Breaking Bad News Ahmer A. Karimuddin September 5 th, 2003.

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Breaking Bad News Breaking Bad News Ahmer A. Karimuddin Ahmer A. Karimuddin September 5 September 5 th th , 2003 , 2003

Transcript of Breaking Bad News Ahmer A. Karimuddin September 5 th, 2003.

Page 1: Breaking Bad News Ahmer A. Karimuddin September 5 th, 2003.

Breaking Bad NewsBreaking Bad News

Ahmer A. KarimuddinAhmer A. Karimuddin

September 5September 5thth, 2003, 2003

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IntroductionIntroduction

ConceptsConcepts

Doctor’s DilemmaDoctor’s Dilemma

Medical EducationMedical Education

Leading upLeading up

InterviewInterview

Cultural FactorsCultural Factors

PrognosisPrognosis

Sudden Death Sudden Death DebriefingDebriefing

SupportSupport

Anger & BlameAnger & Blame

Depression, Despair Depression, Despair & Hope& Hope

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IntroductionIntroduction

Yet the first bringer of unwelcome Yet the first bringer of unwelcome newsnews

Hath but a losing office, and his tongueHath but a losing office, and his tongue

Sounds ever after as a sullen bellSounds ever after as a sullen bell

Remembered knolling a departing Remembered knolling a departing friendfriend

King Henry IV, Part 2, IiKing Henry IV, Part 2, Ii

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IntroductionIntroduction

Physician Patient relationshipPhysician Patient relationship

Breaking bad newsBreaking bad news Common interventionCommon intervention Testing groundTesting ground

Consequences are immenseConsequences are immense

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ConceptsConcepts

““Perception of news as good or bad is a Perception of news as good or bad is a belief, value judgment or affective belief, value judgment or affective response from the provider or receiver of response from the provider or receiver of the information, in a given context” the information, in a given context”

(Bor, et al., 1996)(Bor, et al., 1996)

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ConceptsConcepts

Patient must make value judgmentPatient must make value judgment

Indirect pressureIndirect pressure

Patient autonomy?Patient autonomy?

Never assume or anticipate a reactionNever assume or anticipate a reaction

Bad news does not equal deathBad news does not equal death Change in quality of lifeChange in quality of life Ending of hopeEnding of hope

Cannot withhold informationCannot withhold information

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Doctor’s DilemmaDoctor’s Dilemma

A lack of skills in what to say and how to A lack of skills in what to say and how to say itsay itFear of blameFear of blamePatient emotionPatient emotionPersonal emotionPersonal emotion Fear of death, illness, mortalityFear of death, illness, mortality HelplessnessHelplessness

Premature advice or reassurance is Premature advice or reassurance is implied insensitivity or rejectionimplied insensitivity or rejection

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Doctor’s DilemmaDoctor’s Dilemma

Dosanjh et al. (Med. Educ. 2001)Dosanjh et al. (Med. Educ. 2001) Significant barriers exist to breaking bad newsSignificant barriers exist to breaking bad news Lack of emotional supportLack of emotional support Available timeAvailable time Personal fears about the delivery processPersonal fears about the delivery process Lack of communication skillsLack of communication skills Lack of feedback on prior attemptsLack of feedback on prior attempts Personal feelings, after eventPersonal feelings, after event

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MethodsMethods

1.1. Directly, bluntly and with insensitivityDirectly, bluntly and with insensitivity

2.2. Kindly, sadly without overt support and Kindly, sadly without overt support and encouragementencouragement

3.3. Positive with understanding, empathy, Positive with understanding, empathy, reassurance and flexibilityreassurance and flexibility

Patients overwhelmingly prefer which Patients overwhelmingly prefer which option?option?Brevin et al. (Lancet, 1999)Brevin et al. (Lancet, 1999)

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Medical EducationMedical Education

Dent et al. (BMJ, 1990)Dent et al. (BMJ, 1990) 75% of housestaff never received adequate training75% of housestaff never received adequate training

General lack of evidence in the literatureGeneral lack of evidence in the literature

Campbell et al. (Behav. Med, 1998)Campbell et al. (Behav. Med, 1998) 35% of residents feel competent in breaking bad 35% of residents feel competent in breaking bad

newsnews

Girgis et al. (NZJS, 1999)Girgis et al. (NZJS, 1999) 80% of surgeons feel breaking bad news well is as 80% of surgeons feel breaking bad news well is as

important as technical surgical skillsimportant as technical surgical skills

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Medical EducationMedical Education

Multiple studies demonstrate education Multiple studies demonstrate education works now and later:works now and later: Undergraduate trainingUndergraduate training Video & Audio tapingVideo & Audio taping FeedbackFeedback

Gordon et al. (AGIM, 1993)Gordon et al. (AGIM, 1993) Communication and detection skills Communication and detection skills

deteriorate during internshipdeteriorate during internship

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Medical EducationMedical Education

Observe & practice new behavioursObserve & practice new behaviours

Structured experiencesStructured experiences

Systematic feedbackSystematic feedback

Goal oriented evaluationGoal oriented evaluation

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Medical EducationMedical Education

Methods have no impact on long term patient Methods have no impact on long term patient adjustmentadjustmentDisclosure brings:Disclosure brings: GratitudeGratitude Peace of mindPeace of mind Positive attitudePositive attitude Reduced anxietyReduced anxiety AdjustmentAdjustment

Tactics should mainly be employed to ensure Tactics should mainly be employed to ensure physician comfort and ability (Persaud, 1993)physician comfort and ability (Persaud, 1993)

