Truth disclosure within bad news conversations
A blog post written by Elizabeth Miller
Some people can communicate a complicated message logically and simply. We may say they’re ‘a natural’ or have a gift. For others, though, communication does not come so easily – especially concerning topics that require a great deal of tact and understanding. If you were to ask your family, friends, or acquaintances about their experiences with a bad news diagnosis, there is bound to be at least one story where bad news was given in a manner that left room for improvement.
For health professionals, delivering bad news about life-limiting illnesses can be complex and challenging, even for experienced health professionals. [1] Novice health professionals learning their craft within specialist palliative environments have an advantage in that they can observe and emulate language, style, and relational skills from experienced practitioners. In addition, they understand and regularly see the consequences of late disclosure. When a diagnosis and its implications, the brevity of a prognosis, or the futility of treatment are not conveyed, understood, or accepted, patients are robbed of time in which to make their wishes known, set their affairs in order, or spend their remaining time with those they love. [2,3]
In order to understand the topic of truth disclosure within bad news delivery, the current palliative literature was examined and analysed. [3] A conceptual model was created from the synthesis illustrating a novel way to view the communication process and dynamics. Six elements were identified that were important in establishing a conducive environment within which to deliver bad news. The literature review and conceptual model can be viewed in the paper ‘The experiences of health professionals, patients, and families with truth disclosure when breaking bad news in palliative care: A qualitative meta-synthesis’. These enabling elements included:
- the importance of a therapeutic relationship
- reading cues
- acknowledgment
- language
- time/place
- qualities (of the health professional).
Patients and family members reported the importance of trust and ‘being known’ as outcomes of a therapeutic relationship developed with the health professional. Being known allowed for tailored conversations and a health professional who understood what was important to the patient and family. A conversation with a patient about their life-limiting illness is dynamic as holistic care requires additional variables to be considered, such as health literacy, age, culture, spirituality, and family dynamics. [4, 5] As patients and family members may be in shock, especially after receiving a cancer diagnosis, information should be given incrementally in a circular fashion to allow absorption and clarify any misunderstandings.
For health professionals with less palliative care experience, anticipating the patient or family’s emotional response may give rise to internal stress, avoidance behaviours, or not being entirely truthful. [3] The fear of taking away hope is a strong driver for vague language or an overly optimistic timeline, but this is not ultimately helpful. Through the development of a therapeutic relationship with the promise of support and non-abandonment, hope can be based on reality, not on a cure.
Like everything in life, delivering bad news is a skill that can be learned, but it must be done well to prevent avoidable distress.
References
- Berkey FJ, Wiedemer JP, Vithalani ND. Delivering Bad or Life-Altering News. Am Fam Physician. 2018 Jul 15;98(2):99-104.
- Kalowes P. Improving End-of-Life Care Prognostic Discussions: Role of Advanced Practice Nurses. AACN Adv Crit Care. 2015 Apr-Jun;26(2):151-66. doi: 10.1097/NCI.0000000000000086.
- Miller EM, Porter JE, Barbagallo MS. The experiences of health professionals, patients, and families with truth disclosure when breaking bad news in palliative care: A qualitative meta-synthesis. Palliat Support Care. 2022 Jun;20(3):433-444. doi: 10.1017/S1478951521001243.
- Mostafazadeh-Bora M, Zarghami A. Breaking and Sharing Bad News in End of Life: The Religious and Culture Matters. J Relig Health. 2017 Oct;56(5):1655-1657. doi: 10.1007/s10943-016-0249-0.
- Ptacek JT, Eberhardt TL. Breaking bad news. A review of the literature. JAMA. 1996 Aug 14;276(6):496-502.
Elizabeth Miller, PhD candidate
Institute of Health and Wellbeing
Federation University Australia