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A framework for sharing significant news

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Every family should receive the disclosure of their child’s prognosis in a face-to-face discussion in privacy and should be treated with respect, honesty and sensitivity. Information should be provided both for the child and the family in language that they can understand

“I think that conveying difficult news to parents is just as much of an art form as doing an operation and it’s just as important to be self-critical”

Professor Sir David Hall

haring the significant the news to a family that their child has cancer or is expected to die prematurely is undoubtedly one of the most difficult tasks that any professional has to face. In spite of efforts to improve this area of care, many parents are still treated clumsily or insensitively and the experience lives with them for a very long time (Scope 1994).

At such a difficult and stressful time families need honesty, respect and, above all, time from the professionals disclosing the diagnosis or prognosis. If disclosure is avoided or postponed, parents are likely to stumble on the truth at a later stage and their trust and confidence in professionals is damaged. This was highlighted in a report by Leonard in (1994) called: ‘Right from the Start’, which has now become a national initiative that aims to promote good practice at the time news is shared with families.

Research also confirms that both children and parents need information at this stage and in language that they can understand (Sloper and Turner 1993). However, written information should be used as a back-up to face-to-face discussion not as a substitute for personal communication. Providing details of support groups at the earliest possible stage is also beneficial to families who often feel a sense of isolation following the starkness of a diagnosis. CLIC Sargent, Macmillan and Contact a Family are organisations that provide information on parent support groups and may of the other issues.
From the time of diagnosis parents and professionals should recognise that they will be entering into partnership in caring for the child. In addition, the training and preparation of staff that will have to handle this situation should be a high priority. As part of the NHS Cancer Plan (2000) advanced communication skills training should be part of our professional development. This commitment has been reinforced in the NICE guidance on supportive and palliative care (2004), which emphasise that all health and social care staff working with cancer patients should under take training in advanced communication skills training. As well as this there should be in place appropriate guidelines around sharing significant news using established good practice.

Research suggests that communication skills do not reliably improve with experience alone (Cantwell & Ramirez 1997).

The Right from the start initiative has developed a template – good practice in sharing the news. Some of the key points are:
Value the child – as a child first, their condition or disability second:

  • Always use the child’s name

  • Avoid predictions and pronouncements about the child’s future

  • When sharing news, keep the baby or child with the parents whenever possible

  • When sharing news about an older child, consider whether the child should be present.

Respect parents and families:

  • Support and empower parents

  • Listen to parents and share information sensitively and honestly

  • Treat parents’ concerns seriously

  • Use plain, understandable language and give explanations

  • Discuss prognostic uncertainties openly and provide opportunities to ask questions

  • Check the parents’ understanding of the situation

  • Ensure there is an appropriate follow-up and provide any additional information needed

  • Acknowledge and respect cultural differences.

Support for professionals:

  • Acknowledge and address personal and professional development needs

  • Ensure continuous personal and professional development

  • Give opportunities for debriefing for all team members

  • Use peer support and critical reflection to inform and enhance practice.

Key Goals in breaking bad news

Good practice in breaking bad news has been described by SCOPE (1994):

  • Plenty of time should be made available for a face-to-face discussion, including opportunities to ask questions at the time and subsequently

  • A place should be provided that ensures complete privacy

  • Parents should be together to receive the news; if not possible, every effort should be made to ensure that another relative or a friend is present to support the parent hearing the news first

  • Helpful written material should be provided as a supplement to, but in no circumstances a substitute for, direct communication

  • Information should be conveyed in readily understandable language, using an interpreter where necessary.

The ACT Charter (2004) also states that:

  • Parents should be treated with openness and honesty

  • Parents should be acknowledged as experts in the care of their children.

  • The needs of the child or young person for information appropriate to their age and understanding should also be taken into account.

