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Breaking Bad News - Easy to Break

  1. BREAKING Prof.Dr. Utham Murali. Dept.Of Surgery D Y Patil Medical College Mauritius.
  2. QUOTE -
  3. Contents of Discussion  Definition / Examples  Facts of Bad News  Methods / Protocols  Description of 1 method  Key Points
  4. What is Bad News?  ‘Situations where there is either a feeling of no hope, a threat to person’s mental or physical wellbeing, risk of upsetting an established lifestyle, or where a message is given which conveys to an individual fewer choices in his or her life.’ Bor et al., 1993  ‘...any information which adversely and seriously affects an individual’s view of his or her future’. Buckman, 1992  ‘...any information that is not welcome’. Arber and Gallagher, 2003  ‘...[an] uncomfortable experience for both the giver and the receiver’. Aitini and Aleotti, 2006.
  5. Examples  Life threatening illness. eg: Cancer, HIV  Degenerative conditions. eg: Alzheimer / dementia  Chronic illness. eg: Rheumatoid arthritis / Systemic lupus erythematosus  Mental retardation in children. eg: Downs syndrome / Cerebral palsy
  6. Other Situations  Disease recurrence / spread of disease, or  Failure of treatment to affect disease progression,  Irreversible side effects, results of genetic tests, or  Issue of palliative care and resuscitation.
  7. Why should it be done?  Forms part of clinical practice.  A skill that can be taught and improved.  Patients and relatives appreciate it.  The degree to which news is bad depends on the gap between reality and patient’s perception.  Non disclosure is no longer considered ethical.
  8. Why should it be done?  Better psychological adjustment by patient.  Reduces stress in doctors.  Facilitates open discussion among patients, relatives and doctors.  Empowers patients by allowing them a greater say in treatment.
  9. So,  Bad news is, therefore, a relative concept and should depend on the  patient’s interpretation of information and reaction to it.
  10. Why is it difficult ? The Patient’s Perspective  Patients often have vivid memories of receiving bad news.  Negative experiences can have lasting effects on anxiety and depression  Can facilitate adaptation to illness and deepen the patient-doctor relationship
  11. Why is it difficult ? The Physician’s Perspective  Fear of causing pain / being blamed / fear of therapeutic failure / emotional reaction  Lack of training in breaking bad news  Lack of time / health system constraints / lack of support from colleagues  Cultural constraints / language barriers  Fear of upsetting the patient’s existing family roles or structure.
  12. To Whom the BBN to be Given ?  Certain legal and ethical guidelines in clinical practice make it difficult to withhold important and personal information.  It is good practice first to discuss these situations with a colleague or within a multidisciplinary health care team.  There are some specific situations in which you may need to consider whether to give bad news.
  13. Example -  If a patient is deemed to be psychotic, and presumably may not understand what has happened, there may be reason to withhold bad news.  When treating a child, one usually confers with the parent or guardian before breaking bad news.
  14. Who should give the Bad news ?  For several reasons, it may be more appropriate for another doctor to break bad news.  For example, a patient sent to a hospital for special tests may still expect his or her GP to reveal the results, rather than the hospital consultant.
  15. Contd -  The GP usually has an established relationship with the pt and presumably could anticipate some of the problems that might arise.  Giving bad news usually requires time, so it may be inappropriate for someone to do so at the end of a shift.  It may be preferable to hand over the task to other colleagues, provided they are fully briefed and acquainted with the case.
  16. When should bad news be given ?  You can try gradually to break the news; this in turn gives the patient and relatives time to adjust.  On the other hand, withholding the news may deny them the opportunity to face up to it and begin to make the necessary adjustments in their personal lives.  In some situations, it can actually be hazardous to withhold bad news until a later stage.
  17. Example -  If the patient has an infectious disease or condition (e.g. hepatitis C or HIV infection), he or she can inadvertently infect someone else, or be denied the benefits of early medical information if not fully informed of this condition.
  18. What do patients want? For themselves…  more time to talk  and show feelings From the doctor…  more information, caring, hopefulness, confidence  a familiar face
  19. Methods to Deliver -  Rabow and Mc Phee’s - ABCDE approach.  Baile & Buckman - SPIKES approach.  SAAIQ emergency approach - Pakistan  BREAKS approach by IJPC  SAD NEWS approach – Q.U / Canada
