Presentation on theme: "Breaking Bad News Dr. Riaz Qureshi"— Presentation transcript:
1 Breaking Bad News Dr. Riaz Qureshi Distinguished Professor Family MedicineDept. of Family & