• Save
Breaking the Bad News
Upcoming SlideShare
Loading in...5
×

Like this? Share it with your network

Share

Breaking the Bad News

  • 1,199 views
Uploaded on

S-P-I-K-E-S Strategy in breaking the bad news and discussing advance directives in the clinical setting, especially in hospice and palliative care.

S-P-I-K-E-S Strategy in breaking the bad news and discussing advance directives in the clinical setting, especially in hospice and palliative care.

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
1,199
On Slideshare
1,199
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
0
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. BREAKING THEBAD NEWSDr. Liza Manalo, MSc.Palliative Care, Cancer CenterThe Medical City
  • 2. Breaking Bad News: S-P-I-K-E-S StrategyCommunity Oncology, March/April 2005 Robert A. Buckman, MD, PhD University of Toronto, Canada
  • 3. S-SettingPrivacyInvolve significant othersSit downLook attentive and calmListening mode: silence & repetitionAvailability Community Oncology, March/April 2005
  • 4. P-Patient’s perceptionFind out how much the patient orsurrogate decision-maker knows.“What did you think was going on?”“What have you been told about all this sofar?”“Are you worried that this might besomething serious?”
  • 5. I-InvitationFind out how much the patient orsurrogate decision-maker wants toknow. “Are you the kind of person who prefers to know allthe details about what is going on?”“How much information would you like me to giveyou about diagnosis and treatment?”“Would you like me to give you details of what isgoing on or would you prefer that I just tell you abouttreatments I am proposing?”
  • 6. K-KnowledgeShare the information Warning shot : • “Unfortunately, I’ve got some bad news to tell you, Mrs. Dela Cruz.” • “Mrs. Dela Cruz, I’m so sorry to have to tell you….”  Pause : Wait for them to take a deep breath and get ready to hear the bad news  Use short, simple, clear sentences  Avoid jargon or technical scientific language  Tailor the rate at which you provide information to the patient/surrogate decision-maker
  • 7. E-Empathy Step 1: Listen for and identify the emotion (or mixture of emotions).• “How does that make you feel?”• “What do you make of what I’ve just told you?” Step 2: Identify the cause or source of the emotion
  • 8. E-EmpathyStep 3: Show your patient/surrogate decision-maker that you have identified the emotion and itsorigin •“Hearing the results of the tests is clearly a major shock to you.” •“Obviously, this piece of news is very upsetting.” •“Clearly, this is very distressing.” Empathetic silence: Wait for them to take a deep breathand process the bad newsAnswer questions patientlyBe sensitive and compassionateRespond to the patient’s or surrogate decision-maker’sthoughts and feelings Identify the emotionally critical misperception (ECM)
  • 9. E-EmpathyValidation – normalize the patient’s or surrogatedecision-maker’s feelings •“I can understand how you can feel that way.”  Let the patient or surrogate decision-maker know that showing emotion is perfectly normal, to minimize feelings of embarrassment and isolation  Assure non-abandonment: Inform the patient or surrogate decision-maker that you will be coaching them through the next steps
  • 10. S-Strategy/Summary Educate, summarize, and concretize plan of action  Ensure that the patient or surrogate decision- maker understands the information so that you and they are both on the same page.  Summarize the information in your discussion and give the patient or surrogate decision-maker an opportunity to voice any major concerns or questions.  Outline a step-by-step plan, explain it to the patient or surrogate decision-maker, and contract about the next step.
  • 11. Common Communication Error: Information overload and "medspeak" Emergency Room:• Mrs. Dela Cruz: “Doctor, how is my husband doing?”• Dr. Reyes: “He had a stroke.”• Mrs. Dela Cruz: “Stroke?” But he is only 51. How big is it?”• Dr. Reyes: “Pretty big according to the CT scan. It revealed hemorrhage or a bleed on the right parieto-temporal lobe, with subarachnoid and intraventricular extension. Problem is that he is comatose and hypertensive right now. Also, the pupils are equally dilated and non- reactive and the brainstem reflexes are absent. Anyway…., the Neuro folks are coming. They will explain things more. Meantime, don’t worry!”• Mrs. Dela Cruz: (thinking can-you-talk-to-me-in-English or Tagalog?): “Doc will he make it? I am so worried….”
  • 12. Breaking the Bad News – Emergency Room: BETTER VERSION• Mrs. Dela Cruz: “Doctor, how is my husband doing?”• Dr. Reyes: “Mrs. Dela Cruz, let us find a place to sit down.”• Dr. Reyes: “I am afraid that I have some bad news for you.”Pause for a few seconds (you may want to count till ten) allowing wife to prepare herself for the news.• Dr. Reyes: “Your husband has had a stroke.”Pause and allow Mrs. Dela Cruz to digest the information.• Mrs. Dela Cruz: “He had a stroke?”• Dr. Reyes: “Yes. I am afraid so.”Pause and allow Mrs. Dela Cruz to digest the information.• Mrs. Dela Cruz: “Stroke? But he is only 51. How big is it?”
