EEPPEECC

EEPPEECC

Communicating Bad News

Communicating Bad News

Module 2Module 2Module 2Module 2

The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

ObjectivesObjectives

Know why communication of “bad” Know why communication of “bad” news is importantnews is important

Understand the 6-step protocol for Understand the 6-step protocol for delivering bad newsdelivering bad news

know what to do at each stepknow what to do at each step

Know why communication of “bad” Know why communication of “bad” news is importantnews is important

Understand the 6-step protocol for Understand the 6-step protocol for delivering bad newsdelivering bad news

know what to do at each stepknow what to do at each step

ImportanceImportance

Most people want to knowMost people want to know

Strengthens physician-patient Strengthens physician-patient relationshiprelationship

Fosters collaborationFosters collaboration

Permits patients, families to plan, Permits patients, families to plan, copecope

Most people want to knowMost people want to know

Strengthens physician-patient Strengthens physician-patient relationshiprelationship

Fosters collaborationFosters collaboration

Permits patients, families to plan, Permits patients, families to plan, copecope

6-step protocol . . .6-step protocol . . .

1.1. Getting started Getting started

2.2. What does the patient know? What does the patient know?

3.3. How much does the patient want to How much does the patient want to know?know?

Adapted from Robert BuckmanAdapted from Robert Buckman

1.1. Getting started Getting started

2.2. What does the patient know? What does the patient know?

3.3. How much does the patient want to How much does the patient want to know?know?

Adapted from Robert BuckmanAdapted from Robert Buckman

. . . 6-step protocol. . . 6-step protocol

4.4. Sharing the information Sharing the information

5.5. Responding to patient, family Responding to patient, family feelingsfeelings

6.6. Planning and follow-up Planning and follow-up

Adapted from Robert BuckmanAdapted from Robert Buckman

4.4. Sharing the information Sharing the information

5.5. Responding to patient, family Responding to patient, family feelingsfeelings

6.6. Planning and follow-up Planning and follow-up

Adapted from Robert BuckmanAdapted from Robert Buckman

Step 1: Getting started . . .Step 1: Getting started . . .

Plan what you will sayPlan what you will say

confirm medical factsconfirm medical facts

don’t delegatedon’t delegate

Create a conducive environmentCreate a conducive environment

Plan what you will sayPlan what you will say

confirm medical factsconfirm medical facts

don’t delegatedon’t delegate

Create a conducive environmentCreate a conducive environment

. . . Step 1: Getting started. . . Step 1: Getting started

Allot adequate timeAllot adequate time

prevent interruptionsprevent interruptions

Determine who else the patient Determine who else the patient would like presentwould like present

if child, patient’s parentsif child, patient’s parents

Allot adequate timeAllot adequate time

prevent interruptionsprevent interruptions

Determine who else the patient Determine who else the patient would like presentwould like present

if child, patient’s parentsif child, patient’s parents

Step 2: What does the patient know?Step 2: What does the patient know? Establish what the patient knowsEstablish what the patient knows

child’s parentschild’s parents

Assess ability to comprehend new Assess ability to comprehend new bad newsbad news

Reschedule if unpreparedReschedule if unprepared

Establish what the patient knowsEstablish what the patient knows

child’s parentschild’s parents

Assess ability to comprehend new Assess ability to comprehend new bad newsbad news

Reschedule if unpreparedReschedule if unprepared

Step 3: How much does the patient want to know? . . .Step 3: How much does the patient want to know? . . .

Recognize, support various patient Recognize, support various patient preferencespreferences

decline voluntarily to receive decline voluntarily to receive informationinformation

designate someone to communicate on designate someone to communicate on his or her behalfhis or her behalf

Recognize, support various patient Recognize, support various patient preferencespreferences

decline voluntarily to receive decline voluntarily to receive informationinformation

designate someone to communicate on designate someone to communicate on his or her behalfhis or her behalf

. . . Step 3: How much does the patient want to know?. . . Step 3: How much does the patient want to know?

People handle information differentlyPeople handle information differently

race, ethnicity, culture, religion, race, ethnicity, culture, religion, socioeconomic statussocioeconomic status

age and developmental levelage and developmental level

People handle information differentlyPeople handle information differently

race, ethnicity, culture, religion, race, ethnicity, culture, religion, socioeconomic statussocioeconomic status

age and developmental levelage and developmental level

Advance preparationAdvance preparation

Initial assessmentInitial assessment

Preparation for critical testsPreparation for critical tests

What does the patient know? (step 2)What does the patient know? (step 2)

How does the patient handle How does the patient handle information? (step 3)information? (step 3)

Initial assessmentInitial assessment

Preparation for critical testsPreparation for critical tests

What does the patient know? (step 2)What does the patient know? (step 2)

How does the patient handle How does the patient handle information? (step 3)information? (step 3)

When family says“don’t tell” . . . When family says“don’t tell” . . . Legal obligation to obtain informed Legal obligation to obtain informed

consent from the patientconsent from the patient

Promote congenial family alliancePromote congenial family alliance

Honesty with a child promotes trustHonesty with a child promotes trust

Legal obligation to obtain informed Legal obligation to obtain informed consent from the patientconsent from the patient

Promote congenial family alliancePromote congenial family alliance

Honesty with a child promotes trustHonesty with a child promotes trust

. . . When family says“don’t tell”. . . When family says“don’t tell” Ask the family:Ask the family:

Why not tell?Why not tell?

What are you afraid I will say?What are you afraid I will say?

What are your previous experiences?What are your previous experiences?

Is there a personal, cultural, or religious Is there a personal, cultural, or religious context?context?

Talk to the patient togetherTalk to the patient together

Ask the family:Ask the family:

Why not tell?Why not tell?

What are you afraid I will say?What are you afraid I will say?

What are your previous experiences?What are your previous experiences?

Is there a personal, cultural, or religious Is there a personal, cultural, or religious context?context?

Talk to the patient togetherTalk to the patient together

Step 4: Sharing the information . . . Step 4: Sharing the information . . . Say it, then stopSay it, then stop

avoid monologue, promote dialogueavoid monologue, promote dialogue

avoid jargon, euphemismsavoid jargon, euphemisms

pause frequentlypause frequently

check for understandingcheck for understanding

use silence, body languageuse silence, body language

Say it, then stopSay it, then stop

avoid monologue, promote dialogueavoid monologue, promote dialogue

avoid jargon, euphemismsavoid jargon, euphemisms

pause frequentlypause frequently

check for understandingcheck for understanding

use silence, body languageuse silence, body language

. . . Step 4: Sharing the information. . . Step 4: Sharing the information Don’t minimize severityDon’t minimize severity

avoid vagueness, confusionavoid vagueness, confusion

Implications of “I’m sorry”Implications of “I’m sorry”

Don’t minimize severityDon’t minimize severity

avoid vagueness, confusionavoid vagueness, confusion

Implications of “I’m sorry”Implications of “I’m sorry”

Step 5: Responding to feelings . . .Step 5: Responding to feelings . . . Affective responseAffective response

tears, anger, sadness, love, anxiety, tears, anger, sadness, love, anxiety, relief, other relief, other

Cognitive responseCognitive response

denial, blame, guilt, disbelief, fear, loss, denial, blame, guilt, disbelief, fear, loss, shame, intellectualizationshame, intellectualization

Basic psychophysiologic responseBasic psychophysiologic response

fight-flightfight-flight

Affective responseAffective response

tears, anger, sadness, love, anxiety, tears, anger, sadness, love, anxiety, relief, other relief, other

Cognitive responseCognitive response

denial, blame, guilt, disbelief, fear, loss, denial, blame, guilt, disbelief, fear, loss, shame, intellectualizationshame, intellectualization

Basic psychophysiologic responseBasic psychophysiologic response

fight-flightfight-flight

Step 5: Responding to feelings . . .Step 5: Responding to feelings . . . Be prepared forBe prepared for

outburst of strong emotionoutburst of strong emotion

broad range of reactionsbroad range of reactions

Give time to reactGive time to react

Be prepared forBe prepared for

outburst of strong emotionoutburst of strong emotion

broad range of reactionsbroad range of reactions

Give time to reactGive time to react

. . . Step 5: Responding to feelings. . . Step 5: Responding to feelings Listen quietly, attentivelyListen quietly, attentively

Encourage descriptions of feelingsEncourage descriptions of feelings

Use nonverbal communicationUse nonverbal communication

Listen quietly, attentivelyListen quietly, attentively

Encourage descriptions of feelingsEncourage descriptions of feelings

Use nonverbal communicationUse nonverbal communication

Step 6: Planning, follow-up . . .Step 6: Planning, follow-up . . . Plan for the next stepsPlan for the next steps

additional information, testsadditional information, tests

treat symptoms, referrals as neededtreat symptoms, referrals as needed

Discuss potential sources of supportDiscuss potential sources of support

Plan for the next stepsPlan for the next steps

additional information, testsadditional information, tests

treat symptoms, referrals as neededtreat symptoms, referrals as needed

Discuss potential sources of supportDiscuss potential sources of support

. . . Step 6: Planning, follow-up. . . Step 6: Planning, follow-up Give contact information, set next Give contact information, set next

appointmentappointment

Before leaving, assess:Before leaving, assess:

safety of the patientsafety of the patient

supports at homesupports at home

Repeat news at future visitsRepeat news at future visits

Give contact information, set next Give contact information, set next appointmentappointment

