Before we begin, this is a reminder to turn off all pagers, cell phones, and computers during this educational session. Please also note that you are required to participate in the group debriefing session at the end of this educational training where you will have the opportunity to reflect and evaluate the training that you participated in today. Please complete the “Pre-Program Self-Assessment: Confidence Level” form prior to the beginning of the lecture.
The Patient Safety Training Center at Dartmouth Hitchcock Medical Center presents an educational program addressing Sharing Bad News. This module is one in a series of communication modules that are specifically designed to address high-quality, safe patient-centered care. This module provides a communication strategy as the basis for patient-family encounters related to sharing bad news. Say: I would like to introduce our Patient Family Advisers (PFAs) at this time. [Introduce the PFAs]
Ask your learners for their definitions of bad news. Ask the learners for examples. Then, discuss.
Challenges: Why is sharing bad news so hard to do? -And- Why are we concerned about how we share bad news? Lack of:Guidelines, training, experience, and good role models. Medical personnel & other caregivers may have inadequate preparation and experience in delivering bad news. What is being shared constitutes complex information. How do we talk to anxious others about bad things when we ourselves are anxious and untrained? Concerns of: The provider. Why do I get to share this bad news? The provider may be anxious or apprehensive about having to deliver bad news. It is hard to convey bad news since it is emotionally charged information. The provider may also have the mistaken notion that delivering bad news will adversely affect the relationship s/he already has with the patient (This may be the provider’s perception of preserving the relationship). Further, the provider may feel like s/he has failed in some way (“feel like a failure”) because s/he has to deliver bad news. The patient. Patients want to know the truth. They are more satisfied with the physician when bad news is shared with compassion. The patient’s willingness to hear the information will impact the communication as well.
Remember that the family is defined by the patient. Family is not necessarily legal or biological by definition. A family may consist of an unmarried parent with children, step-children, and grandmother, or a same-sex couple with an adopted child, etc.The overall question is: How can we make the conversation about sharing bad news easier for patient and family, and for the provider? Patient & Family: Include the patient & family in conversations & planning and treat them as care partners.Provider: Training & practicing good communication skills, learning ways to effectively cope with emotionally charged issues, and having another person e.g. chaplaincy, an RN, Social Worker, or PA, available who has been working with the patient and knows the patient well can support the provider in the encounter. Remember that a healthcare ally who really knows what is going on with the patient will be very helpful for your understanding of how to communicate effectively with the patient.
The core concepts of Patient and Family Centered Care at Dartmouth-Hitchcock are to treat the patient with dignity and respect, and to share information.Sharing bad news with patients and families covers several general considerations, including the environment in which the bad news is shared, the components of bad news including emotions, the actual planning before and after sharing the bad news, and following up with the patient and family once the bad news has been shared. The SPIKES mnemonic is a six-step model for sharing bad news with the patient (Baile et al, 2000) that helps the provider prepare for, implement, and follow through the sharing bad news conversation with the patient and family. We will cover each step in the process in depth throughout this discussion. Bear in mind that even though this model covers steps in a linear fashion, the steps may overlap to some degree when having the conversation about bad news. REFLECTION: Ask what the residents thought about what they read in the assigned SPIKES article. Discuss.
This follows our effective communication strategy that we have already established in Module 1 and includes reminding us to perform our hand hygiene and to properly identify each patient, then providing privacy, sitting with the patient, being aware of body language and tone of voice, and introducing oneself (including role) to the patient and others. Determining who else should be present when the bad news is delivered is also important in helping the patient feel supported in the conversation. If family is already present, and the patient wants them to be part of the conversation, then be welcoming and inclusive. If a third party e.g. a social worker, a nurse, etc. is present, ask the patient whether s/he would like this person to remain for the conversation and what role the patient would like this person to play.We are also reminded to provide adequate time with no interruptions for the conversation especially since this conversation is difficult and complex. So, turn off your pager, cell phone and computer, close the door to the room, and do not let anyone interrupt you and the patient. A comfortable environment fosters better communication. Private physical space and psychological comfort are important. Present yourself in a calm way and offer a comfortable chair for the patient to sit on. Sit with the patient after asking for permission to do so. This action creates a respectful beginning for the conversation. Sitting also decreases the patient’s feeling of vulnerability. During the course of the conversation, the distance between you and the patient may change. It should always be possible to adjust your distance to the patient should you need to draw closer to provide reassurance. Create a welcoming (“shame-free”) environment. What does a welcoming environment entail? Remember that “shame free” may simply mean that whatever emotion the patient may exhibit is okay. You provide a welcoming (“shame free”) environment when you are friendly, caring, respectful, and helpful without berating the patient when providing information and asking questions. Remember also that patients are often ashamed of not knowing things and may be ashamed of not being able to read/ write/ understand what the medical provider is trying to convey.Smile, make eye contact, and use a warm tone when speaking. Pay particular attention to using a formal title and using the patient’s last name when you first encounter her/ him. If the patient prefers you call her/ him by first name, do so. The important thing here is to have mutual respect. Be very aware of your own body language. Your words will not be heard if your body language conveys disrespect. Assume a posture of respect by paying attention to the patient when you are having the conversation. Do NOT spend time doing anything distracting (to the patient!) during the conversation. For instance, if you are writing during the conversation, a patient may interpret this as intimidating, or that s/he is not important enough to give your full attention to her/ his concerns. Remember that your eye contact, posture, facial expressions, and gestures are all part of getting the message across to the patient. POSSIBLE REFLECTION: Mirroring the patient: What would you do if you tried to sit close to a patient and s/he backed away from you?
