(IC1) Breaking Bad News

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Transcript of (IC1) Breaking Bad News

  • BREAKING BAD NEWSPERLA ANGELINA B. ILADA- AGAPAY, MD

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  • The doctor patient relationship is founded on trust.It is fostered by honesty but poisoned by deceit.

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  • Breaking bad newsOne of the physicians most difficult dutiesNo formal preparation for this daunting taskInadequate training may lead physicians to emotionally disengage with their patients

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  • And yet, studies reveal that most patients generally desire frank and empathetic disclosure of a terminal diagnosis or other bad news.

    Breaking bad news

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  • Definition Any news that drastically and negatively alters the patients view of his or her futureI left my house as one person and came home anotherLance Armstrong

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  • 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.

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  • 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 serenityrevealling nothing of the patients future or present condition. For many patientshave taken a turn for the worst by forecast of what is to come.

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  • Traditional paternalistic models

    the doctor is always rightkayo napo ang bahala Dok, kayo po ang nakakaalam

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  • Physician issues

    In general, physicians do not wish to take away hope from the patientPhysicians uncertainty and discomfort in delivering the bad news

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  • Difficult situationsPostoperative diagnosis of malignancyImminent deathSudden deathsYoung patients, specially children

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  • Patients/relatives breaking downPreviously misinformed patientPatient in denialWala na pong pag-asaDifficult situations

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  • SIX-STEPSTRATEGY FORBREAKINGBADNEWS (SPIKES)STEP 1: SSETTING UP the InterviewArrange for some privacy.Involve significant others.Sit down.Make connection with the patient.Manage time constraints and interruptions.

  • SPIKES Cont.

    STEP 2: PASSESSING THEPATIENT'SPERCEPTION- 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: IOBTAINING THEPATIENT'SINVITATIONSTEP 4: KGIVINGKNOWLEDGEANDINFOR- MATION TO THE PATIENT

  • STEP 4: KGIVINGKNOWLEDGEANDINFOR- MATION TO THE PATIENT1. 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: EADDRESSING THEPATIENT'SEMOTIONSWITH

    EMPATHICRESPONSESAn empathic response consists of four steps:Observe for any emotion on patients part.Identify the emotion experienced by the patient by naming it to oneself.Identify the reason for the emotion.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: SSTRATEGYANDSUMMARYSharing 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 newsGetting the physical context rightFinding out how much the patient knowsFinding out how much the patient wants to know

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  • Sharing informationResponding to patients feelingsPlanning and following throughSix step protocol for breaking bad news

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  • Getting the physical context rightEnsure that you have timePrivate roomSilent modeSit down near the patient

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  • Ascertain their current understandingWhat do they understand by the words tumor or spot?

    Finding out how much the patient knows

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  • Finding out how much the patient wants to knowAre 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?

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  • Sharing informationUse ordinary language, not medical jargonCheck back on their understandingGo at their paceAllow pauses

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  • Be emphatic and not be afraid to say sorry or I dont knowUse humor with careUse drawings Dont argue

    Sharing information

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  • Responding to patients feelingsListen, listen and listenQuestions should be encouraged

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  • Planning and following throughFurther meetingsTry to leave them with some hope, remember, may pag-asa hanggat humihinga

    Communication

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  • PrognosisDepends on many factorsPatient how long have I got doctor?Doctor I dont know, and nobody knowsSpecial instances

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  • Care of the relativesYou wont tell him will you doctor?Wed prefer you not to tell him doctor Special instances

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  • The family cannot forbid the doctor from discussing diagnosis and prognosis with the patient.

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  • 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.

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  • 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.

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