breaking bad news. objectives: students will: recognize essential principles of breaking bad news....
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Objectives:
Students will:
• Recognize essential principles of breaking bad news.
• Identify pitfalls in delivering breaking bad news.
• Apply skills of breaking bad news in a simulated situation.
Bad News
any news that drastically and negatively alters the patient’s view of their future
Buckman R. BMJ1984
Bad News
any news that drastically and negatively alters the patient’s view of their future
Buckman R. BMJ 1984
Bad News
any news that drastically and negatively alters the patient’s view of their future
Buckman R. BMJ 1984
It alters one’s self-image : “I left my house as one person & came home another.”
Professional cyclist Lance Armstrong’s recollection
Examples of Conditions Examples of Conditions Requiring Breaking of Requiring Breaking of
Bad News ???!!!!Bad News ???!!!!
Examples of Conditions Requiring Breaking of Bad News
• Cancer related diagnoses
• Intra uterine foetal demise
• Life long illness: Diabetes, Epilepsy
• Poor prognosis related to chronic diseases: loss of independence
Examples of Conditions Requiring Breaking of Bad News(cont)
• Informing parents about their child’s serious mental/physical handicap
• Giving diagnosis of serious sexually transmitted disease …catastrophic psychosocial results
• Non clinical situations like giving feedback to poorly performing trainees or colleagues
The Good News! about Bad News!!!
• Using a plan for determining the patient’s values, their wishes for participation in decision making, and a strategy for addressing their distress when the bad news is disclosed can increase our confidence in the task.
The Good News! about Bad News!!!(cont)
• It may also encourage patients to participate in difficult treatment decisions
• Those who do so have a better quality of life
• Clinicians who are comfortable with giving bad news are subject to less stress and burnout.
رضي سنان بن صهيب يحي أبي عن : صلى الله رسول قال قال عنه الله
وسلم عليه :اللهالمؤمن )) ألمر له عجبا كله أمره إن
: خير إن للمؤمن إال ذلك وليسوإن له، خيرا فكان شكر سراء أصابته
له خيرا فكان صبر ضراء ((أصابتهمسلم رواه
Do You Tell?
Recent studies have shown that:• Patients generally (50-90%) desire full & frank
disclosure, though a sizeable minority still may not want the full disclosure. (Ley p. Giving information to patients. New York: Wiley, 1982 )
So the issue is not “do you?”Issue is “how?”
Do You Tell?
In reality, patients who are dying, know they are dying They want confirmation of their
status They want a time frame
YOU would want a time frame when your time approaches
Is this Difficult to break the bad news?
• It is referred by some physicians like “dropping the bomb”
Baile W F, oncologist 2000
Why is this Difficult?
Social factors
Our society values youth, health, wealth
Elderly, sick and poor are marginalizedSick and dying have less social value
Why is this Difficult?
Physician factors
Fear of causing painUncomfortable in uncomfortable
situationsSympathetic pain due to patient’s
distress
Why is this Difficult?
Fear of being blamedPhysicians have authority, control,
privilege and status When medical care fails patient
it’s physician’s fault“blame the messenger”
Why is this Difficult?
Fear of therapeutic failureMedical system reinforces idea that poor
outcome and death are failures of ‘system’and by extension, our failure
“all disease is fixable”“better living through chemistry”
We are trained to feel this way; “if only……”
Why is this Difficult?
Fear of medico-legal system
Everyone has “right” to be cured;If no cure happens, someone is to
blame
Why is this Difficult?
Fear of not knowing
“we don’t do what we don’t do well”Good communication is a skill that is
not highly valued, therefore not taught
Why is this Difficult?
Fear of eliciting reaction“don’t do anything unless you know
what to do if it goes wrong”Not trained to handle reactionsNot trained to allow emotion to
come out
Why is this Difficult?
Fear of saying “I don’t know”
We are never rewarded for lack of knowledge
Can’t know or control everything
Why is this Difficult?