Remember that even though the SPIKES model covers steps in a linear fashion, these steps may overlap to some degree when having the conversation about bad news. Perception means to get a sense of the patient’s state of mind as well as what facts the patient knows.Provider’s preparation before speaking: Think ahead specifically about implications to the patient before having the conversation. Be aware that you will be dealing with different levels of seriousness of diagnoses here. For example, it is very different to be telling a patient that he may not play sports for the rest of the season because of a concussion, but it is very likely he can return to the field in the spring versus telling a patient that her cancer has returned. Part of your task is also to perceive how the news you have delivered impacts the patient, so pay attention to how the patient reacts to what you have said. Ask about patient’s perception: You might say: We’re here to discuss… Tell me what your perception is about… -or- What are you concerned about? What do you know?
Invite the patient to talk by using open-ended questions. Examples: Do you have questions about the lab results you received? How are you feeling today? We must consider cultural, spiritual, and socioeconomic factors. Remember that the patient may not want to hear anything! It is the patient’s right to refuse to listen to what you want to say. Ask how much the patient wants to hear. Ask about whether the patient wants the details or the big picture. You could ask: How much information do you want to hear? If the patient does not want to hear anything, you may say something like: You need to make some decisions about your health. Who would you like to have this information? POSSIBLE REFLECTION: Think about a difficult conversation you have had with a patient, and the emotional impact it had on you. How were you able to begin the conversation with the patient while dealing with your own feelings?
Deliver the message:Use plain, everyday language and pay attention to body language, both yours and the patient’s. Your words will not be heard if your body language conveys disrespect. Assume a posture of respect by paying attention to the patient when you are having the conversation. Do NOT spend time doing anything distracting (to the patient!) during the conversation. For instance, if you are writing during the conversation, a patient may interpret this as intimidating, or that s/he is not important enough to give your full attention to her/ his concerns. Remember that your eye contact, posture, facial expressions, and gestures are all part of getting the message across to the patient. Get to the point. Say what it is! If it is cancer, say it is cancer. Do not use euphemisms. Begin with a straight-forward statement. Say something like: I have some bad news to tell you. –or- I’m afraid I have bad news about…Get to the point quickly: Thisdoes not mean to be sharp or rude in the conversation. It does mean that you directly ask a question or make a statement to find out the information needed. You are concerned with knowing what the patient knows.Give information in small chunks. Avoid the temptation to tell the patient all the information all at once. Pause for 10 seconds so the patient has some time to absorb what you said. You want to create space for the patient to absorb the information and respond to it.Wait for the response. This is hard to do because we all want to help our patients right now. Frequently, we just want to do or say something, anything. Just wait! Verify that the message has been received:Remember that a hallmark of “teach back” technique is the provider verifying that the message has been received. If the patient does not correctly say back what you have told her/ him, it is up to you to say it in another way. You may wish to ask the patient (or the one who the patient has designated as the person responsible for knowing the information) to repeat what s/he has been told. If the patient does not respond, you may want to say something like: I can see that this news has had a big impact on you. Tell me what you think this means. REFLECTION: Have everyone remain silent for ten seconds. Then discuss how everyone felt about the length of time being silent. How do you usually deal with silence? Why is silence so important? What do you usually do to begin the conversation again after a silent period?
