BBN - Breaking Bad News is difficult task for Junior doctors in India as it was not in the Curriculum unlike Western countries. So this slide will give you the Facts / Methods with Description of one method & Key points.
3. Contents of Discussion
īŽ Definition / Examples
īŽ Facts of Bad News
īŽ Methods / Protocols
īŽ Description of 1 method
īŽ Key Points
4. What is Bad News?
īŽ âSituations where there is either a feeling of no hope, a
threat to personâs 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.â Bor et al., 1993
īŽ â...any information which adversely and seriously affects an
individualâs view of his or her futureâ. Buckman, 1992
īŽ â...any information that is not welcomeâ. Arber and
Gallagher, 2003
īŽ â...[an] uncomfortable experience for both the giver and the
receiverâ. Aitini and Aleotti, 2006.
6. Other Situations
īŽ Disease recurrence / spread of disease,
or
īŽ Failure of treatment to affect disease
progression,
īŽ Irreversible side effects, results of genetic
tests, or
īŽ Issue of palliative care and resuscitation.
7. Why should it be done?
īŽ Forms part of clinical practice.
īŽ A skill that can be taught and improved.
īŽ Patients and relatives appreciate it.
īŽ The degree to which news is bad depends
on the gap between reality and patientâs
perception.
īŽ Non disclosure is no longer considered
ethical.
8. Why should it be done?
īŽ Better psychological adjustment by
patient.
īŽ Reduces stress in doctors.
īŽ Facilitates open discussion among
patients, relatives and doctors.
īŽ Empowers patients by allowing them a
greater say in treatment.
9. So,
īŽ Bad news is, therefore, a relative
concept and should depend on the
īŽ patientâs interpretation of information
and reaction to it.
10. Why is it difficult ?
The Patientâs Perspective
īŽ Patients often have vivid memories of
receiving bad news.
īŽ Negative experiences can have lasting
effects on anxiety and depression
īŽ Can facilitate adaptation to illness and
deepen the patient-doctor relationship
11. Why is it difficult ?
The Physicianâs Perspective
īŽ Fear of causing pain / being blamed / fear of
therapeutic failure / emotional reaction
īŽ Lack of training in breaking bad news
īŽ Lack of time / health system constraints / lack of
support from colleagues
īŽ Cultural constraints / language barriers
īŽ Fear of upsetting the patientâs existing family
roles or structure.
12. To Whom the BBN to be Given ?
īŽ Certain legal and ethical guidelines in clinical
practice make it difficult to withhold important and
personal information.
īŽ It is good practice first to discuss these situations
with a colleague or within a multidisciplinary health
care team.
īŽ There are some specific situations in which you may
need to consider whether to give bad news.
13. Example -
īŽ If a patient is deemed to be psychotic, and
presumably may not understand what has
happened, there may be reason to
withhold bad news.
īŽ When treating a child, one usually confers
with the parent or guardian before
breaking bad news.
14. Who should give the Bad news ?
īŽ For several reasons, it may be more
appropriate for another doctor to break
bad news.
īŽ 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 -
īŽ The GP usually has an established relationship
with the pt and presumably could anticipate
some of the problems that might arise.
īŽ Giving bad news usually requires time, so it may
be inappropriate for someone to do so at the
end of a shift.
īŽ 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 ?
īŽ You can try gradually to break the news; this in
turn gives the patient and relatives time to
adjust.
īŽ 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.
īŽ In some situations, it can actually be hazardous
to withhold bad news until a later stage.
17. Example -
īŽ 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 themselvesâĻ
īŽ more time to talk
īŽ and show feelings
From the doctorâĻ
īŽ more information, caring,
hopefulness, confidence
īŽ a familiar face
19. Methods to Deliver -
īŽ Rabow and Mc Pheeâs - ABCDE approach.
īŽ Baile & Buckman - SPIKES approach.
īŽ SAAIQ emergency approach - Pakistan
īŽ BREAKS approach by IJPC
īŽ SAD NEWS approach â Q.U / Canada
20. ABCDE Approach -
īŽ A dvance preparation .
īŽ B uild therapeutic environment .
īŽ C ommunicate well.
īŽ D eal with patient and family
reactions
īŽ E ncourage and validate emotions
21. SPIKES Approach -
īŽ S etting up in privacy.
īŽ P erceptions of the patient.
īŽ I nvitation to break news.
īŽ K nowledge.
īŽ E motions.
īŽ S trategy.
22. SAAIQ Approach -
īŽ SET the scene as soon as possible.
īŽ ASSESS the understanding of the
attendant.
īŽ ALERT them that I have bad news .
īŽ INFORM in clear, understandable words.
īŽ QUICKLY repeat summary of the situation.
