Breaking Bad News.ppt Breaking bad news in healthcare setting Breaking bad news in healthcare...

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Transcript of Breaking Bad News.ppt Breaking bad news in healthcare setting Breaking bad news in healthcare...

  • Bad News Bad News –– What is it?What is it?

    Who breaks it?Who breaks it?

    Who teaches it?Who teaches it?

    Mandy BarnettMandy Barnett

    Associate Clinical Professor in Medical EducationAssociate Clinical Professor in Medical Education Honorary Consultant in Palliative MedicineHonorary Consultant in Palliative Medicine

  • Breaking bad news in healthcare setting Breaking bad news in healthcare setting –– definition (Ptacek & Eberhardt, 1996)definition (Ptacek & Eberhardt, 1996)

    �� “..pertaining to situations where there is either a “..pertaining to situations where there is either a feeling of no hope, a threat to a person's mental or feeling of no hope, a threat to a person's mental or physical well being, a risk of upsetting an established physical well being, a risk of upsetting an established lifestyle, or where a message is given which conveys lifestyle, or where a message is given which conveys to an individual fewer choices in his or her life”. to an individual fewer choices in his or her life”. to an individual fewer choices in his or her life”. to an individual fewer choices in his or her life”.

    �� It is information that “..results in a cognitive, It is information that “..results in a cognitive, behavioural or emotional deficit in the person behavioural or emotional deficit in the person receiving the news that persists for some time after receiving the news that persists for some time after the news is received.”the news is received.”

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  • Who breaks bad news about what? DoctorsWho breaks bad news about what? Doctors

    �� GPs GPs –– often broach initial suspicions of lifeoften broach initial suspicions of life-- threatening/limiting diagnosisthreatening/limiting diagnosis

    �� GPs GPs –– discuss diagnosis of chronic conditions discuss diagnosis of chronic conditions –– need for lifelong treatment need for lifelong treatment –– limitations on limitations on lifestylelifestylelifestylelifestyle

    �� Hospital doctors Hospital doctors –– make original diagnosis of make original diagnosis of many serious illnesses many serious illnesses –– most likely to break most likely to break initial bad news initial bad news

    �� Oncologists Oncologists –– recurrence/progression of cancer recurrence/progression of cancer –– limitations/end of treatment optionslimitations/end of treatment options

    �� Palliative medicine Palliative medicine –– end of active treatment end of active treatment –– limitations of palliative treatment limitations of palliative treatment -- end of lifeend of life

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  • Who breaks bad news about what? Who breaks bad news about what?

    NursesNurses

    �� Specialist nursesSpecialist nurses �� follow up and expand on initial diagnostic informationfollow up and expand on initial diagnostic information

    �� discussion of treatment options e.g. stoma carediscussion of treatment options e.g. stoma care

    discussion of end of life carediscussion of end of life care�� discussion of end of life carediscussion of end of life care

    �� practical limitations on preferred place of carepractical limitations on preferred place of care

    �� Health visitors Health visitors �� child development issues, screening for rare child development issues, screening for rare

    conditionsconditions

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  • Who breaks bad news about what? AHPsWho breaks bad news about what? AHPs

    �� Clinical/developmental psychologistsClinical/developmental psychologists �� Diagnosis of major psychiatric disorderDiagnosis of major psychiatric disorder

    �� Diagnosis of learning disabilityDiagnosis of learning disability

    �� Therapeutic radiographersTherapeutic radiographers �� Patient too ill to receive palliative treatmentPatient too ill to receive palliative treatment

    �� Dieticians Dieticians �� No improvement in cancer No improvement in cancer cachexiacachexia

    �� Diagnostic Diagnostic ultrasonographersultrasonographers�� Diagnostic Diagnostic ultrasonographersultrasonographers �� Abnormal antenatal screening findingsAbnormal antenatal screening findings

    �� PhysiotherapistsPhysiotherapists �� Patient recovery e.g. swallowing after strokePatient recovery e.g. swallowing after stroke

    �� Occupational therapistsOccupational therapists �� Patient safety for dischargePatient safety for discharge

    �� Genetic counsellorsGenetic counsellors �� Results of genetic screeningResults of genetic screening

    �� Social workersSocial workers �� Child protection issuesChild protection issues

