communicating bad news to cancer patients joel s. policzer, md, facp, faahpm sr. vp – national...

Communicating Bad News

to Cancer Patients

Joel S. Policzer, MD, FACP, FAAHPM

Sr. VP – National Medical DirectorVITAS Innovative Hospice Care

Miami, FL

Bad News

any news that drastically and negatively alters the patient’s view of their future

Do You Tell?

50 – 90% of patients want the truth

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 frameYOU would want a time frame when your time approaches

Time Frames

Study looked at prognostication of three groups:

cancer patientschemo nursesoncologists

Looked at accuracy of estimated survival

Time Frames

Patients were very accurate in when they expected death to occur

Chemo nurses closely tracked the patients’ estimates

Oncologists were off by months, usually estimating many months of survival in patients that were close to death

Time Frames

Take home message:if an oncologist tells you that

you have months to live, you’ll probably be dead in a week

Time Frames

Patients do not expect:“5:34 PM on July 21”

People want:“a few months”“a few weeks”“days”“hours”

Time FramesAs physicians and oncologists, if we’ve

taken care of enough patients, we know in our gut, with our clinical instinct, where a patient is in their trajectory

People want to know to be able to planMaybe they want to live the next month in Tuscany or Provence instead of wretching in your chemo room

Why is this Difficult?

Social factors

Our society values youth, health, wealth

Elderly, sick and poor are marginalizedSick and dying have less social value


Physician factors

Fear of causing painUncomfortable in uncomfortable

situationsSympathetic pain due to patient’s

distress


Fear of being blamedPhysicians have authority, control,

privilege and statusWhen medical care fails patient

it’s physician’s fault“blame the messenger”


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……”


Fear of medico-legal system

Everyone has “right” to be cured;If no cure happens, someone is to

blame


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


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


Fear of saying “I don’t know”

We are never rewarded for lack of knowledge

Can’t know or control everything


Fear of expressing emotions

Viewed as unprofessionalSuppressing emotions increases

distancebetween ourselves and patients


Ambiguity of “I’m sorry”

Two meanings“I’m sorry for you”“I’m sorry I did this”

Easily misinterpreted


Fear of one’s own illness and death

Cannot be honest with the dying unless you accept you will die

So How Do We Do This??

Never, never, never, ever…

NEVER “assume”

To assume: to make an ASSASS of UU

and MEME

If you need to know somethingIf you want to know something

If you need to know somethingIf you want to know something

ASK!!ASK!!

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


Listen effectively to response:tells understanding, ability to understand

Repeat back what patient saysDo not interruptMake encouraging cuesMaintain eye contact


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

communicating bad news to cancer patients joel s. policzer, md, facp, faahpm sr. vp – national...

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