Introduction. Medical competence and effectiveness of treatment depends not only on "hard skills" - timely diagnosis and treatment selection according to the latest protocols, but also on "soft skills" - communication skills of the doctor, which constantly should be improved.
The issue of reproductive choice in obstetric or gynecological practice is an emotional challenge for the family. Only the patient and her partner can make the right decision, taking into account their resources available and moral values. The medical information should be provided according to objective data rather than from the subjective position of the doctor. Braking bad news is also a challenge for the doctor.
Aim. To implement in routine practice the protocol of consistent communication of the obstetrician-gynecologist with the patient, starting from the telephone invitation to a face-to-face consultation and ending with further follow-up with the family.
Method. A literature search for key words in scientific literature databases was conducted and a protocol for braking bad medical news was adapted in accordance with the request of an obstetrician-gynecologist in a situation of reproductive choice.
Results. The protocol includes six consecutive steps to build an interview between an obstetrician-gynecologist and a patient in a women's clinic. Those steps are: setting up the interview, assessing the patient’s perception, obtaining the patient’s invitation, giving knowledge and information to the patient, addressing responses, strategy and summary. Specific examples of dialogues, phrases to use, and phrases to avoid in the communication process are suggested. The article also presents the communication tools on how to work out denial, explanation, "here and now" and burn out prevention techniques.
Conclusion. We should be acknowledge the importance of the doctor's good communication skills at all stages of caring for families at risk of perinatal loss. The protocol of braking bad news in obstetric and gynecological practice is a classic one, it has already passed the test of time in world medical practice. Its further implementation in Ukraine is an important step.
Breaking bad news is an emotional challenge not only for the patient but also for the doctor. In obstetrics and gynecology, it is not uncommon for a patient to face a difficult reproductive choice to maintain or terminate a pregnancy in a situation of genetic pathology of fetal development, fetal pathology incompatible with life, severe extragenital pathology in women. Such pathology will inevitably lead to perinatal loss. Perinatal loss is a catastrophic but common experience . In Ukraine in 2019, 2506 women were diagnosed with congenital malformations of the fetus, another 2018 women terminated their pregnancies for medical reasons (Center for Medical Statistics of the Ministry of Health of Ukraine) .
In a situation of reproductive choice, a woman relies heavily on the doctor. It is the communication skills and style of breaking bad news depending on the future mental and emotional state of the woman (grief) and, consequently, the prognosis of recovery. In the situation of reproductive choice, bad news reporting should be in accordance with the specific guidelines, in an atmosphere of empathy and care, which is considered a part of standard care in most obstetric departments in developed countries .
Effective communication with parents is a process that requires clinicians to know what kind of information to provide, how and when to report the information, and how to assess parents' understanding of that information. Physicians caring for parents, who are bearing a loss, need specific knowledge about the behavior and needs of these parents, which is the basis for applying guidelines for breaking bad medical news and involving parents in joint decision-making.
Communication skills are a necessary and integral component of health care, but unfortunately, both in pre- and postgraduate education, as a rule, it is not a priority area of study . The focus of medical care is on physical health very often. Doctors do not know how to behave in the presence of a grieving mother and try to avoid emotional and empathic contact. They lack the skills, strategies, and resources in these situations. As a result, in many cases, the behavior and attitudes of medical staff (doctors, nurses) are not always correct, including distancing, emotional coldness, denial of severity, especially in early pregnancy . The purpose of such avoidant behavior of physicians is to try to reduce the level of their own emotional pain and protect themselves from irrational feelings of guilt and helplessness .
The moment of breaking bad news makes a professional anxious, because of complex feelings and lack of skills. An obstetrician-gynecologist may inadvertently jeopardize their competence, not realizing how bad news will help or harm the grief process and affect trust in future doctor-patient relationships.
The process of grief over perinatal loss begins when bad medical news is reported, so accompanying and assisting parents, who have experienced it, is a process that should not be improvised. Therefore, there is a need to offer doctors a working tool for reporting bad medical news.
This algorithm was developed to improve doctor-patient communication and is intended for obstetricians, family physicians, and physicians of other specialties who face bad news reporting in the perinatal period in clinical practice.
