1. Breaking Bad News In Emergency: How Do We Approach It? Muhammad Saaiq and Khaleeq-Uz-Zaman
Medical Ethics In Debate
Breaking Bad News In Emergency:
How Do We Approach It?
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. In order to structure the process of breaking bad news in emergency
situations , the authors introduce SAAIQ emergency approach that has five components.
i.e. Setting the scene as soon as possible, Assessing the understanding of the
news’ recipient, Alerting about the bad news, Informing clearly and Quickly summarizing
the communication with information based hope. Adherence to this new approach ensures
quick delivery of bad news in an empathic, compassionate and tactful manner.
Pakistan Institute of Medical
Sciences (PIMS)
KEY WORDS: Breaking bad news , Communication skills , SAAIQ emergency approach.
Muhammad Saaiq*
Khaleeq-Uz-Zaman**
*Medical officer, Department of
Surgery, PIMS, Islamabad.
**Professor of Neurosurgery,
PIMS, Islamabad
Correspondence:
Dr Muhammad Saaiq
Medical Officer,
Department of Surgery,
Islamabad.
e-mail: muhammadsaaiq5 @
gmail.com
In this evidence based era it is imperative to redesign
the entire health care delivery from the patient’s
perspective. Breaking bad news to patients or their
relatives is one of the most challenging aspects of
medical practice. Effective communication skills hold the
key to solve such knotty issues of clinical practice as a
well communicated message though tragic, not only
enhances the patient’s understanding of and adjustment
to his illness but also improves the overall satisfaction
of both the patient as well as the care giver.1,2
Communication skills training programmes are
becoming an integral part of medical curriculum in UK
and USA.
Moreover there is growing concern about the
need for even training the experienced clinicians. 3
What constitutes a bad news?
Bad news is an upsetting information which drastically
changes a person’s self-image and sense of
interpersonal meaning. It is often associated with a
terminal diagnosis such as cancer. However bad news
can come in many forms as for example the diagnosis
of a chronic illness like diabetes mellitus, loss of
function such as impotence, a treatment plan that is
burdensome, painful or costly, a pregnant lady’s
ultrasound verifying a fetal demise, a
middle aged lady’s MRI scan confirming the clinical
suspicion of multiple sclerosis4
; diagnosis of a
potentially incurable illness such as AIDS, a
disease that ultimately mutilates the body such as
rheumatoid arthritis and disabling treatment such
as a permanent colostomy.
In the last few decades, the traditional paternalistic
model of patient care has been replaced by one that
emphasizes patient autonomy, empowerment
and full disclosure. Many recent studies have found
that majority of patients want to know the truth about
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
disclosure.8
In fact honest disclosure of diagnosis ,
prognosis and treatment options allows patients
to make informed health care decisions that are
consistent with their goals and values. A small
percentage of patients still may not want full disclosure
and hence physicians need to ascertain the
information needs of their patients.9
The doctor has to
adopt a sartorial approach and
individualize the manner and content of information
according to the needs of the patients. The unique
situation in our set up arises when
the relatives request that the actual facts be withheld
from the patient. Such situations must be handled with
great care and a tactful
approach would better serve neither to harm the patient
nor his miserable relatives.
Why to withhold bad news from
patients ?
We in Pakistan face similar situation as did Hippocrates5
and Thomas Percival6
because we are forced by
circumstances to withhold the bad news.
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2. Breaking Bad News In Emergency: How Do We Approach It? Muhammad Saaiq and Khaleeq-Uz-Zaman
Why breaking bad news a
difficult task?
Barriers to effective disclosure of bad news
include physician’s own issues such as the fear of
being blamed by the patient, of not knowing all
of the answers sought by the patient , of inflicting pain
on the patient , and even the physician’s own fear of
illness and death. Many physicians have no
adequate training in how to break bad news and many
perceive a lack of time in which to present the news.
