You are meeting with a patient on the Medical Admissions Ward to explain some test results. She is a 60-year-old lady with a history of breast cancer (treated by mastectomy 6 years ago). She was admitted with severe back pain, which had come on following a minor fall. Plain radiography suggested a pathogenic fracture, and an isotope bone scan confirms multiple metastatic deposits throughout the spine and ribcage. You have made a referral to Oncology for consideration of treatment options.
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This is a breaking bad news scenario. The candidate should start by going over the patient’s current condition and exploring the relative’s current understanding of what is happening. The candidate should make a reference to confidentiality and state the patient has given him consent to discuss with relatives. The candidate should give a warning shot, eg ‘I have some bad news to tell you’. A good candidate will use time effectively. After delivering the bad news, the candidate should wait for the relatives to speak next. If too much time is passing, a prompt may be used, e.g. ‘I realise this is a lot to take in, take as much time as you need’. It should become obvious that the relatives have many concerns and the candidate should acknowledge this. The candidate should apologise for delays in diagnosis.
This is a clear scenario of breaking bad news. You will have heard of the SPIKES protocol which is extremely helpful in breaking down such a difficult scenario into its component parts and helps the candidate think of all the important aspects. I will not go into each area but will summarise the important points. The candidate here ascertains well the initial symptoms and the reason for presentation. He clearly demonstrates a large gap in the patient’s perception of the problem and realises that this news is going to come as a shock. At this point, he could have asked if she has anyone present with her today or would like anyone to be present. That would act as a warning shot that the news may not be good. The candidate takes his time in the delivery of the word ‘cancer’, but equally does not ‘beat around the bush’. He uses pauses well to emphasize the seriousness of the situation and once the bombshell of cancer is dropped, he leaves the patient time to comprehend it. Pauses are very powerful if breaking bad news, and a candidate who quickly starts talking after delivering such bad news is easy to spot, although it is a difficult skill to obtain especially in the nervous exam setting. He shows good empathy with sentences such as ‘sorry to give you such difficult news’, and ‘I know it has come as a shock’, but if the pause feels to long and uneasy then he could have asked for permission to continue, which shows the examiners you are aware that the patient is in distress and acknowledgement that further information may not be comprehended. The candidate tries to be positive, saying that the cancer is potentially treatable, but acknowledges that it is not his area of expertise, which is entirely valid. With the patient’s permission, he changes the conversation to explain what should happen next very clearly and in order of priority. At the end of the scenario, the patient brought up the common issue of a potential missed diagnosis, and this was handled well by the candidate. He acknowledged it is difficult to comment fully as he was present at the time, but he acknowledged that how she initially presented would not automatically lead to the diagnosis she now has. Breaking bad news is a very common scenario in the PACES communication station and practice locally with colleagues using the SPIKES protocol and the RCP marksheet may be something to concentrate on in the lead up to the exam; especially if it not one of your strengths.
Breaking Bad News - Bone cancer - actor role play.pdf