Breaking Bad News. Objectives: Students will: Recognize essential principles of breaking bad news....

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Transcript of Breaking Bad News. Objectives: Students will: Recognize essential principles of breaking bad news....

  • Breaking Bad News

  • Objectives:Students will:

    Recognize essential principles of breaking bad news.Identify pitfalls in delivering breaking bad news.Apply skills of breaking bad news in a simulated situation.

  • THE BAD NEWS ABOUT BREAKING BAD

    NEWS IS THAT BAD NEWS IS

    BAD NEWS

  • DEFINITION OF BAD NEWS

  • Bad News

    any news that drastically and negatively alters the patients view of their future

    Buckman R. BMJ1984

  • Bad News

    any news that drastically and negatively alters the patients view of their future

    Buckman R. BMJ 1984

  • Bad News

    any news that drastically and negatively alters the patients view of their future

    Buckman R. BMJ 1984

  • It alters ones self-image : I left my house as one person & came home another.Professional cyclist Lance Armstrongs recollection

  • Examples of Conditions Requiring Breaking of Bad News ???!!!!

  • Examples of Conditions Requiring Breaking of Bad News

    Cancer related diagnoses

    Intra uterine foetal demise

    Life long illness: Diabetes, Epilepsy

    Poor prognosis related to chronic diseases: loss of independence

  • Examples of Conditions Requiring Breaking of Bad News(cont)Informing parents about their childs serious mental/physical handicap

    Giving diagnosis of serious sexually transmitted disease catastrophic psychosocial results

    Non clinical situations like giving feedback to poorly performing trainees or colleagues

  • The Good News! about Bad News!!!

    Using a plan for determining the patients 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.

  • The Good News! about Bad News!!!(cont)It may also encourage patients to participate in difficult treatment decisionsThose who do so have a better quality of lifeClinicians who are comfortable with giving bad news are subject to less stress and burnout.

  • : :(( : ))

  • Do You Tell??

  • Do You Tell?

    Recent studies have shown that:Patients generally (50-90%) desire full & frank disclosure, though a sizeable minority still may not want the full disclosure.(Ley p. Giving information to patients. New York: Wiley, 1982 )

    So the issue is not do you?Issue is how?

  • Do You Tell?In reality, patients who are dying, know they are dyingThey want confirmation of their statusThey want a time frameYOU would want a time frame when your time approaches

  • Is this Difficult to break the bad news? WHY?

  • Is this Difficult to break the bad news?

    It is referred by some physicians like dropping the bomb Baile W F, oncologist 2000

  • Why is this Difficult?

    Social factors

    Our society values youth, health, wealthElderly, sick and poor are marginalizedSick and dying have less social value

  • Why is this Difficult?

    Physician factors

    Fear of causing painUncomfortable in uncomfortable situationsSympathetic pain due to patients distress

  • Why is this Difficult?

    Fear of being blamedPhysicians have authority, control, privilege and status When medical care fails patient its physicians faultblame the messenger

  • Why is this Difficult?

    Fear of therapeutic failureMedical system reinforces idea that poor outcome and death are failures of systemand by extension, our failureall disease is fixablebetter living through chemistryWe are trained to feel this way; if only

  • Why is this Difficult?

    Fear of medico-legal system

    Everyone has right to be cured;If no cure happens, someone is to blame

  • Why is this Difficult?

    Fear of not knowing

    we dont do what we dont do wellGood communication is a skill that is not highly valued, therefore not taught

  • Why is this Difficult?

    Fear of eliciting reactiondont do anything unless you know what to do if it goes wrongNot trained to handle reactionsNot trained to allow emotion to come out

  • Why is this Difficult?

    Fear of saying I dont knowWe are never rewarded for lack of knowledgeCant know or control everything

  • Why is this Difficult?

    Fear of expressing emotionsViewed as unprofessionalSuppressing emotions increases distancebetween ourselves and patientsRabow & Mcphee (West J. Med 1999) described: Clinicians focus often on relieving patients bodily pain, less often on their emotional distress & seldom on their suffering.

  • Why is this Difficult?

    Ambiguity of Im sorryTwo meaningsIm sorry for youIm sorry I did thisEasily misinterpreted

  • Why is this Difficult?

    Fear of ones own illness and death

    Cannot be honest with the dying unless you accept you will die

  • So How Do We Do This??

  • Never, never, never, ever

    NEVER assume

  • If you need to know somethingIf you want to know something

  • If you need to know somethingIf you want to know something

    ASK!!

