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Bad news and how not to avoid it

While our sympathies naturally are for the person who receives bad news, spare a thought for the person who is delivering the awful information - giving bad news is also stressful

Raj Persaud
BSc MSc MB BS MPhil FRCPsych
Consultant Psychiatrist  The Maudsley Hospital London
Emeritus Gresham Professor for Public Understanding of Psychiatry

How good are you at breaking bad news? The answer to the question actually depends on what your goal is - if you automatically gave yourself a score in answer to that question without asking yourself what goal you were rating yourself on - minus 10 points from yourself …
 
Nurses on a daily basis contend with the issue of how to give less than great news, yet the training on this predicament is extremely variable - particularly as there is no real consensus on how to give bad news well.

Patients with chronic or serious diseases have to wrestle not just with the bad news of when they were given the diagnosis, but the issue of ongoing news from their carers or doctors. But giving bad news is also stressful. A study found that doctors who frequently have to deliver bad news have been found to suffer higher rates of burnout and stress.
 
Another study found that doctors were so stressed by the prospect of delivering bad news that 40% admitted to putting an inaccurate and overly optimistic gloss on actual life expectancy estimates, in order to partly relieve themselves of the burden of dealing with negative patient reaction.
 
These figures come from a recent paper by Kate Sweeny and James Shepperd, psychologists at the University of Florida, who have just published an extremely useful review of the area in the prestigious academic journal Review of General Psychology.

Their paper presents evidence that implies that you may want to consider the possible strategy of saying to your doctor should they ever give you bad news: "Give it to me straight doc, I can take it, let me know how bad it really is," as this may produce quite a surprisingly altered account of what is really going on.

It also suggests that one strategy when thinking about giving bad news is to consider what the patient wants. Often a patient may not want to hear the truth. The problem for the bearer of bad news is that it may be in the patient's longer-term interests to go through the stress of hearing something they don't want to hear, as it allows them to plan better for their future.

The difficulty with the fundamental psychological drive of both parties to avoid confronting the reality of just how bad the news really is, means that inaccurate appraisal of the predicament prevents the victim from planning the best way forward.

Another frequent hitch is that following the meeting where the bad news was delivered, memory for what was actually said may be significantly impaired by the strong emotions around it. If you don't remember properly what was said, then your ability to act on it will also be impaired.

While there are innumerable courses for nurses and others on how to give bad news, as Sweeny and Shepperd point out, the judgment on how to do this well depends on what the goal is. Often we feel angry at the way superiors deliver bad news to us without realising that it's probably perfectly understandable from their standpoint why they did it the way they did it in terms of their own personal goals.

Often doctors giving bad news to patients have other goals, such as how to help the patient make the best decision in terms of survival; it might be that the patient needs to quickly decide on the best course of action, such as choosing an effective treatment. In which case, the bad news has to be delivered in a way that encourages action, and perhaps involves instilling hope as well as providing the necessary information that allow a sensible action plan to be developed.

It may be that in order to take the right action, it's absolutely imperative that the person receiving the bad news grasps just how bad things are and yet isn't so knocked sideways that they are unable to take the necessary action that will help them - it's in this scenario that the demands on the bearer of bad news are the greatest.

Reference
Sweeny K, Shepperd JA. Being the best bearer of bad tidings. Rev Gen Psychol 2007;11:235-57.