Managing the delivery of bad news: An in-depth analysis of doctors’ delivery style

Abstract

Objective

The purpose of this study was to identify and describe the delivery styles doctors typically use when breaking bad news (BBN).

Methods

Thirty one doctors were recruited to participate in two standardised BBN consultations involving a sudden death. Delivery styles were determined using time to deliver the bad news as a standardised differentiation as well as qualitative analysis of interaction content and language style. Communication performance was also assessed.

Results

Analysis of BBN interactions revealed three typical delivery styles. A blunt style characterised by doctors delivering news within the first 30 s of the interaction; Forecasting, a staged delivery of the news within the first 2 min and a stalling approach, delaying news delivery for more than 2 min. This latter avoidant style relies on the news recipient reaching a conclusion about event outcome without the doctor explicitly conveying the news.

Conclusion

Three typical bad news delivery styles used by doctors when BBN were confirmed both semantically and operationally in the study. The relationship between delivery style and the overall quality of BBN interactions was also investigated.

Practice implications

This research provides a new template for approaching BBN training and provides evidence for a need for greater flexibility when communicating bad news.

Introduction

There is a general consensus in the medical literature that full disclosure, empathy and honesty are required when delivering bad news [1], [2] and presentation of bad news as a logical sequence of events [3] has been highlighted as an effective means of delivery [4], [5], [6]. This staged approach is particularly important in BBN interactions when the news is unexpected, as providing context may reduce news recipient shock and disbelief [7], [8], [9]. Guidelines and BBN teaching programs recommend inclusion of warning shots in the news delivery [10], [11], [12], as forewarning reportedly reduces shock and facilitates information processing [11], [13], [14]. Despite these recommendations, observations suggest doctors also use other BBN approaches [15], [16], [17] some of which result from doctors trying to distance themselves from the news [18].

Sociological analysis of narrative accounts of bad news experiences in both medical and non-medical interactions has identified three theoretically derived approaches to bad news delivery [19]: (1) bluntness, delivering the bad news without preamble, (2) forecasting or preparing the recipient for bad news prior to delivery, and (3) stalling or avoiding bad news delivery. Although not previously empirically assessed, such classifications are consistent with reported use of warning shots [9], [20], provision of information in a logical sequence [3] and abrupt bad news deliveries [16]. Therefore, Maynard's observations may have utility in describing doctors’ actual approaches to delivering bad news.

No systematic classification of typical approaches doctors use when BBN has previously been undertaken. The purpose of this study was therefore to identify and describe doctors’ delivery styles when BBN through in-depth analysis of standardised BBN interactions. The study also sought to establish whether Maynard's categorizations adequately depict doctors’ actual delivery approaches. Given the plethora of recommendations regarding the use of a staged approach with warning shots (that is informing the news recipient of the need to convey bad news [11]) when BBN, it was further hypothesised that this approach would form the basis of the approach utilised by the majority of doctors.