Framework for breaking bad news
Some things to think about before seeing a family or child:-

  • Getting started

  • What does the family know or suspect

  • Give information at families pace

  • Sharing the information

  • Giving space

  • Handling reactions

  • Planning and follow up

Some Do’s:-

1. Have the facts to hand

2. Clear enough time

3. Control potential interruptions

(Switch off bleep, Ask colleagues not to disturb you, Divert phone calls, Use 'do not disturb' sign if in general office)

4. Check if patient wishes anyone else present

5. Negotiate approx time consultation will take and explain need to take notes

6. Clarify what patient knows or suspects

7. Be prepared to follow the patients agenda

8. Observe and acknowledge patient's emotional reactions (Nervousness, Fear)

Some Don’ts:-

1. Make assumptions about:

    • The impact of the news

    • Patients readiness to hear news

    • Who else should be present

    • Patients priorities

    • Patients understanding

2. Give too much information at one time

3. Decide what is most important for the patient

4. Give inappropriate reassurance

5. Answer questions unless you have the facts to hand

6. Hurry the consultation

7. Use euphemisms e.g. 'little ulcer' when you mean 'cancer'

8. Block emotional expression from the patient

9. Break bad news to relatives before telling the patient

10. Agree to relative's demands that you withhold information from the patient
Sharing significant news with parents and children should be seen as a process, rather than a one off event. Before, during and after the session are all key times and it is important to see it as a whole process, which will continue in the minds of the parents and the child.


  • set up appointment as soon as possible

  • allow enough uninterrupted time; ensure no interruptions

  • use a comfortable, familiar environment if possible

  • invite both parents + relative, friend, as appropriate

  • be adequately prepared re clinical situation, records, child’s and family background

  • health care professional to put aside own “baggage” and personal feelings wherever possible

Beginning the session/Setting the scene

  • summarise where things have got to date, check with the patient

  • discover what has happened since last seen

  • calibrate how the child / parents are thinking/feeling as appropriate

  • negotiate agenda with child /parents

Sharing the information

  • assess the child’s understanding first: what the child already knows, is thinking or has been told

  • gauge how much the child / family wishes to know

  • give a warning first that difficult information is coming e.g. "I'm afraid we have some work to do...." "I'm afraid it looks more serious than we had hoped...."

  • give basic information, simply and honestly; repeat important points

  • relate your explanation to the parent’s framework

  • do not give too much information too early; don’t pussyfoot but do not overwhelm them

  • give information in small “chunks”; categorise information giving

  • watch the pace, check repeatedly for understanding and feelings as you proceed

  • use language carefully with regard to the child’s / parents reactions and emotions: avoid jargon

Being sensitive to the child/parents

  • read the non-verbal clues; face/body language, silences, tears

  • allow for “shut down” (when child or parents turn off and stops listening) and then give time and space: allow possible denial

  • keep pausing to give them the opportunity to ask questions

  • gauge child’s / parents needs for further information as you go and give more information as requested, i.e. listen to their wishes as they will vary greatly in their needs for information

  • encourage expression of feelings, give early permission for them to be expressed: i.e. “how does that news leave you feeling”, “I’m sorry that was difficult for you”, “you seem upset by that”

  • respond to their feelings and predicament with acceptance, empathy and concern

  • check their previous knowledge about information given

  • specifically elicit all their concerns

  • check understanding of information given ("would you like to run through what you are going to tell...?")

  • be aware of unshared meanings (i.e. what cancer means for the child / parents compared with what it means for the professionals)

  • do not be afraid to show emotion or distress

Planning and support

  • having identified all the patient’s specific concerns, offer specific help by breaking down overwhelming feelings into manageable concerns, prioritising and distinguishing the fixable from the unfixable

  • identify a plan for what is to happen next

  • give a broad time frame for what may lie ahead

  • give hope tempered with realism (“preparing for the worst and hoping for the best”)

  • ally yourself with the patient (“we can work on this together ...between us”) i.e. co-partnership with the patient / advocate of the patient

  • emphasise the quality of life

  • safety net

Follow-up and closing

  • summarise and check with patient

  • don't rush the patient to treatment

  • set up early further appointment, offer telephone calls etc.

  • identify support systems; involve relatives and friends

  • offer to see/tell spouse or others

  • make written materials available

  • Remember doctor's anxiety - re giving information, previous experience, failure to cure or help

This framework for “breaking bad news” is based on a number of people’s work: Brod et al, 1986; Maguire and Faulkner, (1988); Sanson-Fisher, (1992), Buckman, (1994); Cushing and Jones (1995), Leonard A. (1994).

Provided to NMCN CEN by Francis Edwards July 2010

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