CLINICAL SKILLS How best to communicate bad news over the telephone Elizabeth Taylor This article examines communication issues relating to breaking the news of a sudden and/or unexpected death to family members. It focuses particularly on the delivery of bad news over the telephone. Often it is the nurse who has to make the call. When dealing with unexpected death, nurses may be unsure what to say and resort to various euphemisms or anecdotal practices without full understanding of their implications. Current literature and guidelines will be reviewed in order to inform nurses regarding best practice techniques for communicating with relatives facing unexpected death. The importance of planning for sudden death through building relationships with patients and their families will be discussed. Particular focus is placed on communication skills and the relevance for nurses of training in this area. The ethical dilemma regarding what to say and when will also be explored. Practical suggestions will be included to illustrate points and encourage discussion among colleagues. Conflict of interests: none in a hospital or community setting 2000), it is worth considering whether KEY WORDS when a patient has died suddenly. It is all ‘sudden deaths’ really should be crucial for nurses to understand that unexpected. It may be helpful for the Breaking bad news the way in which bad news is given multidisciplinary team to decide on Communication skills will always be remembered by the reflection whether the death was Sudden death bereaved, whether delivered well or unexpected because the possibility Telephone communication not (McCulloch, 2004). Complaints was not discussed with the family, or frequently focus on inadequacies whether it was genuinely unexpected. in communication (Fellowes et al, 2004), while evidence suggests that While a death may not be he media provides us with daily communication skills can be enhanced imminent, if a person is frail, has a images of brutal and gruesome, with training (Wilkinson et al, 2002; long-term degenerative condition, or is Tor highly romanticised deathbed Fellowes et al, 2004). recovering from a previous significant scenes. Professional literature regarding health event or procedure, health death and its management also tends The literature and principles care professionals (HCPs) should be towards polarised views. For example, of breaking bad news (BBN) are aware that the person may deteriorate palliative care portrays a planned, considered in relation to sudden death. rapidly, or die suddenly. This potential expected, ‘good’ death, whereas critical Particular attention is given to the role deterioration must be included in the care is associated with the trauma of of the person breaking the news, the planning and discussion of care. lives cut short in a dramatic fashion. The nature of the care provided at this reality, for the majority of people, does point and its potential impact on the Breaking bad news not match either of these portrayals grieving process. Communication skills Being the bearer or recipient of bad (Higginson, 2003). with regard to BBN over the telephone news is difficult. Cooley (2005) notes will be considered. Practical suggestions that: ‘Breaking bad news has had more This article examines the role of the will be presented to encourage comment and written word than any nurse in communicating with families discussion among colleagues and other patient/professional encounter promote enhanced levels of care at this and is still considered by health difficult and crucial time. professionals to be the most difficult Elizabeth Taylor, at the time of writing, was scenario.’ The majority of HCPs would Compass Project Manager (a telephone advice What is a sudden death? agree with Buckman (1992) that having service), NHS Direct, NHS Direct South Given that the majority of people in to break the news of someone’s death London, Beckenham, Kent. the UK die from chronic illness (Seale, (and particularly an unexpected death) 30 End of Life Care, 2007, Vol 1, No 1 30-37.Communication 30 12/3/07 14:18:14 CLINICAL SKILLS is one of the most stressful situations Edlich and Kubler-Ross (1992), communication when BBN. The first they face. When bad news is given by Buckman (1992) and Kaye (1996) have focuses on imparting the information telephone the recipient may not fully all published guidelines regarding BBN. and the second on working with the understand what has been said and be There are similarities between all three, subsequent emotions. He considers unsure what is expected of them. The in that all of the guidelines are based the six steps a necessary part of a worries of HCPs include: not speaking around four key principles (Table 2). BBN interview, although the second to the right person; fear that the While there is little empirical evidence and third point are not used when recipient of the bad news will collapse; to support the use of guidelines informing of a death. The reader is being asked outright if the patient has (Fallowfield and Jenkins, 2004), it is recommended to consider this work died and, if that occurs, being unsure recognised that guidelines helpfully for further clarification. The application how to respond (Wright, 1996). provide ‘a backcloth against which bad of the four key principles of BBN (see news can be delivered consistently and Table 2) with reference to unexpected Available evidence sensitively’ (Read, 2002). death will now be considered. Nurses have a responsibility to ‘base their care on current evidence, The principles of breaking bad news Preparation best practice and, where applicable, Buckman’s (1992) six-step protocol In the context of sudden death, validated research’ (Nursing and (Table 3) is particularly helpful and preparation may appear contradictory. Midwifery Council (NMC), 2004). informs much of the following The opposite, however, is true. Planning There is scant evidence in the discussion. He suggests that there for an unexpected death begins as soon literature over the last 10 years are two strands to effective as the HCP and patient meet for the relating to BBN in the context of the case scenario (see box). Two literature reviews on communicating/breaking Case scenario bad news were identified through a literature search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medline Mary Smith, a 78-year-old woman, has been admitted to a medical assessment (1996–2006). ward following a fall. She is very frail and has a severe chest infection. She lives with her elderly husband. Mr Smith was brought to visit his wife by a neighbour The first (Ptacek and Eberhardt, who keeps an eye on them both. They receive daily care from social services and 1996) highlighted the limitations of a district nurse visits regularly. Their daughter lives a considerable distance away the literature on this subject and but she has contacted the ward staff and and plans to visit at the weekend. When the lack of empirical evidence or Mr Smith came to see his wife the nurse found it difficult to gain information justification, particularly with regard from him as he is very hard of hearing. His details are documented in the next to what does and does not work. of kin section of his notes along with his daughter’s number. While Mrs Smith is Fallowfield and Jenkins (2004) focused being helped out of bed she collapses and has a cardiac arrest. Resuscitation fails on the impact of BBN on doctors and the nurse needs to inform the family. Whom should she contact and what and patients in three specific settings: should she say? obstetrics/paediatrics, acute trauma and oncology. Both reviews pertain to communication with/from doctors but much of what is identified may Table 1 be easily transferred to nursing practice. Fallowfield and Jenkins (2004) What recipients of bad news want from health professionals highlighted key areas of good practice throughout their review as identified by the recipients (Table 1). Understanding what is important to patients when sad or upsetting news is given Ptacek and Eberhardt (1996) Informants who show some concern and distress at the news rather than cold recognised two distinct aspects of BBN: professional detachment the setting and the message. They note that ‘the patients’ perception of the Doctors who are confident, show concern and are caring but who also allow physician is less positive if the physician them plenty of time to talk and ask questions appears anxious, depressed, irritated Importance is attributed to the attitude and knowledge of the news bearer, or pressured’. They also identified that clarity of message and privacy when receiving news a warning shot is ‘an effective way of reducing the element of shock’ (see Source: Fallowfield and Jenkins (2004) section on ‘warning shots’). End of Life Care, 2007, Vol 1, No 1 31 30-37.Communication 31 12/3/07 14:18:15 CLINICAL SKILLS guidance (Department of Health, 2005) during the process of BBN. This could Table 2 identifies that the most usual method, if be softened with ‘do you really want The four principles for breaking bad news the identified next of kin is not present to talk about this on the telephone?’ at the death, is by telephone. if a face-to-face conversation is the preferred option (Leash, 1996). In relation to accident and Preparation emergency departments (A&E), Leash Travel times and the likely response Communicating the news (1996), Wright (1996) and Kendrick of the family when arriving to find Managing emotions (1997) advocate informing relatives that the patient had died before they Planning the next step that an accident or sudden illness has embarked need to be considered. It occurred and requesting attendance at is recommended that those with a Source: Edlich and Kubler-Ross the hospital.