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  • Evidence on communication and Evidence on communication and

    education in palliative care education in palliative care -- doctorsdoctors

    �� Junior medical staff feel prepared for information giving Junior medical staff feel prepared for information giving but not for dealing with psychological distress but not for dealing with psychological distress (Cantwell & (Cantwell & Ramirez, 1997)Ramirez, 1997)

    �� General practitioners feel confident in symptom control General practitioners feel confident in symptom control but not in assessing psychological distress or but not in assessing psychological distress or but not in assessing psychological distress or but not in assessing psychological distress or bereavement followbereavement follow--up up (Lloyd(Lloyd--Williams & LloydWilliams & Lloyd--Williams, 1996, Williams, 1996, Low et al, 2006)Low et al, 2006)

    �� Consultants working in oncology who have not received Consultants working in oncology who have not received communication skills training are more likely to communication skills training are more likely to experience burnexperience burn--out out (Graham & Ramirez, 2002)(Graham & Ramirez, 2002)

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  • Evidence on communication and education Evidence on communication and education in palliative care in palliative care –– nurses and AHPnurses and AHP

    NursesNurses

    �� Nursing education has minimal content on palliative/end Nursing education has minimal content on palliative/end of life care of life care (Lloyd(Lloyd--Williams & Field, 2002)Williams & Field, 2002)

    �� Specialist nurses still use blocking behaviours to avoid Specialist nurses still use blocking behaviours to avoid discussing patients emotional concernsdiscussing patients emotional concerns

    �� Courses aimed at senior nurses are effective in changing Courses aimed at senior nurses are effective in changing blocking behaviours blocking behaviours (Wilkinson et al, 1999)(Wilkinson et al, 1999)

    AHPsAHPs

    �� Little evidence for educational approaches to these Little evidence for educational approaches to these groupsgroups

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  • Breaking Bad News ProjectBreaking Bad News Project innovative training for hospital consultantsinnovative training for hospital consultants 20002000--20022002

    1-day skills workshop

    Casenote audit

    2-day experiential workshop

    Patient Interviews

    Self-directed learning

    Consultant questionnaire

    Course Self-evaluation

    Pre-intervention evaluation

    -Simulated consultation

    -PC & WERD

    -Situation confidence

    Consultant questionnaire

    1-day skills workshop

    Post-intervention evaluation

    -Simulated consultation

    -PC & WERD

    -Situation confidence

    2-day experiential workshop Self-directed learning Course Self-evaluation

    Immediate post-workshop

    Six-month post-workshop

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  • Doctors’ QuestionnaireDoctors’ Questionnaire

    MethodsMethods

    �� 285 consultants285 consultants

    �� 30 clinical specialties30 clinical specialties

    �� Postal questionnairePostal questionnaire

    ResultsResults

    �� Response rate 54% (155)Response rate 54% (155)

    �� 29/30 specialties29/30 specialties

    �� Female 15%Female 15%

    Age 32Age 32--69 (m 69 (m 46, sd7) 46, sd7) �� Postal questionnairePostal questionnaire

    �� DemographicsDemographics

    �� Previous training in Previous training in communication skillscommunication skills

    �� Current experience in Current experience in breaking bad newsbreaking bad news

    �� McMichaelMcMichael--Barnett Attitude Barnett Attitude Measures (1994)Measures (1994)

    �� Age 32Age 32--69 (m 69 (m 46, sd7) 46, sd7)

    �� Time since qualifying: Time since qualifying:

    �� 99--42 years (m22, sd7)42 years (m22, sd7)

    �� Time as a consultant: Time as a consultant:

    ��

  • Participation by specialityParticipation by speciality

    Department Approached Responded Percentage

    Maxillo Facial 3 3 100.00

    Palliative Medicine 1 1 100.00

    Plastic Surgery 4 4 100.00

    Rehabilitation 1 1 100.00

    Accident and Emergency 12 10 83.33

    Dermatology 6 5 83.33

    Respiratory Medicine 5 4 80.00

    Haematology 6 4 66.67

    Neurology 3 2 66.67

    Neurosurgery 3 2 66.67

    Paediatrics 14 9 64.29

    Ophthalmology 8 5 62.50

    Cardiothoracic Surgery 5 3 60.00

    Genito-Urinary Medicine 5 3 60.00Genito-Urinary Medicine 5 3 60.00

    Renal 5 3 60.00

    Cardiology 7 4 57.14

    Radiology Department 25 13 52.00

    Anaesthetics 53 27