Fear of expressing emotionsViewed as unprofessionalSuppressing emotions increases
distancebetween ourselves and patients
Rabow & Mcphee (West J. Med 1999) described:
““Clinicians focus Clinicians focus oftenoften on relieving patients’ on relieving patients’ bodily pain, bodily pain, less often less often on their emotional on their emotional distress & distress & seldomseldom on their suffering.”on their suffering.”
Why is this Difficult?
Ambiguity of “I’m sorry”
Two meanings“I’m sorry for you”“I’m sorry I did this”
Easily misinterpreted
Why is this Difficult?
Fear of one’s own illness and death
Cannot be honest with the dying unless you accept you will die
THINGS GO WRONG WHEN:
WE TRY TO ESCAPE: • INAPPROPRIATE DELEGATION• DISTRACTION• FRONTAL ATTACK• INTELLECTUALIZATION• MINIMIZATION• EMPTY REASSURANCE
THINGS GO WRONG WHEN:
WE REACT IN ANGER:
• TO DENIAL• TO IDEALIZATION• TO REHEARSAL OF THE STORY• TO ‘UNREASONABLE’ DEMANDS• TO ANGER AND BLAME
THINGS GO WRONG WHEN:
WHEN WE DILUTE THE AGENDA:
• BILLING
• PRACTICAL ARRANGEMENTS
• REQUEST FOR POST MORTEM
The SPIKES Protocol
• SETTING UP the interview• Assessing patient’s PERCEPTION• Obtaining the patient’s INVITATION• Giving KNOWLEDGE and information• Addressing the patient’s EMOTIONS• STRATEGY and SUMMARY
SPIKES
Step 1: S - SETTING UP the interview• Preparation Preparation- Preparation• Always in person, face to face
NEVER on telephone• Plan, arrange for privacy, involve
significant others• Sitting down, Non Verbal Behaviour• Manage time constraints and
interruptions
SPIKES
• Step 2: P –Assessing The PATIENT’S
PERCEPTION
• Gather before you Give• Patient’s knowledge, expectations and hopes• What do they understand about the situation?
Unrealistic expectations?• What is their state of mind? Hopes?• Opportunity to correct misinformation and
tailor your information
SPIKES
• Step 3: I – Obtaining the patient’s INVITATION
• Gather before you give• How much does the patient want to know? Coping strategy?• Answer questions, offer to speak to another
SPIKES
• Step 4: K – Giving KNOWLEDGE and information to the patient
• Warning shot• Use simple language, no jargon, • Vocabulary and comprehension of patient• Small chunks, avoid detail unless requested• Pause, allow information to sink in• Wait for response before continuing• Check understanding• Check impact
SPIKES
• Step 5: E – Addressing the patient’s EMOTIONS with empathic responses
• Shock, isolation, grief• Silence, disbelief, crying, denial, anger• Observe patient’s responses and
identify emotions• Offer empathic responses
Emotions of the patient
• Respond to patients’ emotions with empathy
• Often shock, isolation, disbelief, grief or angerObserve for emotion on patient’s partIdentify the emotion. Identify the reason for the emotionConnect with the patient
Emotions of the patient
• Exploratory questionsHow do you mean?Tell me more about itYou said it frightens youYou said you were concerned about
your children, tell me moreCould you tell me what you are
worried about?