  • THINGS GO WRONG WHEN:

    * WE TRY TO ESCAPE * WE REACT IN ANGER

    * WE DILUTE THE AGENDA

  • THINGS GO WRONG WHEN: WE TRY TO ESCAPE: INAPPROPRIATE DELEGATIONDISTRACTIONFRONTAL ATTACKINTELLECTUALIZATIONMINIMIZATIONEMPTY REASSURANCE

  • THINGS GO WRONG WHEN:WE REACT IN ANGER: TO DENIALTO IDEALIZATIONTO REHEARSAL OF THE STORYTO UNREASONABLE DEMANDSTO ANGER AND BLAME

  • THINGS GO WRONG WHEN:WHEN WE DILUTE THE AGENDA:

    BILLING PRACTICAL ARRANGEMENTS

    REQUEST FOR POST MORTEM

  • The SPIKES ProtocolSETTING UP the interviewAssessing patients PERCEPTIONObtaining the patients INVITATIONGiving KNOWLEDGE and informationAddressing the patients EMOTIONSSTRATEGY and SUMMARY

  • SPIKES Step 1: S - SETTING UP the interviewPreparation Preparation- PreparationAlways in person, face to face NEVER on telephonePlan, arrange for privacy, involve significant othersSitting down, Non Verbal BehaviourManage time constraints and interruptions

  • SPIKESStep 2: P Assessing The PATIENTS PERCEPTION

    Gather before you GivePatients knowledge, expectations and hopesWhat do they understand about the situation? Unrealistic expectations?What is their state of mind? Hopes?Opportunity to correct misinformation and tailor your information

  • SPIKESStep 3: I Obtaining the patients INVITATIONGather before you giveHow much does the patient want to know? Coping strategy?Answer questions, offer to speak to another

  • SPIKESStep 4: K Giving KNOWLEDGE and information to the patientWarning shotUse simple language, no jargon, Vocabulary and comprehension of patientSmall chunks, avoid detail unless requestedPause, allow information to sink inWait for response before continuingCheck understandingCheck impact

  • SPIKESStep 5: E Addressing the patients EMOTIONS with empathic responsesShock, isolation, griefSilence, disbelief, crying, denial, angerObserve patients responses and identify emotionsOffer empathic responses

  • Emotions of the patientRespond to patients emotions with empathyOften shock, isolation, disbelief, grief or angerObserve for emotion on patients partIdentify the emotion. Identify the reason for the emotionConnect with the patient

  • Emotions of the patientExploratory questionsHow do you mean?Tell me more about itYou said it frightens youYou said you were concerned about your children, tell me moreCould you tell me what you are worried about?

  • Emotions of the patientValidating responsesI can understand how you felt that wayI guess anyone might have the same reactionYou are perfectly correct to think that wayYour understanding of the reason for the tests is very goodMany other patients have had a similar experience

  • Emotions of the patientDoctor: Im sorry to say that the X-ray shows that the chemotherapy is not working [pause]. Unfortunately, the tumor has grown somewhatPatient: Ive been afraid of this! [Cries]Doctor: [Moves his chair closer, offers the patient a tissue and pauses,] I know that this isnt what you wanted to hear. I wish the news were better

  • What is Empathy? The capacity to recognise emotions that are being felt by another person.

  • Empathic ResponsesAn indication to the patient that you recognise what they are feeling (and why)Verbal and Non verbalOften associated with the impact of the news rather than the understanding.Wait for responseClarify

  • Emotions of the patientEmpathic statements

    I can see how upsetting this is to youI can tell you were not expecting to hear thisI know this is not good news for youIm sorry to have to tell you thisThis is very difficult for me alsoI was also hoping for a better result

  • SPIKESStep 6: S STRATEGY and SUMMARYAre they ready?Involve the patient in the decision makingCheck understandingClarify patients goalsSummarise Contract for future

  • REVISION OF THE 6 STEPS

  • Six Step Protocol-arrange physical context-find out what patient knows-find out what patient wants to know-share information-respond to patients feelings-plan follow-through

  • Arrange physical contextAlways in person, face to face NEVER on telephoneAssure privacyVerify who is presentVerify who should be presentASK

  • Arrange physical contextRemove physical barriersSit downpatient-physician eyes at same levelappear relaxed, not casual (avoid open 4)Touch patient (appropriately)above the waist, handshake, shoulder

  • Find out what patient knowsNot just knows, but underst