Before leaving, assess:Before leaving, assess:

safety of the patientsafety of the patient

supports at homesupports at home

Repeat news at future visitsRepeat news at future visits

When language is a barrier . . .When language is a barrier . . . Use a skilled translatorUse a skilled translator

familiar with medical terminologyfamiliar with medical terminology

comfortable translating bad newscomfortable translating bad news

Consider telephone translation Consider telephone translation servicesservices

Use a skilled translatorUse a skilled translator

familiar with medical terminologyfamiliar with medical terminology

comfortable translating bad newscomfortable translating bad news

Consider telephone translation Consider telephone translation servicesservices

. . . When language is a barrier. . . When language is a barrier Avoid family as primary translatorsAvoid family as primary translators

confuses family membersconfuses family members

how to translate medical conceptshow to translate medical concepts

modify news to protect patientmodify news to protect patient

supplement the translationsupplement the translation

Speak directly to the patientSpeak directly to the patient

Avoid family as primary translatorsAvoid family as primary translators

confuses family membersconfuses family members

how to translate medical conceptshow to translate medical concepts

modify news to protect patientmodify news to protect patient

supplement the translationsupplement the translation

Speak directly to the patientSpeak directly to the patient

Communicating prognosis . . .Communicating prognosis . . . Some patients want to planSome patients want to plan

Others are seeking reassuranceOthers are seeking reassurance

Some patients want to planSome patients want to plan

Others are seeking reassuranceOthers are seeking reassurance

Communicating prognosis . . . Communicating prognosis . . . Inquire about reasons for askingInquire about reasons for asking

““What are you expecting to happen?”What are you expecting to happen?”

““How specific do you want me to be?”How specific do you want me to be?”

““What experiences have you had with:What experiences have you had with:

others with same illness?others with same illness?

others who have died?”others who have died?”

Inquire about reasons for askingInquire about reasons for asking

““What are you expecting to happen?”What are you expecting to happen?”

““How specific do you want me to be?”How specific do you want me to be?”

““What experiences have you had with:What experiences have you had with:

others with same illness?others with same illness?

others who have died?”others who have died?”

Communicating prognosis . . .Communicating prognosis . . . Patients varyPatients vary

““planners” want more detailsplanners” want more details

those seeking reassurance want lessthose seeking reassurance want less

Avoid precise answersAvoid precise answers

hours to days … months to yearshours to days … months to years

averageaverage

Patients varyPatients vary

““planners” want more detailsplanners” want more details

those seeking reassurance want lessthose seeking reassurance want less

Avoid precise answersAvoid precise answers

hours to days … months to yearshours to days … months to years

averageaverage

. . . Communicating prognosis. . . Communicating prognosis Limits of predictionLimits of prediction

hope for the best, plan for the worsthope for the best, plan for the worst

better sense over timebetter sense over time

can’t predict surprises, get affairs in can’t predict surprises, get affairs in orderorder

Reassure availability, whatever Reassure availability, whatever happenshappens

Limits of predictionLimits of prediction

hope for the best, plan for the worsthope for the best, plan for the worst

better sense over timebetter sense over time

can’t predict surprises, get affairs in can’t predict surprises, get affairs in orderorder

Reassure availability, whatever Reassure availability, whatever happenshappens

Caregiver communication Caregiver communication

Maintain common chart or log book Maintain common chart or log book

goals for caregoals for care

treatment choicestreatment choices

what to do in an emergencywhat to do in an emergency

likes, dislikeslikes, dislikes

things to do / not to dothings to do / not to do

contact informationcontact information

Maintain common chart or log book Maintain common chart or log book

goals for caregoals for care

treatment choicestreatment choices

what to do in an emergencywhat to do in an emergency

likes, dislikeslikes, dislikes

things to do / not to dothings to do / not to do

contact informationcontact information

EEPPEECC

EEPPEECC Communicating Communicating

Bad News Bad News

SummarySummary

Communicating Communicating Bad News Bad News

SummarySummary