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BREAKIG BAD NEWS

Dr Dibu Sam07-09-2015

A DEFINITION OF BAD NEWS

“any information which adversely and seriously affects an individual’s view of

his or her future”

“eye of the beholder,”

Giving Bad News

• Is an important communication skill

• Is a complex communication task which includes:-• Responding to patients’ emotional reactions• Involving the patient in decision making• Dealing with the stress created• Involvement of multiple family members• How to give hope when situation is bleak

Giving Bad News

• It is a difficult task because:-• It is frequent and stressful • Most patients want to know the truth• We are required to tell them what they desire• The truth is unpleasant and will upset them• We are anxious and fear negative evaluation

Giving Bad News

• We feel a burden of responsibility for the news• The recipient is already distressed• We don’t want to make things worse• We want to be honest but not

destroy hope• We are therefore reluctant to deliver bad news

Giving Bad News

•The Good 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.

Giving Bad News

•The Good News (continued)

• 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.

Giving Bad News

•What do we want to achieve?

• To gather information from the patient.• To provide intelligible information in accordance

with their needs and desires.• To support them to reduce the emotional impact

and isolation experienced.• To develop a plan for management with the input

and cooperation of the patient.

Doctors need to polish soft skills to Deliver “Tough” Bad

News

Various Strategies BBN

ABCDE

• A- ADVANCE PREPARATION• B- BUILD ENVIRONMENT / RELATIONSHIP • C- COMMUNICATION WELL • D- DEAL WITH REACTION• E- ENCOURAGE & VALIDATE EMOTIONS

Various Strategies BBN

BLAT

• BUILD TRUST • LISTEN • APOLOGIZE• THANKS

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• Plan, Privacy, Significant others• Sitting, Non Verbal Behaviour• Time

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 2: P

Questions that u can ask:

could you tell me what’s happened so far?Do you have any ideas as to what problem might be?Is there anything you have been worried about ?

SPIKES Step 3: I

• Obtaining the patient’s INVITATION

• Gather before you give• How much does the patient want to know?• Coping strategy?

• Check if the patient• Wants to know the result now.• Would like a family member to be present.

SPIKES Step 4: K Giving KNOWLEDGE and information to the patient•Build up to the result-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

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.• I see that…. I appreciate ….. • Wait for response• Clarify

SPIKES Step 5: E

• Acknowledge and reflect their emotions back ( including body language)

• Don’t try to solve their problem or reassure them, just listen and summarise/bounce their concerns back to them and expand on them . ( it shows you are listening and conveys empathy)

• If there is a lot of silence, you can ask about their emotions.

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

Obstetrics

• Prenatal diagnosis and anticipation of outcome have become the accepted norms.

• Obstetrician and patient have been placed in the unique opportunity of participating to predict outcome.

• Given the responsibilities for choosing future management.

Duration of scanning:

• Diagnosis often can be made within seconds

• Patient is politely informed that a thorough ultrasound scan was performed if, following the examination, a diagnosis of intrauterine fetal demise or fetal anomaly is made.

Acknowledge the event:

• Most physicians struggle with that first descriptive statement.

• "I am sorry but we have detected a major problem which i need to tell you about."

• If diagnosis is clear ……….

• Show ultrasound screen to parents if they wish:

• Remain with the couple:

• Allow parents private time

• The couple then is allowed to return home.

First trimester miscarriage:

• "Blighted ovum", "vanishing twin", or "passage of tissue“ -- often are viewed by patients as insensitive statements which deny the existence of the early pregnancy.

• Many couples select names for their babies in the first trimester

• Women are being provided a view of their baby as early as 7 or 8 weeks.

• Same impact as a late pregnancy loss.

First trimester miscarriage:

• In some ways the loss is even more complicated

• Husbands • Early pregnancy sensations of nauseousness and breast tenderness as proof of the existence of the pregnancy• Woman assumes complete responsibility for the outcome and may out of guilt attribute the miscarriage to such activities as having a glass of wine, or having intercourse, as her way of assigning cause and effect.

