Breaking bad news: experiences, views and difficulties of pre-registration house officers

Objectives: To obtain information regarding the involvement of pre-registration house officers (PRHOs) in the discussions on bad news, and the competency and difficulties they perceive in clinical practice. Design: Structured telephone interviews. Participants: 104 PRHOs. Main outcome measures: Information about frequency and quality of involvement of PRHOs in discussions on bad news with patients and relatives, perceived competency and difficulties related to this task as well as ethical views concerning the disclosure of bad news. Results: 82 PRHOs (78.9%) had initiated the breaking of bad news to a patient at least once, whilst patients themselves had initiated discussions of bad news by asking the doctors questions (92.3%). Almost all (96.2%), indicated that they had broken bad news to relatives of a patient. The majority of the junior doctors participating in our study felt fairly or very confident (90.4%) to break bad news. 'Often' quoted difficulties for over a fifth of the sample included 'Thinking I was not the appropriate person to discuss the bad news', 'Having all the relevant information available', 'Dealing with emotions of patient/relative', 'Lack of privacy' and 'Patients/relatives do not speak English'. Although 99 PRHOs (95.2%) believed that patients should be informed about a serious life threatening illness, 30.8% of the participants stated that doctors need to judge whether or not to tell a patient bad news. Factors most frequently selected by the PRHOs from a given list of possible factors contributing to a gap between theory and practice included problems with the organization of clinics (73.1%), insufficient postgraduate training (63.5%) and lack of staff (54.8%). Conclusions: The results indicate that PRHOs are frequently involved in the breaking of bad news. Whilst no claims can be made for their actual performance in practice, their perceptions of competency would indicate that the extensive and compulsory undergraduate teaching they had received on this subject has served to prepare them for this difficult task. Organizational and structural aspects need to be taken into account as factors assisting or undermining doctors in their efforts to put into practice ethically sound and skilled communication when disclosing bad news.