In the implementation of the protocol in medical practice, breaking bad news at the institutional level can be an effective tool to prevent burnout. The involvement of staff in this process should not be only the personal responsibility of the health worker but should be a comprehensive approach to the interaction of the organization and employees . Moral distress, which arises as a result of emotional stress due to bad news, is expressed in feelings of helplessness, devaluation of one's own efforts and achievements. And the circle closes because the exhausted doctor tends to give false hope to patients. The distress of the doctor can be shown in a decrease in efficiency, increase in the number of medical errors, decrease in adherence of patients to therapy, decrease in satisfaction of patients with medical services .
There was conducted a search for Ukrainian-language and English-language scientific literature published between 2000 and 2020, which included keywords: reproductive choice, perinatal loss, poor medical news reports, and communication skills. The search was performed using PubMed and Google Scholar databases. Due to the lack of publications on this topic, information retrieval has been extended to a longer period of time than in the standard approach (five years). Based on the results of information retrieval and clinical experience, the adaptation of the protocol of bad news was carried out, consisting of six stages of "A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer (SPIKES)" in oncological practice according to the features of obstetrics gynecological practice in the issue of reproductive choice [9-11]. This protocol was adapted to the needs of clinical practice of the Consultative and Diagnostic Department of Municipal Nonprofit Enterprise “Kyiv City Maternity Hospital # 1” in Kyiv.
Breaking bad news protocol in obstetrics and gynecology
The commencement of work
Preparation at the stage of women's consultation:
You, as a doctor, have received information that will put a woman in front of a reproductive choice. If there is even a small percentage that this information is incorrect - you need to check the probability again to be 100% sure. If the information cannot be confirmed, the patient should be informed during the consultation.
- A face-to-face consultation should be scheduled to report bad news;
- It is not advisable to report bad news by phone;
Phrases to avoid when inviting for a consultation by telephone:
- "Bad screening results have come - it is urgent to terminate the pregnancy";
- "You urgently need to come, because according to the results of the screening there is a high probability that the child will be disabled. We urgently need to terminate the pregnancy before it is too late";
- "Bad screening results have come, but don't worry, the term of pregnancy is such that it allows you to terminate it."
Phrases that are recommended to use:
- "I have a difficult conversation; you need to come for a consultation";
- "I'm sorry, I have bad news."
- Suggest that the patient be accompanied by someone close (partner, friend, or another trustee) over the phone.
- Allow enough time for a consultation. Organize a confidential space so that you are not disturbed during the consultation. In this case, it is good to have a sign that can be hung on the door handle: "Do not disturb, there is a consultation." Prepare napkins in case the patient cries. Prepare a glass of water for yourself and the patient. Prepare visual material (images, drawings) in case the patient wants to get more information.
- Before the consultation, introduce the patient and her partner to the other health professionals who will be present at the consultation and talk about their role:
- "This is Antonina, my midwife, she will fill in all the necessary documents (appointments)";
- "This is Ivan, an intern, he will help with the necessary documents today."
Determining the level of awareness
Find out what the patient already knows about the diagnosis. Maybe this is not her first pregnancy with such a diagnosis, or someone from relatives or loved ones has encountered this diagnosis, and so on.
"Did you hear or know anything about this diagnosis? What exactly do you know?"
Use words that the patient uses. If the patient addresses her baby: a child, a boy, a girl - it is desirable to use these words in conversation. Avoid the words "fetus", "pregnancy".
For example, the patient asks you:
- "What about my boy?"
It would be acceptable to answer:
"I'm sorry your boy has the following pathology."
Determine whether the patient has irrational beliefs about the diagnosis. How she explains it to herself (Karma, God's punishment)
For example, the patient may ask:
- "Doctor, did this happen because I wasn't happy about this pregnancy at first?"
- "It must have happened because I once had an abortion, and God is punishing me."
In this case, in the conversation and explanation, emphasize the rational facts.
Determine your ability to understand the information you are reporting.
- Ask the patient how well she understands the diagnosis.
- If it is an extragenital pathology - ask how worried she is about the symptoms or the disease?
- Was the diagnosis made first during pregnancy?
- What did other doctors tell her about her health or the condition of the child?
These additional questions will make it possible to determine exactly how much information needs to be provided. If the patient had already been informed about the possible risks of pregnancy, she could read something in advance and prepare for different scenarios.