Moreover patients may have multiple
physicians , making it unclear who should break
the bad news. 10
Bad news delivery in a proper way is a relatively new
area of communication skills and is literally still in its
infancy. Several professional groups have published
consensus guidelines on how to discuss bad news ,
however few of those guidelines are evidence based.1
The clinical efficacy of many standard recommendations
has not been empirically
demonstrated 2
Majority of articles on breaking bad
news are rather opinions and reviews by physicians.1,2
and fewer than 25 percent of publications on breaking
bad news are based on studies reporting original
data and those studies commonly have
methodological limitations. 4
Owing to the lack of adequate training, doctors and
nurses fail to give a crisp and clear message . There
is lack of empathy and professionalism in their approach
which at times confuse the scenario
even more. They typically display blocking behaviours
such as telling patients that any distress is normal,
switching the subject
to neutral topics, giving information and advice before
patient’s concerns have been identified, focusing only
on physical aspects of the
condition and using leading, closed and multiple
questions. This as negative psychological
consequences for patients as well as anxiety and
depression is more among patients who have
unresolved
For effective delivery of bad news various authorities
have attempted to devise comprehensive models
of their own. Girgis A et al 14
undertook pioneering
work and published guidelines on how to convey bad
news to patients. They placed special emphasis on
ensuring privacy and allowing adequate time,
assessing patient’s understanding , giving simple and
honest account of diagnosis and prognosis, avoiding
euphemisms, encouraging patients to express feelings,
being empathic, giving a broad but realistic time-
frame concerning prognosis and arranging a
review.
Objective evidence has proved the superiority of the
proper communication skills and there is growing
recognition of the role of intradisciplinary
and multidisciplinary workshops in overcoming the
communication deficiencies of health care
professionals.
Rabow and Mc Phee devised ABCDE mnemonic 15
for breaking bad news. i.e. Advance preparation, Build
a therapeutic environment / relationship, Communicate
well, Deal with patient and family reactions,
Encourage and validate emotions. This mnemonic has
been expanded by adding F for follow-up plan and
hence ABCDEF.16
Baile WF et al 7
devised the
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
break bad news in a straightforward and
empathic manner.
What matters to the patients?
Intensive patient satisfaction research is underway to
explore what matters to patients in an emotionally
charged situation entailing breaking bad news.
Parker PA et al 12
found that physician’s competence,
honesty and attention, the time allowed for
questions, a straightforward and understandable
diagnosis, and the use of clear language are the factors
which matter to the patients in breaking bad news.
Jurkovich GT et al13
worked on how family members
evaluate delivery of bad news and found that privacy,
physician’s attitude, competence, clarity of the message
and time for questions were the top rated areas.
How to tackle the issue of bad
news delivery?
The authors have enjoyed working at the busy Accident
and emergency department of Pakistan Institute of
Medical Sciences (PIMS), Islamabad
for quite some time. PIMS is a premier medical
institution of the country and its catchment area not
only includes the twin cities of Islamabad and
Rawalpindi but also Northern Areas , North West
Frontier Province (NWFP), Azad Jammu Kashmir and
upper Punjab. In emergency situations bad news often
must be delivered in an entirely different context.
Here neither the settings are conducive to intimate
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

3. Breaking Bad News In Emergency: How Do We Approach It? Muhammad Saaiq and Khaleeq-Uz-Zaman
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)
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.
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. 3 Hulsman RL, Ros WJG, Winnubst JAM , Bensing JM. Teaching
clinically experienced physicians communication skills. A review of
evaluation studies. Med Edu 1999 ; 33 : 655-68.
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.
15 Rabow MW, McPhee SJ. Beyond breaking bad news : how to help
patients who suffer . West J Med 1999 ; 171 : 260-3.
16 Moses S . Breaking bad news . Family Practice Notebook:
2004. (Serial online ) : (Cited 2004 Feb 2 ) : (3 screens ) : Available
from : URL : www.fpnotebook.com/HEM 209.htm.22 k
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Ann. Pak. Inst. Med. Sci. 2006; 2(1): 72-74 74