How To Deliver Bad News

I’m hosting a masterclass later today for Consultant Oncologists on delivering and discussing ‘bad news’ with patients. 

When asked, I was hesitant; I mean, these amazing professionals have to deal with difficult conversations on a daily basis and as a communication skills lead, I’m stepping into territory that could potentially patronise and offend.  Subsequent conversations with friends and relatives, bolstered by lots of mind-bending research, showed there is indeed a need and a desire for more training in this area.

Most of us will experience the ‘I’m sorry it’s not good news…’ medical conversation at some point in our lives, if not personally, then with someone close.  My own recollection of sitting in a consultancy room when my husband was diagnosed with cancer is that I can’t remember much; I literally couldn’t hear what was being said, which as it turns out is not uncommon because when we receive bad news the physical and emotional symptoms are similar to what we experience when an aeroplane nose dives. We panic. Heart rate rockets, hands are sweaty, our fight or flight mechanism steps in and this can cause us to make irrational decisions.

Shockingly, research has shown that if the patient feels that the conversation is not done ‘well’, then it can lead to a refusal to be treated. The research I’ve found suggests that in any challenging or potentially devastating situation, there are steps that can be taken to maximise better clinical outcomes. And it all comes down to excellent communication that puts the patient at the heart of the story.

Thankfully, these are not conversations we are likely to have in a traditional business environment, but there are things which will help make potentially distressing and difficult conversations in the workplace more empathetic, more productive and maximise the opportunity for better outcomes. And bad news can be anything from a poor performance review/disciplinary to losing an important customer or redundancy. What’s OK news for you might be bad news for them; a friend of mine left her senior position in a company because she was told she couldn’t take a holiday when she wanted to!

Here’s a brief look at some simple steps that will help level the aeroplane.

Check-in and Credibility

Ideally, a difficult conversation should be conducted face-to-face, whenever possible, in a private setting.  Try to build in more time than you think might be necessary. If it’s on a virtual call, be well lit (otherwise our emotional mind will find reasons to justify you as the ‘shady’ figure you present) and make sure your microphone works well.  Have a background that reflects the mood of the conversation. If it’s redundancies we’re talking about, a Malibu apartment virtual background or one of a beach won’t do the job.

Make it clear what the context of the situation is and check their understanding of why they are there; this will help you present the actual news effectively. Rumours and misconceptions can all feed into how the news is taken; if we’re looking for a positive process moving forward, we don’t want to be the villain in the piece (don’t shoot the messenger is a phrase that comes to mind). Therefore, be clear about your role in the discussion, demonstrate that you are there to help and find out what their understanding is of the situation.

Deliver the News

This is known as ‘the warning shot’ in the medical world.   Be clear and honest about what that bad news is, then…BE SILENT.

At this point, the other person has ‘lost control of the plane’ – anxiety, denial, inability to listen. So, give them time to process. I appreciate that, depending on the severity of the news, there might be legal considerations to consider, but if not, I would hold off for the time being. Give them the silence they need. If necessary, count to 10 slowly before you say anything else.  The balance of empathy you then show is quite nuanced; in the medical world, over-empathetic communication done badly is off-putting (too much ‘you must feel awful’ talk) and the patient gives up hope/it exacerbates despair. What we want is to hand back some sense of control to them even if the situation is something that can’t be changed; we can ‘umbrella that’ – for example ‘given that this is definitely going to happen, let’s talk through anything you want to discuss and see how we can help during the process’.  Simple open questions are the way forward here, using open body language (palms up, good eye contact). Empathise with what they are feeling and LISTEN to what they have to say.

A Clear Course of Action

There is a danger that any suggested way forward will sound confusing; remember, the other person is processing lots of things at this time. When I was working with a nurse talking about self-administered subcutaneous infusions for patients, she said, ‘there is a limit to the amount of information they can take in’ – often they’ve been told the news minutes before they are taken into another room and told how to self-medicate.   She said the information was potentially baffling, so we broke it down into bigger, simpler steps (there’s a reason why there are three bears chasing Goldilocks, three Billy Goats Gruff and three Little Pigs, and we all love a trilogy – it’s simple and manageable). Her three steps were ‘Firstly, how the pump works, secondly, site application, thirdly, any immediate side effects. She was able to walk them through this calmly, adding in the necessary detail to each step.  And summarise back at the end. Remember, in the moments after receiving bad news, we literally can’t hear, so anything to make it easier.

Continue to clarify to find out their thoughts as you go through the suggested course of action.  At this point, there is a temptation (that we may be completely unaware of) to talk and not listen or make assumptions. Use simple questions that reflect back what you have just heard.  For example if someone says ‘I’m angry’ don’t assume you know the reason why they are angry; often repeating back the key emotional words you are hearing are the key to finding out really what’s going in and that will help with the relationship afterwards.  ‘TED’ questions –  ‘tell me more’ ‘explain that in more detail’ or ‘describe that for me’ will illicit more (and more) useful information than ‘where, what, who, how’, which are great questions but will give you limited information.  And finally… avoid the question ‘Why’.  ‘WHY???’ I hear you ask, and immediately I feel judged!  Replace ‘why’ with ‘in what way’ or ‘tell me more’ as this will help keep rapport.

Three simple steps (see what I did there?). Right… I’m off. I’m getting the train to speak to the Oncologists. Wish me luck.