Obtaining consent to the communication of information
Find out if the patient is willing/ready to get more information? Ask an open question:
- "Would you like me to explain to you in more detail why you were invited for a consultation today?"
- "I have prepared materials to help you understand the nature of these complications of pregnancy/illness. Please ask me questions or clarifications as soon as they arise. This will allow you to get the information you need to make a decision."
Recognize and support the different needs of the patient. Watch what questions the patient asks (what she pays attention to, what topic she directs the conversation to); what is bothering her right now (for example, what is the duration and quality of a child's life with this diagnosis).
Be understanding if the patient refuses to receive information. If she asks you to pause or asks you not to talk more about the child or the diagnosis, pause. Offer her water.
It would be appropriate to say: "I see that it is difficult for you now. There is a lot of information, and it takes time to accept it and understand what to do next. Take your time, we still have time for today's consultation. Can I offer you water? We can return to this topic when you are ready. "
Find out if the patient wants to know all possible scenarios. If not, maybe she wants you to tell this information to someone close to the patient?
- "By order of the Ministry of Health, this diagnosis is an indication for abortion. You have a choice - to agree or not. Can I tell you what are the possible options?"
"Do you want to know more, is it enough for today? We can continue this conversation when the results of the additional survey come."
Communication of information
Together with the patient and her partner, decide what should be discussed now (diagnosis, prognosis, etc.). Talk to the patient about all possible scenarios.
"Let's look at the situation if you decide to keep the pregnancy and give birth"
During this conversation, it is desirable to highlight the following points:
- How the pregnancy will proceed
- What health problems may arise
- How this pregnancy can end (antenatal fetal death, premature birth, birth in time. Vaginal delivery, or cesarean section)
- How childbirth can proceed
- Will the newborn need urgent resuscitation or can they be together immediately?
- Will the baby need the advice of narrow specialists (geneticist, cardiologist, surgeon, etc.)
- How long can a baby live with this diagnosis?
"Now we will consider the situation if you decide to terminate this pregnancy"
- Indicate the list of additional tests required with a mandatory indication of the duration of pregnancy at the time of these tests, how long to wait for the result. Because waiting for the test and its results can take several weeks, the patient may feel anxious and stressed all this time. She can cause sleep disorders, suppression of appetite and mood, exacerbate chronic somatic diseases. You can express your words of support:
"During the waiting period, you may feel anxious and tense, and this is natural; during this period you will need support."
- Inform about the next stages after receiving the results of surveys (repeated consultation, consideration by a special commission).
- Report hospitalization to the maternity hospital. What exactly will happen there (it is desirable to name the terms of stay before the procedure and after the procedure, without taking into account force majeure situations).
- Explain how exactly the abortion procedure will take place.
- How this procedure will affect a woman's reproductive health.
- Answer the questions that arise.
Adapt to the patient and "dose" the information. Use clear language for the patient. Try not to use special terms (do not say "amniocentesis" but "taking amniotic fluid"). Make sure your story does not become a monologue. Pause, give the patient the opportunity to respond to emotions. Encourage the patient to ask questions.
Do not make decisions for the patient and her family. Do not persuade her to make a decision that you think is right. Try to present information neutrally. Avoid uncertainty, do not confuse.
Do not soften the severity. If a child with this pathology can not live a full life without special devices - report it. Be delicate, but tell the truth.
DO NOT use phrases:
- "It's good that this diagnosis was made now, not after birth."
- "You are young, you will give birth"
- "This is natural selection"
- "You will forget about it after the procedure"
- "It's good that you already have healthy children"
If a woman does NOT ask when she can plan her next pregnancy, do NOT tell her:
- "After this period, you can plan a new pregnancy"
- "Hold on, everything will be fine"
- "You will still have healthy children"
Phrases that are recommended to use:
- “We will have a difficult conversation. Screening results have arrived. I am sorry that a high percentage of risk of this pathology is revealed. That means ... ”
- "I'm sorry to tell you sad news"
- "I'm sorry"
- “I do sympathize with you”
Check regularly that the patient understands everything. Ask her what exactly she understood from your words. After reporting bad news, a person may be in a state of emotional shock, which blocks the ability to perceive complex information.
- "Please tell, what exactly did you understand from what I told you?"
- "Could you say in your own words what you understood?"
