Breaking a Bad News

Dr. Md. Saddam Hossain MBBS (PMC,DU)

Bangladesh

Phone No: +8801770980080

This presentation includes:

What is a bad news?

To whom bad news can be given?

What are the methods of BBN?

SPIKES protocol

Not to do in BBN

Possible outcomes

“Nothing travels faster than the speed of light with the possible exception of bad news, which obeys its own special

laws‘’ ……….. Douglas Adams

What is a bad news?

“……… any information which adversely and seriously affects an individual’s view of his or her future. ‘’

……………….. Buckman, 1992.

Examples:Death of a patientLife threatening conditions, e.g.: MI, CarcinomaAny condition where emergency surgery needed, e.g.: Acute gangrenous

intestinal obstruction, rupture of any aneurismal artery.Chronic illness, e.g.: chronic pancreatitisFailure of a surgery

To Whom BBN can be given?

To the patient

To the parents of a patient

To the legal guardian

What patient/patient party expect:For themselves:• more time to talk• show feelings

From the doctors:• more information, caring, hopefulness, confidence• a familial face

What are the Challenges in BBN?Lack of: Guidelines Training Experience Good role modelsConcerns of: The provider The patient & family

Why is BBN so important ?

Case Discussion: Abdullah is a patient of yours who comes to see you one day with his wife Sharefa. Sharefa is also a patient of yours who was admitted to hospital for investigations for liver. The results of the liver biopsy showed a well differentiated hepatocellular carcinoma. This result had been disclosed to Abdullah only. He has come to you today asking for your assistance in telling his wife the results of her investigations. How would you handle this situation?

Methods of BBN:Rabow and Mc phee - ABCDE approach

Baile and Buckman - SPIKES approach

SAAIQ emergency approach – Pakistan

BREAKS approach – IJPC

SAD NEWS approach - Canada

SPIKES protocol S – Setting P – Patient’s perception I – Invitation K – Knowledge E – Empathy S – Summary

SPIKESSettings and listening skills:

(1) Where to break news.eg: A quiet room preferably not during ward round.

(2) By appointment.eg: After ward round, at 3p.m.

(3) Ask whether prefers to have relatives. (4) Physical context of interview.

eg: Sitting down, body language, eye contact(5) Introduce your self and ascertain how others are related to the patient.(6) Listening skills – open questions to start, do not interrupt.

SPIKES

Patient’s perception: (1) Ask what he already knows about the medical condition or what he suspects. (2) Listen to level of comprehensions. (3) Accept denial but do not confront at this stage.

SPIKES

Invitation to give information: (1) Ask patient if s/he wishes to know the details of the medical condition and/or treatment. (2) Accept patient’s right not to know. (3) Offer to answer questions later if s/he wishes.

SPIKESKnowledge: (1) Use language intelligible to patient. (2) Give to patient’s level – Consider educational level, socio-cultural background, current emotional state (3) In small chunks (4) Check whether patient understood what you said. (5) Respond to patients reactions as they occur. (6) Give any positive aspects first. eg: Cancer has not spread to lymph nodes, highly responsive to therapy, treatment available locally etc. (7) Give facts accurately about treatment options, prognosis, costs etc.

SPIKES

Explore emotions/Empathy: (1) Identify emotion. (2) Identify cause/source of emotion. (3) Respond in a way that you have recognized connection between 1 and 2. (4) In empathetic response not necessary for you to feel same emotion or agree to patient’s view point.

SPIKESStrategy and summary: (1) Close the interview. (2) Ask whether they want to clarify something else. (3) Offer agenda for the next meeting. eg: I will speak to you again when we have the opinion of cancer specialist.

In a summary:

Level of language :

Emotional responses to a bad news:

DenialDespair

AngerBargaining

Depression

Acceptance

How to overcome the Emotional responses:1. If patient begins to cry (a) Allow sometime to cry. (b) Could say, “I can see you are very upset” (c) Could touch the patient appropriately. (d) After a few moments you should continue talking even if patient continue to cry.

2. If patient becomes angry (a) Defensive or irritation with patient are unhelpful. (b) Acknowledge patient’s position and avoid talking about it.

3. If the patient refuses to accept the diagnosis (a) Explore reasons for patient’s denial. (b) Do not be combative. (c) Appreciate that there is an information gap and try to educate the patient. (d) Check that patient has a clear understanding of the problem. (e) Empathize with patient. (f) Get family members involved if appropriate. (g) Give time to adjust to new information.

What not to do…….

1. Jargon and technical language 2. Euphemisms 3. Evasion 4. Conflicting informations 5. “everything is going to be fine’’

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)

Thank you