Reflecting on an experience: breaking bad news



In this example, a doctor uses the 'What, so what, now what' template to reflect on a time when breaking bad news didn't go well, and the impact this had on the patient's family.

Image shows an equally split pie chart with the headings:- what (thinking), so what (feeling) and now what (doing).

What? (thinking)

Focuses on thoughts at the time of an experience. It explores how those may have impacted on actions and feelings and on what has been learned.

What was I thinking when I took the actions or made the decision that I did? What do I think now?
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A patient had just died during the previous shift. At handover the registrar asked me to pop up and see the patient's relatives as they had to go to HDU to see a deteriorating patient.

I arrived on the ward and found the relatives by the patient's bed, they were very angry and asked me what had happened. I recognised that I was unprepared for this conversation and said that I would go and get the patient's notes and come back to see them. I went to talk to the ward sister, who said that she had just returned from holiday and had only received a brief handover from the night staff. She asked if I would deal with the patient's relatives as she was short of staff and wanted to finish the morning drugs round. I was unfamiliar with the ward and asked her where I could take the relatives to talk to them. She pointed vaguely in the direction of what looked like a side room.

I sat for 5 minutes reading the patient's notes and then went to collect the relatives to talk to them. One was very angry and kept saying that the patient had been doing so well and that they had not been expecting this turn of events. The relative asked why they had not been called in when the patient had first become unwell.

During the conversation it became clear that this room was being used as a nurse's locker room, whilst their old one was being decorated. Several nurses came into collect their handbags before they went home. I went through the "What to do if your relative dies" booklet with the relatives and they left the ward still crying.

I was thinking that I wanted to help the relatives through a very difficult and emotional experience to the best of my ability, but that I wasn't informed enough to handle the situation well and had been given an unsuitable environment to do it in.

So what? (feeling)

Involves considering the significance of what happened as well as the values and feelings that may influence future learning or actions.

So what did I feel at the time of the experience? So what do I feel now?
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At the time I felt upset that I was put on the spot like that with no prior knowledge of the case, didn't have time to process my own emotions on the situation and had to have a difficult conversation in an unsuitable environment.

I have spent some time reflecting on the experience, and think there are actions I can take to improve my performance in the future in a similar situation, which will in turn benefit patients and their relatives.

Now what? (doing)

Looks at learning from the experience, identifying future actions, reflection on those actions, and how to use these to develop further.

Now what can I learn from or do differently next time? Now what will I do next?
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I think that there are some things that I could have done better in this situation which, whilst they would not have changed the outcome for the relatives, would have left them understanding why certain actions had been taken and the sequence of events.

When I arrived on the ward, instead of going straight to the bed to see the relatives it would have been better if I'd spent time looking at the patient's notes and asking the ward staff for an update on their perception of events leading to the patient's death. This would have meant that I would have been more informed when I had gone to see the relatives, as I had felt exposed and unprepared.

Before I went to see them, I should have identified a quiet space that we could have spoken in and I should have spent time preparing for our conversation. If I had to use the same room I should have put a notice on the door asking the staff to not enter. Even better would have been to find another area, perhaps on the next ward, where we would not be disturbed.

I have looked up some articles since then on breaking bad news and they say that preparation is the key to the success of any conversation. In the future, if I do not know the answers to relatives' questions I will seek help from another doctor, who perhaps knows them better. If this cannot be arranged at the time, the relatives could be asked to come in at a later date for this to occur.

I have decided to book myself onto a breaking bad news simulation day at the Trust.