• Blighted ovum:• Acknowledge to the couple that the pregnancy existed and was not in• Fact a nonpregnancy.

A second trimester ultrasound diagnosis of intrauterine fetal death or fetal structural anomalies incapable of life:

• Most intense and most devastating moment for this couple.

• Even though death occurs later, the moment of loss…………………

• Couples have been forced to make choices regarding management.

> 24 weeks

• Allow labor and vaginal delivery to occur unmonitored.

• Perform a cesarean section realizing that it would not change the outcome.

• Perform tests of fetal well-being in the rare chance that our diagnosis is incorrect and perform a cesarean section if fetal distress is encountered.

• Vaginal delivery under fetal heart rate monitoring with cesarean section as an option if fetal distress is encountered.

Managing Patients In The HospitalFollowing A Pregnancy Loss• Anesthesia for labor must be planned

which does not sedate with the intent to allow the patient to experience the birth, but also the grief which accompanies that birth.

• Discomfort experienced by the patient, both physically and emotionally, often drives care providers to withdraw, leaving the patient feeling isolated and lonely.

Many emotions surface as the patient and her partner experience labor for a late pregnancy loss.• Labor as a painful experience without reward.

• Appearance of her newborn following delivery.

• Feel guilt.

• Anger, either at herself or as a protective shield against those around her.

• Loneliness and isolation as the sensation of "why me?" Surfaces.

• Interpret this outcome as punishment for activities that they have indulged in during their life.

MANAGING DELIVERY OF A STILLBIRTH• Care provider must be sensitive to the unique nature of this

birth.

• Dead baby should be placed in a blanket immediately after delivery.

• Stillborn baby should never be delivered into a bucket or pan or left straddling the delivery table.

• Initial encounter with their dead baby.

• Care providers also must remember during this period that the woman and her family are observing them as they interact with the dead baby.

POSTPARTUM MANAGEMENT

• Must be consistent with that care provided during labor and delivery.

• NAMING THE BABY

TAKING A PICTURE

• Photos of the dead baby provide an important foundation for resolving grief.

• Counselling session

OBTAINING AN AUTOPSY

• Often provides answers to "Why did it happen?“ and "Will it happen again?“

• Initially often refuses.

• Impression that disfiguring procedure that will not provide new information.

MANAGEMENT OF THE PATIENT AFTER DISCHARGE FROM THE HOSPITALOne week

• Most traumatic is the first night in which the family returned home.• Cultural change– nursery, cloths, • Support system• Misconceptions• Six weeks – family struggles unaided• Important foundation for future counselling sessions• Care provider is not disinterested, or uncomfortable with conversations about the dead baby.

When care providers fail to provide these answers, well intentioned family

members, friends, or lawyers can find answers

DIFFERENCES BETWEEN MEN AND WOMEN• Respond differently to pregnancy losses

• Common for a brief period of days or even weeks following a loss

• Men tend to recover more quickly

• Women, on the other hand, will recover more slowly with specific setbacks.

Get all the FACTSExpress EMPATHY and EDUCATE

Search for sources of ANGERHave the patient RECITE back to you her

understanding of your explanation.Evaluate the EXTENDED family response.

DOCUMENT the conversation.

“We just wanted to see if you would be

honest.”

Although ultrasound technology in many ways

has redefined obstetrics, the physician's rapport with his

patient will never be displaced as the

cornerstone of medical care.

Having a conversation with a family after the successful birth

of a healthy newborn is easy. Offering a conversation with a

family after an adverse unanticipated event draws on the most noble resources in

medicine, having compassion.

References

• SPIKES – A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. WF Baile, R Buckman et al.

• The Oncologist 2000;5:302-311

• What Do I Say and How Do I Say It? Communicating Intended and Unintended Events In Obstetrics Editors James Woods, Fay Rosovsky Jossy Bass, San Francisco, Calif [April 2003]

• STRATEGIES FOR COMMUNICATING BAD NEWS IN OBSTETRICS James R. Woods, Jr., M.D. Henry A. Thiede Professor and Chair Department of Obstetrics and Gynecology University of Rochester School of Medicine and Dentistry Rochester, New York