Emotions of the patient
• Validating responsesI can understand how you felt that wayI guess anyone might have the same
reactionYou are perfectly correct to think that
wayYour understanding of the reason for the
tests is very goodMany other patients have had a similar
experience
Emotions of the patient
• Doctor: “I’m sorry to say that the X-ray shows that the chemotherapy is not working [pause]. Unfortunately, the tumor has grown somewhat”
• Patient: “I’ve been afraid of this!” [Cries]
• Doctor: [Moves his chair closer, offers the patient a tissue and pauses,] “I know that this isn’t what you wanted to hear. I wish the news were better”
Empathic Responses
• An indication to the patient that you recognise what they are feeling (and why)
• Verbal and Non verbal• Often associated with the impact of the
news rather than the understanding.• Wait for response• Clarify
Emotions of the patient
Empathic statements
I can see how upsetting this is to youI can tell you were not expecting to
hear thisI know this is not good news for youI’m sorry to have to tell you thisThis is very difficult for me alsoI was also hoping for a better result
SPIKES• Step 6: S – STRATEGY and
SUMMARY• Are they ready?• Involve the patient in the decision making• Check understanding
• Clarify patient’s goals• Summarise • Contract for future
Six Step Protocol
-arrange physical context-find out what patient knows-find out what patient wants to know-share information-respond to patient’s feelings-plan follow-through
Arrange physical context
Always in person, face to face NEVER on telephone
Assure privacyVerify who is presentVerify who should be present
ASK
Arrange physical context
Remove physical barriersSit down
patient-physician eyes at same levelappear relaxed, not casual (avoid ‘open 4’)
Touch patient (appropriately)above the waist, handshake, shoulder
Find out what patient knows
Not just knows, but understands
Use open questions closed questions excellent for
history-takingprevent discussion
Find out what patient knows
Listen effectively to response:tells understanding, ability to understand
Repeat back what patient saysDo not interruptMake encouraging cuesMaintain eye contact
Find out what patient knows
Tolerate silences
Listen for “buried question”question asked while you are speaking
Find out what patient wants to know
Ask!!Do not allow families to run
interference
If patient chooses not to know now, may ask later
Share the information
Plan agenda know beforehand what information has to get across
eg diagnosis, treatment, prognosis, support
Start by aligning with what patient knows
Share the information
Allow patients to ‘get ready’Impart information in small packets
best case retention = 50%Speak English, not “Doctor”Verify message is received
Respond to feelings
Acknowledge emotionsstrong emotions prevent communicationidentify and acknowledge them
Learn to be comfortable with silence and with emotion
Respond to feelings
Range of normal reaction is widegive latitude as much as possiblestay calm, speak softlybe gentle, yet firmstick to basic rules of interview:
question-listen-hear-respond
Respond to feelings
Distinguish between adaptive and maladaptive behaviors
Adaptive Maladaptiveanger ragecrying collapsebargaining manipulationfulfilling an ambition impossible “quest”fear anxiety/panichope unrealistic hope
Respond to feelings
Respond with empathic responses“it must be very hard to…”“you sound angry (afraid, depressed)…”
Respond to feelings
In the face of true conflict: act, don’t react
If you cannot change behavior, get help
Planning follow-through
Have plan of actionMake certain patient’s understand
what is fixable and what is notAlways be honestPatient leaves with contract:
what will happen, who to call, how to call, when to return
You have one chance to get this conversation right
Patient/family will remember this always
How do you want to be remembered?
How to Break Bad News: A Guide for Health Care Professionals
Robert Buckman, M.D.Johns Hopkins University Press,
1992 ISBN: 0-8018-4491-6
• Scenario 1Tariq, a 55-year-old chain smoker taxi driver with persistent cough for 3 months, attends your clinic to find out the biopsy report of a lesion shown on a chest x-ray and CT scan. He is rather anxious, that he has a serious condition.
His biopsy report confirms that he has a Bronchogenic Carcinoma of right lung.
You are required to proceed with this consultation.
Scenario 2• A 54-year-old lady attends your clinic to find
out the result of an MRI of her spine. She has had constant pain all over her spine for the last 2 months. She also has a history of Breast cancer, which was treated 5 years ago.
• Her report shows that she has secondaries all over her spine
Proceed with this consultation. (Examination not required)
SAQs(1) One of the famous strategy for breaking bad news is the SPIKES Model:Explain briefly any 3 of the 6 areas mentioned in this model?
(2) What is a warning shot? What you say and what skills you use after and before breaking bad news?
(3) Breaking bad news is difficult: Give 3 reasons for that?
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