  • 13. Breaking the Bad News – Emergency Room: BETTER VERSION• Dr. Reyes: “I ran some initial tests on him. Looks like it is a rather big bleed. You did great by bringing him in so quickly.”• Mrs. Dela Cruz: “Doc will he make it? I am so worried.…”• Dr. Reyes: “Mrs. Dela Cruz, we already know that your husband has a stroke and I have started him treatment to remove the pressure on the brain. I have talked to the neurology specialists. They will be here momentarily to take over. I’m afraid however that even if we do everything we can, the damage to his brain is such that I feel we will not be able to pull him through, I’m sorry.”Pause and allow Mrs. Dela Cruz to digest the information.• Dr. Reyes: “How are you doing? What is going through your head?”Pause and allow Mrs. Dela Cruz to digest the information and formulate her questions.
  • 14. Phraseology : Dos and DontsWhat not to say What to say• "I know exactly how you • "My past experience with feel." many patients in this Sweeping statements that situation has taught me are not grounded in that you must be in personal or professional distress right now." experiences are hard to • "I can imagine how upset believe. you must be." http://endoflife.stanford.edu/M19_communic/dos_and_donts.html
  • 15. Phraseology : Dos and DontsWhat not to say What to say• "Your husband have • "Unfortunately, the failed medical __________ therapy decompression therapy." does not seem to beThis implies that it is the working very well." patients fault that the therapies are not working. http://endoflife.stanford.edu/M19_communic/dos_and_donts.html
  • 16. Phraseology : Dos and DontsWhat not to say What to say• "There is nothing else we • "Looks like the ________ can do." is not working very well. However, you can be sure that we will do everything in our power to make sure that you (your husband) wont suffer." http://endoflife.stanford.edu/M19_communic/dos_and_donts.html
  • 17. What not to say• "There is nothing more that can be done. I am going to refer you to hospice and palliative care."What to say• "Doctor: As we have just discussed, it looks like the ________ treatment we tried is not working. So we have to stop the ________medication.• Mrs. Dela Cruz: What do we do next, doc?• Doctor: At this time, I do not have other viable medications that I can offer to you”• Mrs. Dela Cruz: .....• Doctor: I would like to refer you to hospice and palliative care. Hospice professionals have a lot of expertise in treating symptoms and increasing comfort and quality of life. They will help your husband by managing your husband’s ________________ (dyspnea, agitation/restlessness, respiratory secretions, etc). http://endoflife.stanford.edu/M19_communic/dos_and_donts.html
  • 18. DNR Discussions with Surrogate Decision-Maker: Patient With a Life-Limiting Illness• What not to say• “Mrs. Dela Cruz, do you want every thing done for your husband?”• What the doctor might say instead• Dr. Reyes: “Mrs. Dela Cruz, I want to talk to you more about what we call advance directives and Do Not Resuscitate orders for your husband.”(Pause and give the decision-maker time to digest the information.)• “As you know, your husband had a massive stroke and the medical team members agree that his prognosis is grave and his chances for survival and recovery nil.”• “In thinking about decisions regarding resuscitation there is a whole spectrum of choices. In event of an adverse situation, some patients would like to be connected to life support and would like us to do heroic life sustaining treatments. Others do not want such measures.”(Pause and give the decision-maker time to digest the information.) http://endoflife.stanford.edu/M19_communic/dnr_disc_bbn.html
  • 19. DNR Discussions with Surrogate Decision-Maker: Patient With a Life-Limiting Illness• Mrs. Dela Cruz: “But I don’t want my husband to die.”• Dr. Reyes: Mrs. Dela Cruz, of course you want your husband to live, but with good quality of life. I do not want you and him to suffer and as your doctor, I will do what is in my power to help both of you.”(Pause and give the decision-maker time to digest the information.)• Mrs. Dela Cruz: “Yes. I do not want him to suffer.”(Pause and give the decision-maker time to digest the information.)• Dr. Reyes: “Your husband is now in coma. If his heart were to stop, putting him on life support will not prolong life. It would only prolong the dying process.”(Pause and give the decision-maker time to digest the information.) http://endoflife.stanford.edu/M19_communic/dnr_disc_bbn.html
  • 20. DNR Discussions with Surrogate Decision-Maker: Patient With a Life-Limiting Illness• Mrs. Dela Cruz: ……(Pause and give the decision-maker time to digest the information.)• Dr. Reyes: “Things look grim for your husband and the increasing intracranial pressure has compressed the brain that at this point, any life support measures would be ineffective.”(Pause and give the decision-maker time to digest the information). http://endoflife.stanford.edu/M19_communic/dnr_disc_bbn.html
  • 21. DNR Discussions with Surrogate Decision-Maker: Patient With a Life-Limiting Illness• Mrs. Dela Cruz: ……• Dr. Reyes: “In a situation like this, it is my opinion that we should hold back on futile resuscitative measures, but really focus on making your husband comfortable.”(Pause and give the decision-maker time to digest the information).• Mrs. Dela Cruz:……(If decision-maker still seems reluctant)• Dr. Reyes: “I want you to think a little more about this and we can talk again in a while. I want you to remember that no matter what, I will still be your husband’s doctor and I am here to help both of you.” http://endoflife.stanford.edu/M19_communic/dnr_disc_bbn.html
  • 22. Breaking Bad News: S-P-I-K-E-S StrategyS – SettingP – Patient’s PerceptionI – InvitationK – KnowledgeE – EmpathyS – Strategy/Summary Before you tell, ASK! “What is your understanding of your illness?”