Breaking Bad (and Good) NewsAn art or a skill

Dr. Jim Shalom

Introduction

Modern Medicine

• The Modern Medicine paradigm is geared towards curing: dealing with a medical problem until it is solved.

• Common examples include– Antibiotics for infection

– Suturing for lacerations

– Casts for fractures

The Gap between Theory and Practice

Goal to cure Success in curing

The Gap between Expectations and Reality

There are common medical problems that cannot even be controlled

Examples

• CVA / stroke• Cancer which does not respond to treatment• Acute injuries too severe to rectify• Irreversible Complications of chronic illnesses

Where does that leave us?

• Our desire may be to cure, and while it does happen some of the time, often at best we are involved in minimizing damage.

• Medical books and training tend to over-emphasize the strengths of Medicine while glossing over its inadequacies

Conclusion: We are poorly prepared to deal with things that don’t go well.

What is the physician’s role?

• CVA / stroke• Cancer which does not respond to treatment• Acute injuries too severe to rectify• Irreversible Complications of chronic illnesses

Breaking Bad news

Susan Sontag Illness is the night-side of life. Everyone who is born holds dual citizenship; in the kingdom of the well and in the kingdom of the sick. Sooner or later each of us is obliged, at least for a spell, to identify ourselves

as citizens of that other place .

healthy sick

What is bad news?Definition: Any result which does not meet our

expectations• A cognitive recognition that our expectations

will not be met• An emotional response to it which is often

unpleasant / (unrealistic)

What is bad news?

• Non medical examples of bad news• Medical examples• Bad news for one person may not necessarily be

considered bad news for another person• Bad news is in the eyes of the beholder– A piano player who suffers a minor injury to his baby

finger may feel that his world has collapsed– A patient who has had a colonoscopy for abdominal

pain may feel relief to find he has diverticulitis and not cancer

Dilemmas / Issues in presenting Bad News

• Should it be done at all?• Can it not make things worse?– Is there not a risk of taking away hope?– Might it not be better for the patient to live with

an unrealistic positive expectation rather than be compelled to face an unpleasant reality?• The person may “give up”.• The patient may even commit suicide.

• Cultural Issues

What about hope?• In research done with hemato-oncologists 75% had a

positive influence when the information was provided sensitively and leaving hope.

• Marjorie: Despite having a terminal illness, one is alive. After confronting death, every day is a miracle

• Theodore Roethke – In a dark time, the eye begins to see• Tagore: Faith is the bird that feels the light when the

dawn is still dark. . ماء دون كنبات أمل دون اإلنسان

• Human without hope like plant without water.

Hope for what?

• Even in situations where hope for a cure is unlikely, there are invariably other wishes the patient hopes for which can be met:– Relief of pain– Non abandonment– Respecting wishes

Cultural Issues

• Does one size fit all?• It is important for physicians to openly address

cross-cultural differences in patients’ preferences about the delivery of bad news.

• Some cultures believe that even articulating bad news may be associated with adverse consequences.

•. عقولهم قدر على الناس خاطب• Address people in the language they understand.

Why break bad news?

• Avoid isolation• Avoid futile treatment• Allow planning• Allow process of healing• If done properly it can improve outcome

• While bad news is always unpleasant it does not always come as a total surprise

Avoiding isolation

• Can cause isolation: everyone around the patient knows the real situation – a conspiracy of silence

• If the patient actually knows what is going on, then there is the problem of the “elephant in the room”.

Everybody knows the bad news but it is not up for discussion

Futile Treatment

Futile Treatment• Futile medical care is the continued provision of

medical care or treatment to a patient when there is no reasonable hope of a cure or benefit.

There is no chance that the small man will win

The cost of futile treatment• The use of unnecessary tests, medications,

treatments and consultations– Some of these interventions such as unnecessary

chemotherapy can be damaging• Misleads / deceives the patient• The cost of alternative time: With little time left the

patient could be doing other things which may be more important to them

The cost of futile treatment• Thanh N. Huynh JAMA Intern Med. 2013;173(20):1887-1894.

doi:10.1001/jamainternmed.2013.1026• During a 3-month period, there were 6916 assessments by 36 critical

care specialists of 1136 patients. • About 123 were perceived as receiving futile treatment • They received 464 days of treatment (range, 1-58 days• 84 of the 123 patients perceived as receiving futile treatment died

before hospital discharge and 20 within 6 months of ICU care ; with survivors remaining in severely compromised health states.

• The cost of futile treatment in critical care was estimated at $2.6 million.

Conclusions and Relevance In 1 health system, treatment in critical care that is perceived to be futile is common and the cost is substantial.

