Breaking Bad News – A Six-step Protocol

8/7/2019 Breaking Bad News – A Six-step Protocol

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BREAKING BAD NEWS ±

A SIX-STEP PROTOCOL

HO Pui Gi



INTRODUCTION

´ Breaking Bad News: Patient, Family, and

Professional Perspectives

By Dr. Robert Buckman

´ http://www.youtube.com/user/HEATINCca#p/a

/f/0/Q5Q-isP-JqY



WHY IS IT A CRITICAL SKILL?

The Patient·s perspective

´ Patient·s often have vivid memories of

receiving bad news´ Neg ative experiences can have lasting effects

on anxiety and depression

´

Can facilitate adaptation to illness and deepenpatient- doctor relationship



WHY IS IT A CRITICAL SKILL?

The Physician·s perspective

´ High deg ree of diff iculty + Physician anxiety

-> high risk of performing poorly



NATURE OF BREAKING BAD NEWS

INTERVIEW

´ Asymmetrical

´ 2 components:

«Divulging information: impart info to patient« Therapeutic dialogue: listen to, hear and respond to

patient·s reaction to information



ADVOCACY

� Support of patient involve:

± Listening , hearing , acknowledging emotions that patient is experiencing

± Advocacy on patient·s behalf

� Ground Rule: If you can·t answer a question, do

n·t

tr

y.

Instead,

act

as

pat

ie

nt·s

ad

vocate,

listen to question and take it elsewhere for f urther information.



STEP 1 GETTING STARTED

� Ground Rule:

Always try to g et the physical setting right ->

1. To reassure yourself (because you are in control, and doing something with which you are similar)

2. To reassure your patient (because you look

more relaxed, and seem to know what you are doing )




� Where?

1. Separate room ² problem with the long walk

2. Draw curtains (for in-patients) ² give illusion of privacy

3. Standing up ² leaning ag ainst the wall give

illusion that professional is there for some time, not about to run away.




� Who Should be There?

1. Never guess. Always ask patient g ently what

relationship the visitors have to the patient. 2. Ask patient if s/he would like to continue the

interview with the visitor present.




� Starting off

1. Attend to normal courtesy

2. Start conversation with question

± ´How are you feeling at the moment?µ± ´How are thing s today?µ

± ´Do you feel well enough to talk for a bit?µ

3. If patient is nauseated, in pain or just had sedative

drug ± ´I know you·re not feeling well, but perhaps we could

talk for a few minutes now, then I would come back tomorrow.µ




� Important messag es to patient:

1. You are interested in patient·s condition

2. The conversation is to be two-way3. It g ets the patient talking

4. Allow you to assess patient·s current medical

symptoms, mental state and vocabulary



STEP 2 FINDING OUT HOW MUCH THE

PATIENT KNOWS

´What patient already knows about the illness ²

« how serious s/he thinks it is,

« how much it will affect the f uture

«NOT about basic pathology or nomenclature of his

or her diagnosis




PATIENT KNOWS

� Important information on 3 major aspects of

patient·s situation:

A.

Patient·s understanding of medical conditionB. The style of patient·s statement

C. The emotional content of patient·s statement




PATIENT KNOWS

A.Patient·s understanding of medical condition

� Patient may say they have been told nothing at all.

� May or may not be true

� Even if you know it is false, accept it as symptom of denial and don·t confront it immediately:

1. Patient may deliberately deny previous

information to see if you tell the same story2. Patient is now in denial, therefore unlikely to be

supportive if launch immediate confrontation




PATIENT KNOWS

B. The style of patient·s statement

´ Pay attention to:

«

Emotional state« Educational level

« Ability in articulation

´ Note: even if patient is member of health care

profession, do not assume they are expert in

their own disease.




PATIENT KNOWS

C.The emotional content of patient·s

statement

´ Verbal

´ Non-verbal

« Sitting back away from the doctor

«Hunched forward

«Crying

« Tight hand-wringing




PATIENT KNOWS

C. The emotional content of patient·s statement

´ Look for discordance between verbal and non-

verbal communication« If hands showing anxiety and words are speaking

calm bravery

=> major anxiety exists and being suppressed.

´ No need to judg e the response are normal or

abnormal




PATIENT WANTS TO KNOWS

´ Do not ask patient directly what they want to

know because:

1.

You are removing from the patient the choices of not discussing the situation

2. Asking the patient·s view will cause distress to

the patient

´ Instead, ask ´at what level do you want to know

what·s g oing on?µ





´ Several studies and detailed case histories

(Goldie, 1982) conf irm that more distress is

caused by not discussing the information than

by discussing it.

´ Proportion of patients who want to know is

higher than 50% and is in the rang e of 75-97%.





´ Phasing the questions

« ´If the condition turns out to be something serious, are you the kind of person who likes to know exactly

what·s g oing on?µ« ´Would you like me to tell you the f ull details of

what·s wrong ² or would you prefer just to hear about the treatment plan?µ

« ´Would you like me to tell you the f ull details of your condition ² or is there somebody else that you·d like me to talk to?µ





´ If patient don·t want to hear f ull details ->

maintain contact and communication about the

treatment plan

´ Patient need to have some information about

his/her condition in order to make informed

condition about treatment.



STEP 4 SHARING THE INFORMATION

(ALIGNING AND EDUCATING)

´ Decide on Your Ag enda

´ Depends on patient·s disease status and your own role in health-care team in relation to

patient

´ Structure:

«Diagnosis

« Treatment plan« Prognosis

« Support





´ Ground Rule: It is not essential to state your

own ag enda, but it is essential to have one (or

at least part of one.)





´ Your ag enda may not be the same as the

patient

´ A mentally competent and informed patient has

the righta. To accept or reject any treatment offered

b. To react to the news and express their ownfeeling s in any (leg al) way s/he chooses

´ Many interviews end in frustration because the professional feels the patient has to accept the proffered treatment or has to react in a certain way.





A.Start from the patient·s starting point (Aligning )

´ Reinforce those parts of what the patient has

said

(using

th

e pat

ie

nt·s

words

if poss

ib

le)

´ -> gives patient g reat deal of conf idence

´ -> realise that his/her view of the situation has

been heard and is being taken seriously (even

if it is being modif ied or corrected)





B. Educating

´ Assess the magnitude of diverg ence between

what the patient understands and the medical

facts.

´ Give information in small chunks: The Warning

shot

´ Studies show most patients fail to retain up to

50% of information given





´ ´ Well, the situation does appear to be more seriousthan that«µ

´ Gradually introducing more serious prognostic

points, waiting for patient to respond at each stag e´ ´ The chest x-ray shows that there is tumour on the

lung. (Pause.) Does that make you think of any particular questions?µ

´ Following the warning shot, a narrative of events can be an extremely usef ul technique to help patient understand what has been happening .





´ Use English not Medspeak

´ Some words in Medspeak sound the same as in

English but have completely different meaning s

´ E.g . ´The patient complaints of«µ, ´there is

considerable morbidity«.µ

´ Should use words for the benef it of listener but not

ourselves.





´ C heck reception frequently and clarify

« ´Am I making sense?µ

« ´ Do you follow what I·m saying?µ

« ´ Do you see what I mean?µa. Demonstrate that it matters to you if patient doesn·t

understand what you are saying

b. Allow patient to speak

c. Allow patient to feel an element of control over the interview

d. Validate patient·s feeling s





´ Reinforce Information Frequently and C larify

´ Clarif ication: make sure you both mean the

same thing

´ Repeat important points

´ Use diag rams and written messag es

´

Use Any written or Recorded Material Available





´ Check your level: adult-to-adult or parental adult-

child pattern

´ Listen for the Patient·s Ag enda

1. Try to elicit the ¶shopping list·

² E.g .: patient may be more concerned about the effect of a colostomy

on his/her sex life then on long term complication of ulcerative

colitis

²

E.g .: patient often more worried about hair-loss due to chemotherapythen about the potential risk of the primary disease