  20. ABCDE Approach -  A dvance preparation .  B uild therapeutic environment .  C ommunicate well.  D eal with patient and family reactions  E ncourage and validate emotions
  21. SPIKES Approach -  S etting up in privacy.  P erceptions of the patient.  I nvitation to break news.  K nowledge.  E motions.  S trategy.
  22. SAAIQ Approach -  SET the scene as soon as possible.  ASSESS the understanding of the attendant.  ALERT them that I have bad news .  INFORM in clear, understandable words.  QUICKLY repeat summary of the situation.
  23. BREAKS Approach -  B ackground  R apport  E xplore  A nnounce  K indling  S ummarise
  24. SAD NEWS Approach -  S et up & Sit down  A sk , don’t tell  D eliver the news  N o fancy lingo  E xpect, permit & respond to emotion  W ait  S upport & Summarise
  26. S etting the Environment -  Provide privacy  Introduce self  Determine who else should be present  Ensure no interruptions  Provide comfortable space  Create welcoming environment
  27. Perception  Ask what he already knows about the medical condition or what he suspects.  Listen to level of comprehensions.  Accept denial but do not confront at this stage.
  28. Invitation - Information  Ask patient if s/he wishes to know the details of the medical condition and/or treatment.  Accept patient’s right not to know.  Offer to answer questions later if s/he wishes.
  29. 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
  30. 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
  31. 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
  32. Response to Reaction -
  33. If pt Cries -  Allow sometime to cry.  Could say, “I can see you are very upset”  Could touch the patient appropriately.  After a few moments you should continue talking even if patient continue to cry.
  34. If pt – Angry  Defensive or irritation with patient are unhelpful.  Acknowledge patient’s position and avoid talking about it.
  35. If pt refuses – Accept Diagnosis  Explore reasons for patient’s denial.  Do not be combative.  Appreciate that there is an information gap and try to educate the patient.  Check that patient has a clear understanding of the problem.  Empathize with patient.  Get family members involved if appropriate.  Give time to adjust to new information.
  36. Common Pitfalls -  Inadequate time / information.  Failure to elicit patient’s understanding of situation.  Giving news at doctor’s speed.  Not allowing time for responses.  False reassurances about the future.  Allowing denial to remain.  Removing all hope.
  37. Lay Synonyms for Medical Terminology Medical Term Medical Acronym Lay Equivalent  Cardiac arrest Code Heart stopped Patient died  Anoxic encephalopathy Brain damage  Cardiopulm - resuscitation CPR Resuscitation/Reviving  Cardiovascular Accident CVA Stroke  Intracranial Bleed IC Bleed Stroke  Subarachnoid hemorrhage SAH Stroke  Myocardial infarction MI Heart attack  Cancer/Malignancy CA Cancer  Renal failure ARF Kidney failure  Dialysis Kidney machine  Respiratory failure Breathing failure  Ventilator Vent Breathing machine Life support
  38. Unclear  "Your mother has had a severe IC bleed. She is in the ICU and has been intubated and ventilated. Neurosurgery has placed a ventriculostomy to reduce the pressure in her brain. We do not anticipate a good prognosis.”
  39. More Clear  "Your mother has had a severe IC bleed. She is in the ICU and has been intubated and ventilated. Neurosurgery has placed a ventriculostomy to reduce the pressure in her brain. We do not anticipate a good prognosis.”  "Your mother has had a severe stroke. She is in the intensive care unit and has been placed on life support. The brain surgeons have inserted a tube to reduce the pressure in her brain. We do not think she will survive."
  40. Communication of BBN  Communication is a 2-way street  Patients also have to be honest with us regarding their symptoms, preferences, and concerns.  Realistic hopes and aspirations can only be generated from honest disclosure
  41. Key points  Delivering bad news is an important part of a physician's job.  The manner in which the news is delivered to family members will have a long lasting effect.  Proper training and experience will facilitate the process.  Remember to treat your patients as you would like to be treated.
  42. 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)
  43. Practice makes a man.. perfect

Editor's Notes

  1. Survey of 100 parents with kids with cleft lip/palate
  2. 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: This does 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?
  3. 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 patient Be 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?
  4. 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?