Breaking Bad News. Objectives: Students will: Recognize essential principles of breaking bad news....

Breaking Bad News

Objectives:

Students will:

• Recognize essential principles of breaking bad news.

• Identify pitfalls in delivering breaking bad news.

• Apply skills of breaking bad news in a simulated situation.

THE BAD NEWS ABOUT BREAKING BAD

NEWS IS THAT BAD NEWS IS

BAD NEWS

DEFINITION OF BAD NEWS

Bad News

any news that drastically and negatively alters the patient’s view of their future

Buckman R. BMJ1984

Bad News

any news that drastically and negatively alters the patient’s view of their future

Buckman R. BMJ 1984

It alters one’s self-image : “I left my house as one person & came home another.”

Professional cyclist Lance Armstrong’s recollection

Examples of Conditions Examples of Conditions Requiring Breaking of Requiring Breaking of

Bad News ???!!!!Bad News ???!!!!

Examples of Conditions Requiring Breaking of Bad News

• Cancer related diagnoses

• Intra uterine foetal demise

• Life long illness: Diabetes, Epilepsy

• Poor prognosis related to chronic diseases: loss of independence

Examples of Conditions Requiring Breaking of Bad News(cont)

• Informing parents about their child’s serious mental/physical handicap

• Giving diagnosis of serious sexually transmitted disease …catastrophic psychosocial results

• Non clinical situations like giving feedback to poorly performing trainees or colleagues

The Good News! about Bad News!!!

• Using a plan for determining the patient’s values, their wishes for participation in decision making, and a strategy for addressing their distress when the bad news is disclosed can increase our confidence in the task.

The Good News! about Bad News!!!(cont)

• It may also encourage patients to participate in difficult treatment decisions

• Those who do so have a better quality of life

• Clinicians who are comfortable with giving bad news are subject to less stress and burnout.

رضي سنان بن صهيب يحي أبي عن : صلى الله رسول قال قال عنه الله

وسلم عليه :اللهالمؤمن )) ألمر له عجبا كله أمره إن

: خير إن للمؤمن إال ذلك وليسوإن له، خيرا فكان شكر سراء أصابته

له خيرا فكان صبر ضراء ((أصابتهمسلم رواه

Do You Tell??

Do You Tell?

Recent studies have shown that:• Patients generally (50-90%) desire full & frank

disclosure, though a sizeable minority still may not want the full disclosure. (Ley p. Giving information to patients. New York: Wiley, 1982 )

So the issue is not “do you?”Issue is “how?”

Do You Tell?

In reality, patients who are dying, know they are dying They want confirmation of their

status They want a time frame

YOU would want a time frame when your time approaches

Is this Difficult to break the Is this Difficult to break the bad news? bad news?

WHY?WHY?

Is this Difficult to break the bad news?

• It is referred by some physicians like “dropping the bomb”

Baile W F, oncologist 2000

Why is this Difficult?

Social factors

Our society values youth, health, wealth

Elderly, sick and poor are marginalizedSick and dying have less social value


Physician factors

Fear of causing painUncomfortable in uncomfortable

situationsSympathetic pain due to patient’s

distress


Fear of being blamedPhysicians have authority, control,

privilege and status When medical care fails patient

it’s physician’s fault“blame the messenger”


Fear of therapeutic failureMedical system reinforces idea that poor

outcome and death are failures of ‘system’and by extension, our failure

“all disease is fixable”“better living through chemistry”

We are trained to feel this way; “if only……”


Fear of medico-legal system

Everyone has “right” to be cured;If no cure happens, someone is to

blame


Fear of not knowing

“we don’t do what we don’t do well”Good communication is a skill that is

not highly valued, therefore not taught


Fear of eliciting reaction“don’t do anything unless you know

what to do if it goes wrong”Not trained to handle reactionsNot trained to allow emotion to

come out


Fear of saying “I don’t know”

We are never rewarded for lack of knowledge

Can’t know or control everything


Fear of expressing emotionsViewed as unprofessionalSuppressing emotions increases

distancebetween ourselves and patients

Rabow & Mcphee (West J. Med 1999) described:

““Clinicians focus Clinicians focus oftenoften on relieving patients’ on relieving patients’ bodily pain, bodily pain, less often less often on their emotional on their emotional distress & distress & seldomseldom on their suffering.”on their suffering.”


