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Psychosocial palliative care: Breaking bad news well

In this second piece in the three-article series on psychosocial palliative care, we focus on communication skills. Thoughtful communication and counselling between healthcare professionals, patients and families is crucial to ensure that patients are afforded the opportunity and right to die in dignity and as peacefully as possible.
Psychosocial palliative care: Breaking bad news well

One of the key issues the psychosocial professional may need to assess, and address, is the patient’s understanding and insight into his or her illness. Most clients and families have some understanding of their diagnosis, but often they need to have this information clarified and reinforced, which then becomes the task of the members of the interdisciplinary team.

Sometimes a patient will speak of feelings of extreme anger in terms of how the diagnosis was given by the medical staff. Responses to a diagnosis given insensitively may include feelings of shock and disbelief, experiencing a lack of caring or insensitivity on the part of the doctor, and a sense of being abandoned – all of which may contribute to the client’s sense of isolation. It then becomes the task of members of the interdisciplinary team to confirm or break the bad news. On occasions, the team may have to break the bad news again, this time in a gentle manner, moving at the client’s pace, and also be prepared to explore the effects of the previous breaking of bad news on the patient and their family.

When breaking bad news is done well

Generally, the psychosocial professional will have been requested to have this conversation by another member of the interdisciplinary team, usually the professional nurse or doctor. By way of preparation, the psychosocial professional makes sure that she or he is fully informed about the patient’s medical condition, family situation, treatment or care plan to be able to navigate these difficult conversations. The psychosocial professional will also check what the patient has been told up to this point.

Some of the following questions could be asked:

  • “What have you been told about your medical situation so far?“
  • ”Could you tell me what you understand from the doctor about your illness up to this point?“
  • “How did you know that something was going wrong in your body?“
  • ”What do you make of your illness?“

    Not everyone wants to know the full extent of their illness, and some people may not be ready to absorb the full extent of their situation. Not all cultures place the same value on patient autonomy. In some cultures, it may be the family who needs to find out about the prognosis and plan of care and, in these situations, it will be necessary for the psychosocial professional to be sensitive about how this news is imparted. The following questions can be asked:

  • "Some people want to know everything about their condition, others prefer that we talk with their families. How would you like to be given this information?"
  • “Are there things that you would like to know about the illness?”
  • “Has the doctor/nurse told you all that you want to know so far or are there still some things you have questions about?”
  • “Would you like to know the results of your blood tests?”

    If the patient does not want to know any information, the counselor might ask:

  • “Do you think that ‘not-knowing’ could affect your relationship with your family in any way?”
  • “How will ‘not-knowing’ help you?”

    The wishes of the person are always respected. Sometimes people just need more time before they are ready to face more bad news. Denial is a useful defense mechanism to protect the integrity of the psyche.

    Giving people a chance to express the effect of the news in terms of thoughts, feelings, and actions is an important step. Naming thoughts and feelings may bring a sense of control. Powerful feelings may subside once acknowledged. Silence and non-verbal support and simply being present, may be all that is needed at this time.

    When done well, breaking bad news can achieve realistic hope and optimism, in that patients experience a measure of control and a sense that something can be done. Not life-saving actions, but actions that can assist and support. Families often feel far more empowered too, and trust is built with the healthcare team. Uncertainty in relation to an illness can be very hard for people to bear, as can inappropriate hope that may result in unnecessary treatments, expense, pain, guilt and anxiety.

    Breaking bad news well allows for appropriate adjustment. Adjusting to bad news takes time and is a process. Patients and their families need to know about the situation in order to adjust both emotionally and practically and for both parties to start moving towards an end-of-life situation that is perhaps more bearable and dignified.

    This series contains information from the Hospice Palliative Care Association (HPCA) Psychosocial Palliative Care Course manual. Online courses take place regularly, with the next courses planned for 9 May, 24 July and 11 September 2023. For more details, visit https://bit.ly/3nSpN1X

  • HPCA Care & Support
    The Hospice Palliative Care Association (HPCA) is a registered NPO in South Africa. Founded in 1987, the HPCA is a member organisation for South African hospices. As a national charity, the association champions and supports around 89 member organisations that provide hospice services to approximately 100,000 patients and their families per year. HPCA's member hospices across South Africa care for patients with a variety of life-threatening diseases, predominantly in the comfort of their own homes.



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