It is NORMAL for the patient to have a strong emotional response in this type of situation. There will be emotion! Remember that emotions may come from a family member and a third party in the room as well as the patient. For example, the patient may be calm, but the spouse may be sobbing loudly. Anticipate emotions. The common emotions in a sharing bad news situation may be fear, anger, sadness, denial, and guilt. Your responses:Expect to feel discomfort.Listen.Be aware of body language.Acknowledge emotions.Allow the patient time to process information. Show empathy: Comfort the patientBe aware that “comforting the patient” will mean different things to different people. Something simple, but helpful is to have tissues and water available to offer to the patient. You may wish to say something like: I can see that this is upsetting for you. Be mindful of patient safety in this emotionally charged time as you prepare for the next step, strategy & summary. POSSIBLE REFLECTION: Think of a time when a patient was very upset. How did you feel? How did you react?
Assess patient’s readiness for planning:Negotiate next steps. Use a Patient & Family team approach. Ask the patient: Are you ready to discuss treatment options? Verify support structure. Is the patient safe? Think about whether the patient may attempt to harm him or her-self, and the timing of discharge after the bad news conversation. For example, sharing bad news on a Friday afternoon with a patient who will be home alone for the weekend afterwards may not be a good idea. Be sure to inquire whether the patient has someone present at home or nearby. You may wish to ask a question like, “Do you have someone at home or someone available to help you?” Acknowledge and answer questions. Be sure to tell the patient that you still have a relationship with her/ him even though other providers will be involved with care. You are not abandoning the patient. If the patient asks, provide the prognosis as a range. Do not get specific. Summarize plan:Use “teach back” technique. Verify that the patient & family can verbalize the plan. If not, re-teach! Do not assume the patient and family will remember everything (or much) so write everything down including contacts, appointments, medications, and any other pertinent information. Follow up. Offer to come back and speak with the patient and family. Have a telephone conversation in 24 hours to check up on the patient and to ask if the patient has any questions. POSSIBLE REFLECTION: How would you feel if, after asking the patient about whether s/he is ready to discuss treatment options, s/he said NO? What would you do?
Tell your learners to pay particular attention to the various parts of the SPIKES model as the conversation between the patient and physician happens in this video clip. [Switch to DVD player to play video clip; The video clip is NOT embedded in the “thought cloud” on the slide. When video clip done, switch back to PC to finish slideshow]
Facilitate discussion based on questions posed in this slide.
What’s next? Explain what will happen next and discuss expectations regarding the OSCEs portion of the training. This is an opportunity to explain that how the physician delivers the bad news is the priority of the encounter, NOT the medical details. Expectations : Each learner will complete the “Multi Source Evaluation” right after the encounter, then complete the “Post-Program Self-Assessment: Confidence Level” form, and participate in the group debriefing session. Reminders include telling the learners to return to the debrief room after the encounter to complete the evaluations (“Multi Source Evaluation” and the “Post-Program Self-Assessment: Confidence Level” form), to review the SPIKES model article if needed, and to wait until the entire group is present in the debrief room to participate in the debriefing.
Sharing Bad News powerpoint
Reminders Turn off all pagers, cell phones, and computers during this educational session. You are required to participate in the group debriefing session when you have completed the Standardized Patient (SP) encounter. Please complete the “Pre-Program Self Assessment: Confidence Level” form
Effective PatientCommunication Module 2: Sharing Bad News Module development supported by a grant from the Picker Institute / Gold Foundation 2010 Challenge Grant
Learning Objectives Define bad news Demonstrate use of the SPIKES model when sharing bad news with the patient During the patient encounter, attend to the major emotional components of sharing bad news, especially expressions of fear, anger, sadness, denial, and guilt 3
Expected Outcomes Recognize challenges and supports to effectively sharing bad news with the patient & family Demonstrate the SPIKES model communication strategy when sharing bad news with the patient & family Demonstrate empathy when sharing bad news with the patient 4