Ambiguity of “I’m sorry”

Two meanings“I’m sorry for you”“I’m sorry I did this”

Easily misinterpreted


Fear of one’s own illness and death

Cannot be honest with the dying unless you accept you will die

So How Do We Do This??

Never, never, never, ever…

NEVER “assume”

If you need to know somethingIf you want to know something

If you need to know somethingIf you want to know something

ASK!!ASK!!

THINGS GO WRONG WHEN:

* WE TRY TO ESCAPE * WE REACT IN ANGER

* WE DILUTE THE AGENDA


WE TRY TO ESCAPE: • INAPPROPRIATE DELEGATION• DISTRACTION• FRONTAL ATTACK• INTELLECTUALIZATION• MINIMIZATION• EMPTY REASSURANCE


WE REACT IN ANGER:

• TO DENIAL• TO IDEALIZATION• TO REHEARSAL OF THE STORY• TO ‘UNREASONABLE’ DEMANDS• TO ANGER AND BLAME


WHEN WE DILUTE THE AGENDA:

• BILLING

• PRACTICAL ARRANGEMENTS

• REQUEST FOR POST MORTEM

The SPIKES Protocol

• SETTING UP the interview• Assessing patient’s PERCEPTION• Obtaining the patient’s INVITATION• Giving KNOWLEDGE and information• Addressing the patient’s EMOTIONS• STRATEGY and SUMMARY

SPIKES

Step 1: S - SETTING UP the interview• Preparation Preparation- Preparation• Always in person, face to face

NEVER on telephone• Plan, arrange for privacy, involve

significant others• Sitting down, Non Verbal Behaviour• Manage time constraints and

interruptions

SPIKES

• Step 2: P –Assessing The PATIENT’S

PERCEPTION

• Gather before you Give• Patient’s knowledge, expectations and hopes• What do they understand about the situation?

Unrealistic expectations?• What is their state of mind? Hopes?• Opportunity to correct misinformation and

tailor your information

SPIKES

• Step 3: I – Obtaining the patient’s INVITATION

• Gather before you give• How much does the patient want to know? Coping strategy?• Answer questions, offer to speak to another

SPIKES

• Step 4: K – Giving KNOWLEDGE and information to the patient

• Warning shot• Use simple language, no jargon, • Vocabulary and comprehension of patient• Small chunks, avoid detail unless requested• Pause, allow information to sink in• Wait for response before continuing• Check understanding• Check impact

SPIKES

• Step 5: E – Addressing the patient’s EMOTIONS with empathic responses

• Shock, isolation, grief• Silence, disbelief, crying, denial, anger• Observe patient’s responses and

identify emotions• Offer empathic responses

Emotions of the patient

• Respond to patients’ emotions with empathy

• Often shock, isolation, disbelief, grief or angerObserve for emotion on patient’s partIdentify the emotion. Identify the reason for the emotionConnect with the patient


• Exploratory questionsHow do you mean?Tell me more about itYou said it frightens youYou said you were concerned about

your children, tell me moreCould you tell me what you are

worried about?


• Validating responsesI can understand how you felt that wayI guess anyone might have the same

reactionYou are perfectly correct to think that

wayYour understanding of the reason for the

tests is very goodMany other patients have had a similar

experience


• Doctor: “I’m sorry to say that the X-ray shows that the chemotherapy is not working [pause]. Unfortunately, the tumor has grown somewhat”

• Patient: “I’ve been afraid of this!” [Cries]

• Doctor: [Moves his chair closer, offers the patient a tissue and pauses,] “I know that this isn’t what you wanted to hear. I wish the news were better”

What is Empathy?

The capacity to recognise emotions that are being felt by another person.

