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Case Scenario: Breaking Bad News – Unstable Pelvic Fracture in a Child

Updated: Mar 19



Summary:

This case involves delivering difficult news to a parent regarding their child who has sustained an unstable pelvic fracture following a road accident. The child requires immediate surgery due to their unstable condition. The focus is on breaking bad news appropriately, maintaining clear and empathetic communication, and ensuring proper safety netting for the parent.

Key Points:

Breaking Bad News – SPIKES Protocol

  • Setting: Ensure privacy and introduce yourself and your role.

  • Perception: Assess the parent's understanding of the situation before delivering the news.

  • Invitation: Ask if they want someone to be present and prepare them for the bad news.

  • Knowledge: Deliver information in layers (avoid overwhelming the parent immediately).

  • Emotions: Identify and validate the parent's emotions using the EVE (Emotion, Validation, Empathy) method.

  • Strategy & Summary: Provide next steps, address concerns, and ensure safety netting.

Diagnostic Approach:

  • Recognize the severity of the injury (unstable pelvic fracture).

  • Assess the child’s condition and explain why surgery is required.

  • Avoid giving absolute statements about prognosis ("He’s not going to die"). Instead, use cautious language like "It is highly unlikely, but we are doing everything we can."

Management Plan:

  1. Reassurance Before News Delivery:

    • "Your child is in safe hands. We are doing everything we can."

    • "Before we discuss further, I need to ask a few important questions."

  2. Data Gathering (Before Breaking News):

    • What exactly happened?

    • Pre-existing medical conditions?

    • Current medications and allergies?

  3. Breaking the News in Stages:

    • Step 1: "As you mentioned, he was in a road accident."

    • Step 2: "We did an X-ray, which showed a fracture."

    • Step 3: "Unfortunately, the fracture is unstable, and he needs immediate surgery."

  4. Emotional Support (EVE Protocol):

    • Identify the emotion ("I can see that you are upset and worried.")

    • Validate ("It is completely understandable to feel this way.")

    • Empathize ("I know this is difficult, and I assure you we are taking the best possible care of him.")

  5. Addressing Uncertainty in Prognosis:

    • Never give absolute assurances.

    • "It is highly unlikely that he will not make it, but we are closely monitoring and managing his condition."

  6. Safety Netting for the Parent:

    • Ensure emotional support: "Do you have someone with you? Would you like to call someone?"

    • Offer hospital support services if needed.

  7. Communication Techniques:

    • Avoid stock phrases that sound rehearsed.

    • Speak in a structured, clear, and compassionate manner.

    • Avoid unnecessary questioning or excessive reassurance.

Communication Skills:

  • Use clear and understandable language.

  • Signposting (but avoid unnecessary permission-seeking like "Can I ask you a personal question?").

  • Avoid assumptions or making up information (e.g., stating a specific surgery duration when unknown).

  • Encourage the parent to ask questions and express emotions.

Ethical Considerations:

  • Honesty and Transparency: Do not provide false reassurances.

  • Parental Support: Recognize emotional distress and ensure safety netting.

  • Consent & Decision-Making: Ensure the parent understands the medical plan.

Additional Resources:

  • GMC Good Medical Practice Guidelines​.

  • PLAB 2 Examiner Tips on Communication & Breaking Bad News​​.

  • Understanding PLAB 2 Scoring Criteria & Examiner Expectations​.

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