The Task of Breaking Bad News“If we do it badly, the patients or family members may never forgive us; if we do it well, they may never forget us.”(Buckman, 1992) 5
What is Bad News?Information that negatively alters the patient’s view of the future (Buckman, 1992) (Tissot, 1872) 6
Challenges Lack of: Guidelines Training Experience Good role models Concerns of: The provider(Siegmund, 2008) The patient & family 7
Supporting Patient & Provider Patient & Family are supported by: Being included in conversations & planning Being treated as care partners Provider is supported by: Training & Practicing good communication skills Learning ways to effectively cope with emotionally charged issues Having another person available who knows the patient 8
SPIKES Model: The Six Steps Setting Perception Invitation Knowledge Emotions Strategy & Summary Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist, 5, 302-311; 2000. SPIKES mnemonic used with permission. 9
Setting the Environment Provide privacy Introduce self Determine who else should be present Ensure no interruptions Provide comfortable space Create welcoming environment 10
Perception Prepare before speaking Ask about patient’s perception of what is going on (Renoir/ Bjoertvedt, 2010) 11
Invitation Ask questions to invite the patient into conversation Ask how much information the patient wants to hear(Pissarro, 1881) 12
Knowledge Deliver the message Use plain language Be mindful of body language Get to the point Give information in small chunks Pause Wait for reaction Use “teach back” to verify that message was received 13
Emotions and Empathy Be prepared for patient’s and family’s emotional response Anticipate fear, anger, sadness, denial, guilt Be mindful of your own response Comfort the patient 14
Strategy and Summary Assess patient’s readiness for planning Negotiate next steps Verify support structure Acknowledge & answer questions Summarize plan Use “teach back” technique Follow-up 15
Discussion of the Video How well did the doctor handle the situation? What worked well? What could have been handled better? Have you experienced a scene like the one shown? What was your role? Describe the encounter 17
ReferencesAmerican Academy on Communication in Healthcare (AACH). Enhancing Communication Skills. http://www.aachonline.org/?page=EnhanceCommSkills. Accessed October 20, 2010.Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist, 5, 302-311; 2000.Bjoertvedt. File: Auguste Renoir Conversation.JPG. National Museum Stockholm; 2008. Wikimedia Commons. http://commons.wikimedia.org/wiki/File:Auguste_Renoir_Conversation.JPG. Accessed December 6, 2010.Boyle WE, Colacchio TA. Patient and Family Centered Care at Dartmouth-Hitchcock. [DVD]. Lebanon, NH: Dartmouth- Hitchcock Media Services; 2010.Bub B. Communication Skills That Heal. United Kingdom: Radcliffe Publishing Ltd; 2006.Buckman R. How to Break Bad News: A Guide for Health Care Professionals. Baltimore, MD: The Johns Hopkins University Press; 1992.Buckman R. Talking to Patients About Cancer. BMJ, 313, 699-700; 1996.Coulehan JH, Block MR. The Medical Interview, Mastering Skills for Clinical Practice. 5th ed. Philadelphia, PA: F.A. Davis Company; 2006. 20
File: James Tissot-Bad News.jpg. National Museum Cardiff; 1872. Wikimedia Commons. http://commons.wikimedia.org/wiki/File:James_Tissot_-_Bad_News.jpg. Accessed December 6, 2010.File:Pissarro Conversation.jpg. Tokyo: The National Museum of Western Art; 1881. Wikimedia Commons http://commons.wikimedia.org/wiki/File:Pissarro_Conversation.jpg.. Accessed December 6, 2010.Frampton S, Guastello S, Brady C, Hale M, Horowitz S, Smith SB, Stone S. Patient-Centered Care Improvement Guide. Picker Institute; 2008. http://pickerinstitute.org/wp-content/uploads/2010/06/pcc_improvement_guide.pdf. Accessed October 29, 2010.Henry Ford Health System Department of Medical Education. Sharing Bad News. [DVD]. Detroit, MI: Henry Ford Health System; 2009.Lloyd M, Bor R. Communication Skills for Medicine. 3rd ed. London: Elsevier; 2009.Mahmud A. File: Serious Discussion image by Ashfaq.JPG. Dhaka University Institute of Fine Arts; 2008. Wikimedia Commons. http://commons.wikimedia.org/wiki/File:Serious_Discussion_image_by_Ashfaq.JPG. Accessed December 6, 2010.Rider EA, Nawotniak RH, Smith G. A Practical Guide to Teaching and Assessing the ACGME Core Competencies. Marblehead, MA: HCPro, Inc; 2007.Siegmund W. File: Mount Rainier 5839.JPG. 2008. Wikimedia Commons. http://commons.wikimedia.org/wiki/File:Mount_Rainier_5839.JPG. Accessed December 6, 2010.Weiss BD. (2007). Removing Barriers to Better, Safer Care, Health Literacy and Patient Safety: Help Patients Understand, Manual for Clinicians. 2nd ed. American Medical Association Foundation and American Medical Association. http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf. Accessed December 15, 2009. 21