship and effective communication may entail multiple visits (both before and after the painful information is conveyed) and, at times, may be best managed by a well-coordinated interdisciplinary team. The author is remiss in not addressing the importance of spiritual and existential issues in terminal illness. The references are carelessly documented.
The good news is that, at last, we have a wise, useful, and readable textbook on the communication of unpleasant information. Aside from a few chapters in textbooks on interviewing, a medical student or practitioner has nowhere else to turn for guidance on this difficult subject. The bad news is that even this fine book cannot make the sharing of bad news easy or pleasant. However, Buckman has treated an enormously important and complex topic in a sensible, practical, and engaging fashion. Sophisticated concepts are put forth concisely, clearly, and simply, with relatively little jargon.
This book should be recommended reading for students in basic clinical-skills courses. It belongs in every clinical library used by trainees and should be required reading for teachers of interviewing and basic clinical skills. It would make a fine gift for students and other clinicians in training. The focus on terminal illness makes the book particularly appealing to oncologists, hospice physicians, primary care practitioners, and others working regularly with dying patients, but this thoughtful and stimulating presentation will be appreciated by all clinicians faced with the difficult task of sharing bad news. Our patients will be grateful that we now are paying careful attention to our skills in communicating unpleasant information.
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