23. BREAKS Approach -
īŽ B ackground
īŽ R apport
īŽ E xplore
īŽ A nnounce
īŽ K indling
īŽ S ummarise
24. SAD NEWS Approach -
īŽ S et up & Sit down
īŽ A sk , donât tell
īŽ D eliver the news
īŽ N o fancy lingo
īŽ E xpect, permit & respond to emotion
īŽ W ait
īŽ S upport & Summarise
26. S etting the Environment -
īŽ Provide privacy
īŽ Introduce self
īŽ Determine who else should be present
īŽ Ensure no interruptions
īŽ Provide comfortable space
īŽ Create welcoming environment
27. Perception
īŽ Ask what he already
knows about the
medical condition or
what he suspects.
īŽ Listen to level of
comprehensions.
īŽ Accept denial but do
not confront at this
stage.
28. Invitation - Information
īŽ Ask patient if s/he
wishes to know the
details of the medical
condition and/or
treatment.
īŽ Accept patientâs right
not to know.
īŽ Offer to answer
questions later if s/he
wishes.
29. Knowledge
īŽ Deliver the message
īŽ Use plain language
īŽ Be mindful of body language
īŽ Get to the point
īŽ Give information in small chunks
īŽ Pause
īŽ Wait for reaction
īŽ Use âteach backâ to verify that message was
received
30. Emotions and Empathy
īŽ Be prepared for patientâs and familyâs emotional
response
īŽ Anticipate fear, anger, sadness, denial, guilt
īŽ Be mindful of your own response
īŽ Comfort the patient
31. Strategy and Summary
īŽ Assess patientâs readiness for planning
īŽ Negotiate next steps
īŽ Verify support structure
īŽ Acknowledge & answer questions
īŽ Summarize plan
īŽ Use âteach backâ technique
īŽ Follow-up
33. If pt Cries -
īŽ Allow sometime to cry.
īŽ Could say, âI can see you are very upsetâ
īŽ Could touch the patient appropriately.
īŽ After a few moments you should continue
talking even if patient continue to cry.
34. If pt â Angry
īŽ Defensive or irritation with patient are
unhelpful.
īŽ Acknowledge patientâs position and avoid
talking about it.
35. If pt refuses â Accept Diagnosis
īŽ Explore reasons for patientâs denial.
īŽ Do not be combative.
īŽ Appreciate that there is an information gap and
try to educate the patient.
īŽ Check that patient has a clear understanding of
the problem.
īŽ Empathize with patient.
īŽ Get family members involved if appropriate.
īŽ Give time to adjust to new information.
36. Common Pitfalls -
īŽ Inadequate time / information.
īŽ Failure to elicit patientâs understanding of
situation.
īŽ Giving news at doctorâs speed.
īŽ Not allowing time for responses.
īŽ False reassurances about the future.
īŽ Allowing denial to remain.
īŽ Removing all hope.
37. Lay Synonyms for Medical
Terminology
Medical Term Medical Acronym Lay Equivalent
īŽ Cardiac arrest Code Heart stopped
Patient died
īŽ Anoxic encephalopathy Brain damage
īŽ Cardiopulm - resuscitation CPR Resuscitation/Reviving
īŽ Cardiovascular Accident CVA Stroke
īŽ Intracranial Bleed IC Bleed Stroke
īŽ Subarachnoid hemorrhage SAH Stroke
īŽ Myocardial infarction MI Heart attack
īŽ Cancer/Malignancy CA Cancer
īŽ Renal failure ARF Kidney failure
īŽ Dialysis Kidney machine
īŽ Respiratory failure Breathing failure
īŽ Ventilator Vent Breathing machine
Life support
38. Unclear
īŽ "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.â
39. More Clear
īŽ "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.â
īŽ "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
īŽ Communication is a 2-way street
īŽ Patients also have to be honest with us
regarding their symptoms, preferences, and
concerns.
īŽ Realistic hopes and aspirations can only
be generated from honest disclosure
41. Key points
īŽ Delivering bad news is an important part of
a physician's job.
īŽ The manner in which the news is delivered
to family members will have a long lasting
effect.
īŽ Proper training and experience will facilitate
the process.
īŽ Remember to treat your patients as you
would like to be treated.
42. The Task of Breaking Bad News
âIf we do it badly, the patients or
family members may never forgive
us; if we do it well, they may never
forget us.â( Buckman, 1992)
Survey of 100 parents with kids with cleft lip/palate
Deliver the message:
Use plain, everyday language and pay attention to body language, both yours and the patientâs. 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. âor- Iâm afraid I have bad news aboutâĻGet 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!
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Verify that the message has been received:
Remember that a hallmark of âteach backâ 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.
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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.
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Anticipate emotions. The common emotions in a sharing bad news situation may be fear, anger, sadness, denial, and guilt.
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Your responses:
Expect to feel discomfort.
Listen.
Be aware of body language.
Acknowledge emotions.
Allow the patient time to process information.
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Show empathy: Comfort the patient
Be aware that âcomforting the patientâ 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.
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POSSIBLE REFLECTION: Think of a time when a patient was very upset. How did you feel? How did you react?
Assess patientâs readiness for planning:
Negotiate next steps. Use a Patient & Family team approach. Ask the patient: Are you ready to discuss treatment options?
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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, âDo you have someone at home or someone available to help you?â
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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.
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Summarize plan:
Use âteach backâ 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.
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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?
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