Explain and repeat the information regularly. Use schematic visuals to make the patient more understandable. Give the patient the opportunity to decide how much and what information she wants to receive. Remind her that she has the ability to stop you at any time when the information received is sufficient.
- "If you find it difficult to accept the information, tell me about it. We will pause or postpone this discussion to the next meeting."
React to feelings
Manifestations of strong emotions are an expected component of bad news. The doctor needs to acquire the skill to withstand strong feelings when breaking bad news. Remember that this is an emotional reaction to the information received, not to you personally.
- "I see that it is difficult for you now. If tears come - do not hold back (give napkins to the patient).
- - This is a really difficult conversation that requires courage from you.
Normal emotional reactions:
- affective reactions: shock, anger, anxiety, fear, relief, shame, guilt, despair, loss, tears, sadness;
- cognitive reactions: denial, accusation, intellectualization;
- the main psychophysiological reaction "fight or flight" (men); seeking support or isolation (women).
Results and planning
Provide the patient with a brief summary of the consultation and outline the following steps:
- "We didn't have a simple conversation today, but you held on bravely. There was a lot of information, and you need some time to understand it. I want to reiterate our next steps in the near future."
- Encourage the patient to write down the steps you have voiced. Because the meeting was emotionally and informationally rich, the patient will not remember everything.
- Indicate the time frame that the patient has to make a decision (if the obstetric situation allows it). Focus on the reasons for the anxiety (symptoms that may indicate that you urgently need medical attention).
- Plan the next steps.
- Offer additional information (this could be the links to professional sources, information brochures, or parent forums raising children with this diagnosis)
- Discuss potential sources of support (these may be contacts of specialized support groups, a psychologist, or relevant organizations).
Tools for reporting the diagnosis
- Warning. At the beginning of the conversation, it will be appropriate to say a phrase that will prepare you for a difficult conversation: "I'm sorry, but I have bad news for you." If there is a pause in the conversation, do not rush to fill it. Give the patient time for awareness and emotional response, observe non-verbal manifestations (gaze, facial expressions, gestures, posture).
- Denial. Denial is a protective reaction of the psyche, a way to withstand a difficult situation. It is also a way to control the amount of information. On the other hand, it is an attempt by parents to remain "good parents", to try not to lose hope when everyone has already lost it.
- Explanation. When reporting the diagnosis, use different methods of conveying information (verbal, visual). Stimulate dialogue. Choose words, avoid harsh words. Use pauses and non-verbal communication (your look, facial expression, posture, intonation - it all matters). Encourage the patient to write down the questions that come to you after the consultation and be sure to discuss them at the next meeting.
- "What worries you the most at the moment?" Give time to answer open questions, listen, do not try to interrupt or give premature guarantees. Do not try to encourage the patient, it can give them unfounded hope and can undermine trust in you as a doctor.
- Take care of yourself. It is always difficult for a doctor to break bad news. Even if you did everything you could, there may be situations where the patient may still blame you. Remember that all the emotions identified are related to the situation and the diagnosis, not to your personality or competence. It is important that the doctor has the opportunity to live their emotions associated with this situation. After the consultation, give yourself time to be alone, drink warm tea, talk to a colleague. You may want to talk about your feelings with a mental health professional. There are also specialized psychological support groups for doctors (Balint groups) to discuss complex cases in medical practice.
During the period 2020-2021, this protocol was introduced into the clinical practice of the Consultative and Diagnostic Department of the Municipal Nonprofit Enterprise “Kyiv City Maternity Hospital #1” in Kyiv.
The importance of the doctor's communication skills at all stages of caring for families at risk of perinatal loss should be recognized. Clinicians who communicate with parents who have experienced perinatal loss should be well informed about the algorithm for reporting bad medical news, which effectively reduces emotional disorders, anger, and depression, as well as increases self-confidence in mothers. In addition, clinicians who know how to care for parents who have suffered losses should serve as mentors for their colleagues to increase the pool of competent clinicians. This algorithm will be useful not only for young professionals who are at the beginning of their careers but also for experienced professionals, helping to build a clear structure of the conversation. The protocol of breaking bad news in obstetric and gynecological practice is a classic protocol that has already been tested in time in world practice. It should continue to be implemented in Ukraine.
Conflict of interests
The authors declare no competing interests exist.
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