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Is there a wrong and right way to break bad news?


Being the bearer of bad news is one of medicine’s more emotionally challenging responsibilities. Getting it right is crucial not only for patients and their families, but also for the well-being of doctors themselves.

“If you’re giving someone bad news, it’s going to be pretty brutal for both the person receiving the news and the one giving it,” says Professor Stewart Dunn, a medical psychologist specialised in the psychological care of cancer patients and their families.

To look at what happened to doctors when they gave bad news, Professor Dunn and his team monitored the heartbeats of consultants and registrars as they interacted with a professional actor playing a woman finding out that she’d lost her husband.

“From even before the woman comes through the door, the doctors’ heartbeats went up by an average of 35 beats above baseline, which underlines how stressful the situation is. And there was no difference between consultants and registrars, which suggests this doesn’t get any less stressful with experience.”

Professor Dunn said his team identified three main approaches doctors used to giving bad news. There was the “blunting style”, where the doctor quickly gets to the point and gives the news using non-euphemistic terms such as “has died” or “has passed away”.

The record, Professor Dunn said, was a mere eight seconds from when the woman walked in the door to the doctor telling her that her husband had died.

While the “blunting style” was relatively common, more common still was the “forecasting style”, where the doctor fires warning shots to let the person know there’s bad news coming.

“For example, the doctor may start out by reminding the woman that when her husband had his first heart attack, she’d been told there would be damage to the heart and that he was still in a danger period. The doctor is telegraphing that something bad has happened, but takes one to two minutes to come out and actually say it,” Professor Dunn said.

Then finally there was a small group of doctors who were “stallers”, who took a long time to get to the point and concretely convey the news.

“These doctors obviously get very distressed themselves, and it’s like they’re waiting for the woman to say, ‘Oh, he’s dead’, so that they don’t have to say it themselves.”

Professor Dunn said that while the first two styles could be effective, depending on how the doctor handled the period after they’ve broken the bad news, the “stalling” method was to be avoided.

“When the doctor stalls, the person knows something bad’s happened but is getting more and more confused and hanging onto the hope that it’s not the worst possible news. And when they find out that it is, they feel betrayed.”

It normally takes around three minutes for the news to properly sink in and for the person to appreciate what it means, Professor Dunn said. During that period the person might question it, for example asking the doctor whether they’re sure they’ve got the right name.

“It’s a stage of disbelief. If you tell someone something terrible that will change their lives forever, it takes a while to come to terms with it.”

Following that, there may be a period of sitting with the patient, riding out the storm with her. This period of support is crucial, particularly for the doctors who tend towards a “blunting style”. Then, within reason, doctors should allow the patient to decide when the encounter comes to an end, usually after about 10 minutes or so. This is the point when the person says they need to act – call a relative, or see the body.

Professor Dunn said patients want doctors to express some emotion; they want reassurance that the doctor expects and understands that the patient is devastated.

“But a no-no is to say ‘I know how you feel’. You can never know how a person feels in such circumstances. It’s better to say something along the lines of ‘I understand that this is devastating for you.’”

After an encounter, it’s important that doctors debrief, which is not something they always do.

“All the literature on burnout shows that it comes from unresolved situations where stress accumulates. Doctors often say they reduce their stress by things like exercise, playing music or playing sport. Those things do reduce stress but they don’t necessarily impact on burnout in the way that debriefing and talking to colleagues do.”

Professor Dunn will be moderating three workshops in Sydney on complex communication in health care this year. The workshops will cover breaking bad news, open disclosure, end-of-life conversations and dealing with conflict in the workplace. Read more about the workshops and sign up here.

The quick fix that dramatically cuts antibiotic use


Simply asking patients to wait a couple of days to see if their symptoms resolve before filling their script substantially cuts antibiotic use, an Australian meta-analysis has found.

The Cochrane review, led by the University of Queensland’s Primary Care Clinical Unit, looked at 11 studies involving 3,500 patients with suspected common respiratory tract infections. It essentially found no significant clinical difference in outcomes between patients randomised to immediate prescription of antibiotics, delayed prescription, or no prescription.

There were also very low rates of complications or missed treatment of serious complications in those randomised to the ‘wait-and-see’ prescriptions.

But delaying prescription led to a massive drop in antibiotic use. Over 90% of patients with an immediate prescription filled it, compared with around 30% of those with a delayed prescription.

Patients were more satisfied with being given a delayed prescription compared with being given no prescription at all – a significant finding since it’s well recognised that some of the pressure to prescribe antibiotics comes from the patients themselves.

The studies reviewed involved acute respiratory tract infections, including cough, sore throat, colds and otitis media.

Lead author Dr Geoffrey Spurling said the review showed delayed prescribing could be an acceptable compromise if a doctor didn’t believe antibiotics were needed at the time of the consult, but was uneasy about adopting a ‘no-antibiotics’ approach.

“The evidence indicates that delayed prescribing is an effective strategy for reducing antibiotic use and now we need to get this message out the medical community,” he said. “Individual GPs can feel confident implementing this strategy for reducing antibiotic use as a way of treating infections if they are uncomfortable with not prescribing antibiotics.”

As outlined in research recently published in the MJA, Australia has a very high rate of prescribing antibiotics for respiratory tract infections, with antibiotics prescribed at 4-9 times more often than is recommended by therapeutic guidelines.

Australia’s Chief Medical Officer recently sent written warnings to the top 30% of antibiotic prescribers, asking them to think about what they can do to reduce their prescribing.

You can access the Cochrane Review here.