² Try to listen to patient·s concern, then identif y and acknowledg e

them





2. Listen for buried question

3. Be prepared to be led



STEP 5 RESPONDING TO PATIENT¶S

FEELINGS

Assessment of patient·s response

A. Acceptable vs unacceptable behaviour

B. Adaptive vs maladaptive reactionC. Fixable vs unf ixable problem




FEELINGS

A.Acceptable vs unacceptable behaviour

´ Ground rules for assessment of unacceptable

behaviour

«Give as much latitude as you can

« Try to stay calm, and speak softly

«Be g entle while you·re being f irm




FEELINGS

Adaptive Maladaptive

Humor Guilt

Denial Pathological denial

Abstract ang er

Ang er ag ainst disease Ang er ag ainst helpers

Crying Collapse

Fear Anxiety

Fulf illing an ambition The impossible ¶quest·

Realistic hope Unrealistic hope

Sexual drive Despair

Barg aining Manipulation




FEELINGS

C.Fixable vs unf ixable problem

´ If one particular response is not helping the

patient, can we intervene to reduce the distress

or not?

´ If we cannot intervene successf ully ourselves,

are there other professionals who could

improve the situation?

´ Do not try to f ix the unf ixable ² accept it.




FEELINGS

C. Fixable vs unf ixable problem

Diagnostic signs:

1. Insight: Does the patient have any knowledg e of the

way in which the behaviour is worsening the situation? Does the patient acknowledg e the problem if youpoint it out?

2. Motivation: Does the patient have any desire to alter

the behaviour?3. Neg otiating abilities: Are there steps that the patient

is able to take to modif y the behaviour pattern?




FEELINGS

C. Fixable vs unf ixable problem

´ If you think a problem is unf ixable but cannot

be sure, ask someone else.

« E.g ., psychology department, psychotherapist, social worker, other physician, nurse who knows the patient, chaplain or a relatively family member

´ Second opinion gives new perspective on the situation -> signif icantly alter plan of

manag ement




FEELINGS

Conf licts ² some g eneral hints on coping

´ ´In the event of a f ire ² stay calm.µ

´

The more diff icult the situation is, the more important it is to stick to the basic rules.

« Prepare ² question ² listen ² hear ² respond

« Six steps of breaking bad news




FEELINGS

1. Try to Take One Step Back

« The emotional involvement of the professional is

likely to cloud judg ement and to inf luence his/her

ability to make sound clinical decisions.

« Take one step back during an emotional conf lict

means trying to assess the patient·s emotional

stance, and your own.




FEELINGS

2. Describe Your own Emotions ² Don·t DisplayThem

´ ´Look, I·ve already told you four times, there·s not a

shred of evidence that diet makes any difference ²forget it and eat what you like!µ ² display of emotion

´ ´ I·m really sorry to sound impatient about this, Mrs.Brown, but I·ve told you the facts as we know them

today ² vitamins don·t affect the outcome of breastcancer. I·m afraid I cannot go on repeating it, butthose are the facts.µ ² describe of emotion




FEELINGS

3. Try Not to be Pushed too Far from the Truth

´ We may be tempted to respond to an over-

anxious patient with over-reassurance and

over-optimism.

´ In the event of conf lict, try to act (on clinical

judg ement) and not to react (to the conf lict).



STEP 6 PLANNING AND FOLLOW-

THROUGH

´ Org anising and planning

´ Offer clinical perspective and guidance

´ 5 steps:

´ Demonstrate understanding of patient·s problem list

´ Indicate that you can distinguish the f ixable from the unf ixable

´ Make a plan or strategy and explain it

« Preparing for the worst and hoping for the best

´ Identif y coping strategies of patient and reinforce them´ Identif y other sources of support for the patient and

Incorporate them




THROUGH

´ Making a contract and following through

´ Show the patient you have been listening and have picked up the main concerns and issues

´ Do not have to provide all solutions to all problems at the f irst discussion

´ Give patient an idea of sequential decision-tree, or alg orithm

´ E.g.: We·ll redo chest X-ray at the time of each treatment,and if there is no improvement after two courses, thenwe·ll stop and make a new plan.




THROUGH

´ Make a contract for the f uture

´ At the conclusion of the interview patient may

be left with the feeling that there is no f uture

and may be glad to hear that there is one.

´ If not intending to see the patient ag ain (for

tertiary referral centre), then indicate lines of

communication.



´The task of breaking bad news is a testing

g round for the entire rang e of our professional

skills and abilities.

If we do it badly, the patients or family

members may never forgive us;

If we do it well, they will never forg et us.µ

- Robert Buckman



Thank You

Breaking Bad News – A Six-step Protocol

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