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Re: Bad news will be unpleasant

Bad news is called bad news because it is … bad news. To be told that their child has cerebral palsy is devastating for parents and it is naïve to expect parents to be anything other than deeply distressed.

Baird et al interviewed parents to ask their views and feelings about how the bad news was broken to them.[1] Firstly, there are two sides to every story. They did not interview the doctors involved. As Bill Dobyns, the eminent geneticist writes, “When parents first hear that their child has a serious problem they are often not ready to understand or accept it. In this situation there is no good way to give the news. I have on several occasions heard professional friends give the most compassionate discussion I could image only to hear later they were ‘insensitive’ and so on.”[2]

Articles about breaking bad news inevitably do not take account of the ‘arousal gap’ – parents are in a heightened state of arousal so that every word, gesture or silence is given a meaning far beyond its intention.[3] Nor do the authors seem to show an understanding of the grieving process. Very few parents are honest enough to admit at this stage – or ever – what and who it is they are really angry with: they are angry with the child, themselves, God, life, etc; they feel guilty about that anger.

Secondly, Baird recommends that junior doctors are not present at the time of disclosure. I disagree. I hold a regular ‘hand over’ clinic with the neonatologist and a physiotherapist where these diagnoses are often confirmed and/or disclosed. The physiotherapist is not necessarily the one who has been or will be seeing the child, but represents her colleagues at the clinic and is an experienced and valued member of the team. A junior doctor from SCBU is also present. It is important that the junior medical staff see a variety of styles of delivering bad news and, equally importantly, a variety of responses from the parents.

Thirdly, the authors suggest that one obstacle to progress may be senior staff believing they know how to break bad news. The implication is that any doctor who does not go along with the guidelines recommended in the article is being obstructive and arrogant. I admit I think I do know how to break bad news but do not regard myself as an ‘obstacle’. I run several joint clinics with colleagues from other paediatric and related disciplines: these act as ongoing peer review on this and many other aspects of our practice for both the consultants present.

Dr Charles Essex
Consultant Neurodevelopmental Paediatrician
Child Development Unit
Gulson Hospital, Coventry CV1 2HR, UK

References
(1) Baird G, McConachie H, Scrutton D. Parents’ perception of disclosure of the diagnosis of cerebral palsy. Arch Dis Child 2000;83:475-80.

(2) Dobyns W. Lissencephaly : Frequently asked questions. http://www.lissencephaly.org/medical/doctor/index.htm