(IC1) Breaking Bad News
-
Upload
rose-ann-mecija -
Category
Documents
-
view
250 -
download
0
description
Transcript of (IC1) Breaking Bad News
BREAKING BAD NEWS
PERLA ANGELINA B. ILADA- AGAPAY, MD
The doctor – patient
relationship is founded on
trust.
It is fostered by honesty but
poisoned by deceit.
Breaking bad news
One of the physician’s most difficult duties
No formal preparation for this daunting task
Inadequate training may lead physicians to emotionally disengage with their patients
And yet, studies reveal that most
patients generally desire frank and
empathetic disclosure of a terminal
diagnosis or other bad news.
Breaking bad news
Definition
“Any news that drastically and negatively alters the patient’s view of his or her future”
“I left my house as one person and came home another”
Lance Armstrong
Breaking bad news is seldom a
question of “to tell or not to tell”,
but more of a matter of “when and
how to tell”.
Why is breaking bad news difficult? Fear of its effect on the patient
Hippocrates advised “concealing most things
from the patient while you are attending to him,
give necessary orders with cheerfulness and
serenity…revealling nothing of the patients
future or present condition. For many patients…
have taken a turn for the worst …by forecast of
what is to come.”
Traditional paternalistic models
“the doctor is always right”
“kayo napo ang bahala Dok, kayo
po ang nakakaalam”
Physician issues
1. In general, physicians do not wish
to take away hope from the patient
2. Physician’s uncertainty and
discomfort in delivering the bad
news
Difficult situations
Postoperative diagnosis of
malignancy
Imminent death
Sudden deaths
Young patients, specially children
Patients/relatives breaking down
Previously misinformed patient
Patient in denial
Wala na pong pag-asa
Difficult situations
SIX-STEP STRATEGY FOR BREAKING BAD NEWS (SPIKES)
STEP 1: S—SETTING UP the Interview Arrange for some privacy. Involve significant others. Sit down. Make connection with the patient. Manage time constraints and
interruptions.
SPIKES Cont.
STEP 2: P—ASSESSING THE PATIENT'S PERCEPTION-
Important task of determining if patient is engaging in any variation of illness denial:
Wishful thinking, omission of essential but unfavorable medical details of the illness, or unrealistic expectations of treatment
SPIKES Cont.
STEP 3: I—OBTAINING THE PATIENT'S INVITATION
STEP 4: K—GIVING KNOWLEDGE AND INFOR- MATION TO THE PATIENT
STEP 4: K—GIVING KNOWLEDGE AND INFOR- MATION TO THE PATIENT
1. Start at the level of comprehension and vocabulary of the patient.
2. Use nontechnical words such as “spread” instead of “metastasized” and “sample of tissue” instead of “biopsy.”
3. Avoid excessive bluntness- leave the patient isolated and later angry, with a tendency to blame the messenger of the bad news
4. Give information in small chunks and check periodically as to the patient's understanding.
5. When the prognosis is poor, avoid using phrases such as “There is nothing more we can do for you.” - inconsistent with the fact that patients often have other important therapeutic goals such as good pain control and symptom relief.
(SPIKES Cont.) STEP 5: E—ADDRESSING
THE PATIENT'S EMOTIONS WITH EMPATHIC RESPONSESAn empathic response consists of four steps:1. Observe for any emotion on patient’s part.2. Identify the emotion experienced by the
patient by naming it to oneself.3. Identify the reason for the emotion.4. Let the patient know that you have
connected the emotion with the reason for the emotion by making a connecting statement.
Doctor: I'm sorry to say that the x-ray shows that the chemotherapy doesn't seem to be working [pause]. Unfortunately, the tumor has grown somewhat.
Patient: I've been afraid of this! [Cries]
Doctor: [Moves his chair closer, offers the patient a tissue, and pauses.] I know that this isn't what you wanted to hear. I wish the news were better.
(SPIKES Cont.)
STEP 6: S—STRATEGY AND SUMMARY Sharing responsibility for decision-
making with the patient may also reduce any sense of failure on the part of the physician when treatment is not successful.
Communicating Bad News With
COMFORT
CommunicationOrientationMindfulnessFamilyOngoingReiterativeTeam
Six step protocol for breaking bad news
1. Getting the physical context right
2. Finding out how much the patient
knows
3. Finding out how much the patient
wants to know
4. Sharing information
5. Responding to patient’s feelings
6. Planning and following through
Six step protocol for breaking bad news
Getting the physical context right
Ensure that you have time
Private room
Silent mode
Sit down near the patient
Ascertain their current
understanding
What do they understand by the
words tumor or spot?
Finding out how much the patient knows
Finding out how much the patient wants to know
Are you the kind of person who
likes the full details or would you
prefer just to hear the treatment
plan?
“Hanggang saan po ninyo gustong
malaman?”
Sharing information
Use ordinary language, not
medical jargon
Check back on their understanding
Go at their pace
Allow pauses
Be emphatic and not be afraid to
say sorry or I don’t know
Use humor with care
Use drawings
Don’t argue
Sharing information
Responding to patients feelings
Listen, listen and listen
Questions should be encouraged
Planning and following through
Further meetings
Try to leave them with some hope,
remember, “may pag-asa hanggat
humihinga”
Communication
Prognosis
Depends on many factors
Patient ‘how long have I got doctor?
Doctor ‘I don’t know, and nobody
knows
Special instances
Care of the relatives
“You won’t tell him will you doctor?”
“We’d prefer you not to tell him
doctor”
Special instances
“The family cannot forbid the
doctor from discussing diagnosis
and prognosis with the patient.”
The ethics of medical
confidentiality states that relatives
can only be told with the explicit
permission from the patient and
not the other way around.
The key is to see both the patient and the
family initially apart from each other then
do a family meeting.
Tell the family that if the patient knows, it
is his opportunity to fix unfinished
business, and participate in his treatment.