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Leading upLeading up

Know the history wellKnow the history wellAcknowledge social circumstancesAcknowledge social circumstancesUnderstand the prognosisUnderstand the prognosisQuality of life issuesQuality of life issuesPrivacyPrivacyComfortable environmentComfortable environmentTimeTimeAvailability of a person of choiceAvailability of a person of choiceBE CERTAINBE CERTAIN

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InterviewInterview

Simple clear languageSimple clear language

Minimal to no medical jargonMinimal to no medical jargon

Match verbal and emotional cuesMatch verbal and emotional cues

Team approachTeam approach

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InterviewInterview

““I am sorry, I have some bad news to tell I am sorry, I have some bad news to tell you”you”

Discuss reason for being hereDiscuss reason for being here

Tell patient firstTell patient first

Small dosesSmall doses

Ask if patient understands frequentlyAsk if patient understands frequently

Repeat and summarizeRepeat and summarize

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InterviewInterview

Alllow time to assimilateAlllow time to assimilate

““How do you feel?”How do you feel?”

List of questionsList of questions

InformationInformation

HopeHope Positive approachPositive approach Sincere, controlled optimismSincere, controlled optimism Hope leads to a will to live, does it increase longevity?Hope leads to a will to live, does it increase longevity?

Probabilities & AbsolutesProbabilities & Absolutes

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ReactionReaction

Most distressing aspect for physicianMost distressing aspect for physician

Outpouring of emotionOutpouring of emotion

SilenceSilence

Inappropriate responseInappropriate response

Do not break the silenceDo not break the silence

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ReactionReaction

QuestioningQuestioningDenialDenial Inability to copeInability to cope RepeatRepeat Ask to explainAsk to explain

AngerAnger DefensivenessDefensiveness

AcceptanceAcceptance ““I notice you are taking the news calmly, many people I notice you are taking the news calmly, many people

react differently”react differently”

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ReactionReaction

LonelinessLonelinessBurdenBurden To familyTo family To systemTo system

Manner of dyingManner of dying Suffocation, choking, bleedingSuffocation, choking, bleeding Loneliness, poveryLoneliness, povery

AbandonmentAbandonmentConfirmation of suspicionConfirmation of suspicion 88% of patients suspect bad news before they are 88% of patients suspect bad news before they are

toldtold

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Cultural FactorsCultural Factors

English speaking countriesEnglish speaking countries Full disclosureFull disclosure

Asian and Hispanic communitiesAsian and Hispanic communities Family centered model of decision makingFamily centered model of decision making

Patients should be asked if they wish to Patients should be asked if they wish to delegate treatment decisions to families or delegate treatment decisions to families or be informed of full storybe informed of full story

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““How long do I have?”How long do I have?”

Productive quality of lifeProductive quality of life

Expected survival – Admission of failureExpected survival – Admission of failure

Gloomy prognosis may lead patient elsewhereGloomy prognosis may lead patient elsewhere

Process of dyingProcess of dying Avoid detailsAvoid details

Ensure patient wants to know expected survivalEnsure patient wants to know expected survival

Be honest, not overly optimistic or pessimisticBe honest, not overly optimistic or pessimistic

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Sudden DeathSudden Death

Death = ShockDeath = Shock

Over the telephone?Over the telephone? 64% NO64% NO 26% YES26% YES

Privacy with other staff membersPrivacy with other staff members

Medical trauma to Family traumaMedical trauma to Family trauma

Feelings of failure, inadequacy, guiltFeelings of failure, inadequacy, guilt

Contradict self recriminationContradict self recrimination

Allow silence and emotionAllow silence and emotion

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Sudden DeathSudden Death

ReviewReview

PrivacyPrivacy

ViewingViewing Avoid disturbing imagesAvoid disturbing images

Autopsy?Autopsy? SensitivitySensitivity TimeTime

Broken Heart SyndromeBroken Heart Syndrome

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DebriefingDebriefing

Caregiver reactionsCaregiver reactions Sadness, anger, guilt, self reproachSadness, anger, guilt, self reproach AvoidanceAvoidance OveractivityOveractivity

Grief of rescuersGrief of rescuersCritical Incident debriefingCritical Incident debriefing Critical responsibilityCritical responsibility Health educationHealth education

Should occur after every CPR attemptShould occur after every CPR attempt

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Support for Patient & FamiliesSupport for Patient & Families

SupportSupport Time spent listening and acknowledging Time spent listening and acknowledging

emotionsemotions Frame their fearsFrame their fears Answer their questionsAnswer their questions Acceptance vs. denialAcceptance vs. denial

Denial of diagnosisDenial of diagnosis

Denial of implicationsDenial of implications

Denial of deathDenial of death

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Anger & BlameAnger & Blame

Overt vs. subtleOvert vs. subtleAgainst health care professionalsAgainst health care professionals OverwhelmingOverwhelming Negative responseNegative response

Against disease, loss of control, God, self, Against disease, loss of control, God, self, friends, familyfriends, familyIdentify the cause of the angerIdentify the cause of the anger Fear?Fear?

Guilt = problemGuilt = problem

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Depression, Despair & HopeDepression, Despair & Hope

DepressionDepression IdentifyIdentify DiagnoseDiagnose TreatTreat

SuicidalitySuicidality

Hope vs. despairHope vs. despair Undeliverable promisesUndeliverable promises AbandonmentAbandonment

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ConclusionsConclusions

Difficult taskDifficult task

Part of patient carePart of patient care

Patients are dissatisfied with the quality of Patients are dissatisfied with the quality of informationinformation

Clinicians are uncomfortable with Clinicians are uncomfortable with providing informationproviding information

Lack of empirical dataLack of empirical data

Medical educationMedical education