Empathic Responses

• An indication to the patient that you recognise what they are feeling (and why)

• Verbal and Non verbal• Often associated with the impact of the

news rather than the understanding.• Wait for response• Clarify


Empathic statements

I can see how upsetting this is to youI can tell you were not expecting to

hear thisI know this is not good news for youI’m sorry to have to tell you thisThis is very difficult for me alsoI was also hoping for a better result

SPIKES• Step 6: S – STRATEGY and

SUMMARY• Are they ready?• Involve the patient in the decision making• Check understanding

• Clarify patient’s goals• Summarise • Contract for future

REVISION OF THE 6 STEPS

Six Step Protocol

-arrange physical context-find out what patient knows-find out what patient wants to know-share information-respond to patient’s feelings-plan follow-through

Arrange physical context

Always in person, face to face NEVER on telephone

Assure privacyVerify who is presentVerify who should be present

ASK

Arrange physical context

Remove physical barriersSit down

patient-physician eyes at same levelappear relaxed, not casual (avoid ‘open 4’)

Touch patient (appropriately)above the waist, handshake, shoulder

Find out what patient knows

Not just knows, but understands

Use open questions closed questions excellent for

history-takingprevent discussion


Listen effectively to response:tells understanding, ability to understand

Repeat back what patient saysDo not interruptMake encouraging cuesMaintain eye contact


Tolerate silences

Listen for “buried question”question asked while you are speaking

Find out what patient wants to know

Ask!!Do not allow families to run

interference

If patient chooses not to know now, may ask later

Share the information

Plan agenda know beforehand what information has to get across

eg diagnosis, treatment, prognosis, support

Start by aligning with what patient knows

Share the information

Allow patients to ‘get ready’Impart information in small packets

best case retention = 50%Speak English, not “Doctor”Verify message is received

Respond to feelings

Acknowledge emotionsstrong emotions prevent communicationidentify and acknowledge them

Learn to be comfortable with silence and with emotion

Respond to feelings

Range of normal reaction is widegive latitude as much as possiblestay calm, speak softlybe gentle, yet firmstick to basic rules of interview:

question-listen-hear-respond

Respond to feelings

Distinguish between adaptive and maladaptive behaviors

Adaptive Maladaptiveanger ragecrying collapsebargaining manipulationfulfilling an ambition impossible “quest”fear anxiety/panichope unrealistic hope

Respond to feelings

Respond with empathic responses“it must be very hard to…”“you sound angry (afraid, depressed)…”

Respond to feelings

In the face of true conflict: act, don’t react

If you cannot change behavior, get help

Planning follow-through

Have plan of actionMake certain patient’s understand

what is fixable and what is notAlways be honestPatient leaves with contract:

what will happen, who to call, how to call, when to return

You have one chance to get this conversation right

Patient/family will remember this always

How do you want to be remembered?

How to Break Bad News: A Guide for Health Care Professionals

Robert Buckman, M.D.Johns Hopkins University Press,

1992 ISBN: 0-8018-4491-6

• Scenario 1Tariq, a 55-year-old chain smoker taxi driver with persistent cough for 3 months, attends your clinic to find out the biopsy report of a lesion shown on a chest x-ray and CT scan. He is rather anxious, that he has a serious condition.

His biopsy report confirms that he has a Bronchogenic Carcinoma of right lung.

You are required to proceed with this consultation.

Scenario 2• A 54-year-old lady attends your clinic to find

out the result of an MRI of her spine. She has had constant pain all over her spine for the last 2 months. She also has a history of Breast cancer, which was treated 5 years ago.

• Her report shows that she has secondaries all over her spine

Proceed with this consultation. (Examination not required)

SAQs(1) One of the famous strategy for breaking bad news is the SPIKES Model:Explain briefly any 3 of the 6 areas mentioned in this model?

(2) What is a warning shot? What you say and what skills you use after and before breaking bad news?

(3) Breaking bad news is difficult: Give 3 reasons for that?

Breaking Bad News. Objectives: Students will: Recognize essential principles of breaking bad news....

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