BREAKING BAD NEWSBy :

Mubarak Alajmi Khalid Elenizi Sultan Alhaddad

OBJECTIVES Importance of breaking bad news To define the bad news To be aware of :

What to do? How to do it? What not to do ?

To become familiar with common illnesses which may require giving bad news.

WHAT IS BAD NEWS?

WHAT IS BAD NEWS? "any information, which adversely and

seriously affects an individuals view of his or her future"

Bad news can be/mean different things to different people ( a surgeon having hand tremor might be concerned more than the average person )

(a women who lost her mom to breast cancer will/ might react worse to the news of a diagnosis than a woman who has not).

WHAT IS BAD NEWS? The common denominator is that bad news is a

message, which has the potential to shatter hopes and dreams leading to very different lifestyles and futures.

bad news examples: Disease onset ,recurrence, spread of disease ,

or failure of treatment to affect disease

progression Infertility , death of a loved one , Child illness , physical handicap

WHY IS BREAKING BAD NEWS AN IMPORTANT SKILL

TO LEARN ?

WHY IS BREAKING BAD NEWS AN IMPORTANT SKILL TO LEARN?

Breaking bad news to someone is never a pleasant task but breaking it at the wrong time or in the wrong way can be even worse, so it's important to know the best approaches to breaking bad news.

Studies show that patients who have had an open honest empathic disclosure are more likely to be compliant with their treatment plan and show an overall well being .

WHY IS BREAKING BAD NEWS AN IMPORTANT SKILL TO LEARN?

Studies have consistently shown that the way a doctor or other health or social care professional delivers bad news places an remarkable mark on the doctor/professional-patient relationship.

Medical professionals are shown to lack training and education about this needed skill .

HOW TO BREAK BAD NEWS!? Jose is a 62-year-old man who just had a

needle biopsy of the lung showing adenocarcinoma. You run into his brother in the hall, and he begs you not to tell Jose because the knowledge would kill him even faster. A family conference to discuss the prognosis is already scheduled for later that afternoon .

How should you handle this?

HOW TO BREAK BAD NEWS!? Getting started.

The physical setting ought to be private, with both physician and patient comfortably seated. You should ask the patient who else ought to be present, and let the patient decide.(studies show that different patients have widely varying views on what they would want). It is helpful to start with a question like, "How are you feeling right now?" to indicate to the patient that this conversation will be a two-way affair.

SETTING See the pt. as soon as you know the

diagnosis Ask not to be disturbed ,give out your bleep,

and close your phone. Have some one related to pt. near him/her(if

possible and if wanted ) Insure privacy This meeting could take long time than usual

so prepare yourself.

FINDING OUT HOW MUCH THE PATIENT KNOWS.

By asking a question such as, "What have you already been told about your illness?" you can begin to understand what the patient has already been told ("I have lung cancer, and I need surgery"), or how much the patient understood about what's been said ("the doctor said something about a spot on my chest x-ray"), the patients level of technical sophistication ("I've got a T2N0 adenocarcinoma"), and the patient's emotional state ("I've been so worried I might have cancer that I haven't slept for a week").

PERCEPTION Assess pt. knowledge and understanding

about his/her condition. Ask what happen and what pt. knows since

last appointment This will make news drop more easily

FINDING OUT HOW MUCH THE PATIENT WANTS TO KNOW.

It is useful to ask patients what level of detail you should cover. For instance, you can say, "Some patients want me to cover every medical detail, but other patients want only the big picture--what would you prefer now?" This establishes that there is no right answer, and that different patients have different styles. Also this question establishes that a patient may ask for something different during the next conversation.

INVITATION Do not impose information , by finding how

much pt. want to know .

Differs from pt. to pt. some of them wants to know all the details others want very little detail

SHARING THE INFORMATION. a) disclose diagnosis of lung cancer; b)

discuss the process of workup and formulation of treatment options ("We will have the cancer doctors see you this afternoon to see whether other tests would be helpful to outline your treatment options"). Give the information in small chunks, and be sure to stop between each chunk to ask the patient if he or she understands ("I'm going to stop for a minute to see if you have questions"). Long lectures are overwhelming and confusing. Remember to translate medical terms into simple words , and don't try to teach pathophysiology.

KNOWLEDGE Giving warnings could be helpful by telling the

pt. that the news is more serious than we hopped

Give information in small amounts and stop after each piece and insure pt. understand.

Do not give all the information and always pause frequently .

Do not use technical terms. Explain that some symptoms could happen

and others could not . Be prepared for any questions Provide positive information and hope.

RESPONDING TO THE PATIENTS FEELINGS.

If you don't understand the patient's reaction, you will leave a lot of unfinished business, and you will miss an opportunity to be a caring physician. Learning to identify and acknowledge a patient's reaction is something that definitely improves with experience, if you're attentive, but you can also simply ask ("Could you tell me a bit about what you are feeling?").

EMPATHY Responding to the pt. emotion is one of the

important manners that must be provided. Our religion emphasis on giving empathy in

life maters . Always be prepared to a pt. expressing

emotion and calm them down. Always be sensitive . If pt. cries allow them time. Stop interview if necessary and arrange

another meeting.

PLANNING AND FOLLOW-THROUGH. At this point you need to synthesize the

patient's concerns and the medical issues into a concrete plan that can be carried out in the patient's system of health care.

Outline a step-by-step plan, explain it to the patient, and contract about the next step. Be explicit about your next contact with the patient ("I'll see you in clinic in 2 weeks")

Give the patient a phone number or a way to contact the relevant medical caregiver if something arises before the next planned contact.

STRATEGY AND SUMMARY Make sure pt. understood what have been

discussed .

You must meet the pt. concerns and tell them the crucial information about the diagnosis, treatment , and prognosis.

The pt must have a clear sense of the treatment plan

WHAT TO DO? Introduce yourself. Look to comfort and privacy. Determine what the pt. already knows. Determine what the pt. would like to know. Warm the pt. that bad news is coming . Break the bad news. Identify the patient's main concerns. Summaries and check understanding. Offer realistic hope. Arrange follow-up. Try to insure there is someone with the pt. when he

leaves.

HOW TO DO IT? Be sensitive. Be empathic. Maintain eye contact. Give information in small chunks. Repeat and clarify. Regularly check understanding. Give the pt. time respond Do not be afraid of silence or tears. Explore the pt.'s emotions. Use physical contact if this feels natural to you. Be honest. If you are unsure about something,

say you will find out later and get back to the pt.

WHAT NOT TO DO? Hurry. Give all the information in one go, or give too

much information. Use euphemisms or medical jargon. Lie or be economical with the truth. Be blunt( just another day at the

office) .words are like loaded pistols. Prognosticate (she's got six months, may be

seven).

THANK YOU FOR YOUR KIND ATTENTION

Any questions ?