Breaking the bad news

Not infrequently we have to break bad news to patient or care taker. It is not easy when we as doctors to whom the patient come to get hope shattering their dreams. But no matter what we have to conclude it is mostly how we conclude that matters.

Planning is very important. We need to plan to whom to inform, where and when to inform, who to involve in the conversation. We need a quite private room to sit and discuss the case. Make an appointment with the parents. If you want to call parent to inform regarding the appointment it is best to ask some one else to call for you. This is to avoid to answer the parent telling the diagnosis by you on phone. Most of the time parents ask what is wrong with the baby once you request them to come and meet you. So if some one else call on behalf you he or she can tell the prents that you are going to tell about it.

Before parents come make sure that you diagnosis is correct or atleast not completelly opposite. .And it is the same baby that you are talking about. Get some more information or refresh your information regarding the condition. This can be done using text books, internet or collegue of the same or different descepline. Some times it is even better if you can invite collegues from other departments.

Know about the parents previouse history.

Do not talk only regarding the pproblem of the patient. Focus on thepositive aspects as well. eg; A down syndrome patient can also attend special schools where he can perform well. offer them what you can do for the patient no what you can not unless they ask. tell them about other agencies where thehy can get help. help them in makind desisions,

Do not give too much information. be diirect and tell the problem. And the give information slowly and not too much. Most of the time once they hear the bad news theor ears get shut. Nothing goes in or even ifit goes it does not retain. Thats why moost of the time parents will say doctor did not tell "anything" inspite of you told a lot.

Some use the formula Plan Assess, Choose and Evaluate then meet.
body language is also very important. eye to ye contact and if you want a pen and paper use it.
Before you start always introoduce your self. Show empathy and even sympathy to some extent can help. If they want a shoulder to cry give it, if you can not atleast a tissue will do the job. expect the parent as it is. If they want to cry do not try to stop them.
SOme of them might be psychiatric or mental even before so be carefful regarding that. Always break the news wioth 2 ofthe relatives.
Make sure no interruption and people are not laughing behind the door.
The timing should not be in the middle of night when they are sleeping or not during the visiting hour. this nake the visitors ask lot of questions from the one who recieve the news.
Shall we tell the children? it is important to know how much the child already knows. His concepts of universality, irreversability, nonfunctionality, causality should be addressed. Even though we hide everything from them some times it seems that they already know that some thing horrible has happened to them and some even thin that they are dying. Unless we openly discuss these issues it is difficult to proceed further.
do not make them feel guilt for not taking the child sooner when it is reallt not real. explain possible treatment and do not let them running around hunting for alternative care because of your explanation.
listen to them. Give prognosis with facts in a general population, not to the probabilty of the specific person.
For the family badnews is a process not an event. The families descision will be changing over time, let them go home. and call them again. always new questions arise once they are back at home. even descisions like DNR may change.

adopted from lecture by AP Hans, added from Nelson peds