The cost of futile treatment

• When patients do not have an accurate understanding of their situation, they tend to be unrealistic about insisting on futile, unnecessary treatments including life saving devices contributing to unnecessary suffering

• Repeatedly patients describe the manner in which they were told the news as influencing their decision as to whether to continue with therapy

Allow planning• People can make plans to accommodate

predicted changes in their situation• Especially true if their time is limited.

What can I still do?

What is most important for me to do?

However, they can only make plans if they know what their situation is.

Healing

Healing

• An internal process by which a person comes to terms with their condition

Nobody said it was easy No one ever said it would be this hard~ ColdPlay, The Scientist

I can't go on.I'll go on.~ Samuel Becket

Characteristics

• Only the person themselves can do it• It is a process.• You cannot simply “decide” to accept your

destiny.• IT CAN ONLY HAPPEN IF A PERSON KNOWS

WHAT THEIR CONDITION IS

Your present circumstances don't determine where you can go; they merely determine

where you start. ~ Nido Qubein

The healing Paradox

• “When we are no longer able to change a situation, just think of an incurable disease such as inoperable cancer, we are challenged to change ourselves.” – Viktor Frankl, Man’s Search for Meaning

• While it can be horrible to encounter bad news, many people get relief when they come to terms with their condition. They then suffer less. They can move on.

Improving Outcome

Improving outcome

• In a research project done on 100 women who were interviewed 6 months after their operation a direct correlation was found between adjustment to the disease and the manner in which it was explained to them

• More women developed depression when their concerns were not addressed.

Breaking Bad News

To Tell or not to tell

• Let me not pray to be sheltered from dangers but to be fearless in facing them - Rabindranath Tagore

The Physician’s Circumstance

• During your career there will be repeated situations in which you will have to pass on bad news

• The questions asked are:1. How skillful will you do it?2. How comfortable will you feel about it?

Difficulties for the Caregiver

• Difficulty being the “bad guy” the deliverer of bad news• Emotional strain on the caregiver; Many physicians

experience intense emotions of their own when they communicate bad news to a patient.

• The caregiver may have a sense of failure• How well does the caregiver himself / herself cope with

bad situations?• Concern that talking about bad news cause the

situation to get worse• Concern about taking away hope from the patient

Breaking Bad News

• Who should do it?• When should it be done?• The skill of breaking bad news

Breaking Bad news

• It is the physician’s responsibility to break bad news

• However every health care worker will sooner or later encounter situations in which the patient’s condition has taken an irreversible turn for the worse

• We all will frequently encounter situations in which the patient’s expectations are not met. Someone in the medical system may be expected to relate to this.

Dilemmas / Issues

• When should it be done?• To whom should it be presented? (To the

patient; to their family)• To what degree should cultural factors play a

role (Ethnic background, religion, culture..)

Who should receive the news?

• In Western society it is typically the patient.• In other cultures patient autonomy may have

less of a value than family style and concern

When should it be done?• There never is a perfect time. Assess when the best

time is. – We tend to procrastinate with things we do not like to do.– There may not be another opportunity

• . الغد إلى اليوم عمل تؤجل ال• Do not postpone today's work till tomorrow.

•“. حاميا" مادام الحديد إضرب• Strike while the iron is hot.

Technical issues

• What degree of technical detail should be used• Language of precision or language of implication– Example: You have cancer in your bowel versus– We found something bad in your bowel

• Should the emphasis be on the healthy aspect of the patient or the sick aspect?

Technical Detail

• Physicians are most comfortable with Medical language; patients not always including educated ones

• Patients are often overwhelmed emotionally in the encounter and cannot always take in the information

• On the other hand, some patients want all the information; the more specific the better for them

Specifics versus Implied

• Words have denotations and connotations. Some of the most precise terms such as cancer also have heavy connotations which can unnecessarily upset the patient.– For some patients it will be appropriate to use

vague terms at the first stage; • Warning shot

– others will expect precision

I understand a fury in your words, but not the words. Shakespeare

Patient Expectations• Gaps between what patients want to know and how physicians

perform are evident when patients are asked whether physicians discussed the implications of the bad news.

• In one study of cancer disclosure experiences, only 14% of patients felt that diagnostic disclosure was the most important aspect of a bad news discussion; many patients felt that prognosis (52% of patients) and treatment (18% of patients) were more important.

• In the patients with breast cancer or melanoma, 57% wanted to discuss life expectancy, although only 27% of physicians actually did this. Most of these patients (63%) wanted to discuss the effects of cancer on other aspects of life, yet only 35% reported having these discussions.

• In another study, patients reported rarely receiving prognostic information

How Should Physicians Communicate Bad News?

• Most patients in the U.S. want to have straightforward, honest discussions with their physicians (and cultural patterns of disclosure are changing throughout the world).

• Patients also want their physicians to be sensitive in these conversations, and they value hope

• Can use standard script as a guideline but each case should be individualized

What about the Experienced Doctor?

• Does experience itself improve the quality of delivery?

• Physicians are poor at identifying their patients reactions. Research done on oncologists found that only one in 5 was able to accurately asses patient distress even though most of the physicians thought that they were ding a good job

• Another research project showed that experience itself does not improve the quality of delivering bad news.

Can it be learnt?

• Use of video with feedback has been shown to improve communication skills in breaking bad news.

One size fits all?

• Is there one right way in which to deliver bad news?

• NO• There are general guidelines, but each case has to

be individualized• Factors which may matter include culture /

religious background.– American culture tends to be more receptive to

providing details while conservative cultures tend to be more circumspect.

Technique for Delivering Bad News

SPIKES - method

SPIKESS- Setting

P - Patient's Perception

I - Invitation to Proceed

K - Knowledge

E- Empathy & Emotions

S - Summary & Strategy

Setting

Goal: to make sure that both you and your patient are comfortable

• Arrange for some privacy. • Involve significant others. • Sit down. Sitting down relaxes the patient and is also• Make connection with the patient.• Manage time constraints and interruptions. Inform

you expect. • Set your mobile phone on vibrate or turn off.

Patient Perception

• The perception of your patient may be very different from your own.

• In order to be effective, you should try to meet them where they are.

Examples• “What have you been told about your medical

situation so far?” • “What is your understanding of the reasons

we did the MRI?”.

Invitation to proceed

• How would you like me to give the information about the test results?

• Would you like me to give you all the information or sketch out the results and spend more time discussing the treatment plan?”.

• If patients do not want to know details, offer to answer any questions they may have in the future or to talk to a relative or friend.

Knowledge

• Warning the patient that bad news is coming may lessen the shock that can follow the disclosure of bad news and may facilitate information processing

• Examples of phrases that can be used include: Unfortunately I’ve got some bad news to tell you”

Giving medical Facts• Start at the level of comprehension and vocabulary of the

patient. • Try to use nontechnical words such as “spread” instead of

“metastasized” and “sample of tissue” instead of “biopsy.”• Third, avoid excessive bluntness (e.g “You have very bad cancer

and unless you get treatment immediately you are going to die.)• Give information in small chunks and check periodically as to the

patient’s understanding. • Even when the prognosis is poor, avoid using phrases such as

“There is nothing more we can do for you.” There is always something that can be done from symptom control to respecting the wishes of the patient.

Use of Empathy

• Doctor: I’m sorry to say that the x-ray shows that the chemotherapy doesn’t seem to be 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.

• If the patient is overwhelmed emotionally they will not be able to absorb the technical information you tell them.

Type of Responses

• Empathic statements • “I can see how upsetting this is to you.” “How do you

feel?” • “I know this is not good news for you.” • Exploratory questions • “Tell me more about it.” • “Could you explain what you mean?” • Validating responses• “I guess anyone might have that same reaction.”• “I can understand how you felt that way.”

Summary & Strategy

• Patients who have a clear plan for the future are less likely to feel anxious and uncertain.

• It can be as simple as scheduling the next appointment to continue the discussion

• Before discussing a treatment plan, it is important to ask patients if they are ready at that time for such a discussion.

Patients Responses

• In a study of patients diagnosed with cancer, the most frequent responses were shock (54%), fright (46%), acceptance (40%), sadness (24%), and “not worried” (15%).

• Patient confusion can be an important contributor to the distress commonly seen following a bad news discussion, and the biggest source of patient misunderstanding is technical language.

• An abnormal reaction to an abnormal situation is normal behavior. Viktor Frankl

Summary• Breaking bad news is an essential skill for

physicians and caregivers• Improving your delivery skills can ease the

suffering of your patients and their family

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Hope does not lie necessarily in a way out, but also in a way through.

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In the hour of adversity be not without hope, For crystal rain falls from black clouds." - Nizami Ganjavi – Azeri poet

Breaking Good News

• Presenting good news can sometimes be tricky. What may seem to you as good news may be perceived as bad news by the patient.

• A patient who has emotionally invested in a test result, may be hurt if the news is given too superficially.

• Making an issue of “good news” can put some sunshine in a patient’s journey with their illnesses

ReferencesEnhancing Physician-Patient Communication Stephanie J. Lee,

Anthony L. Back, Susan D. Block, and Susan K. Stewart

SPIKES—A Six-Step Protocol for Delivering Bad News:Application to the Patient with Cancer WALTER F. BAILE,

ROBERT BUCKMAN, RENATO LENZI, GARY GLOBER, ESTELA A. BEALE, ANDRZEJ P. KUDELKA

Jim Shalom: jim.shalom@gmail.com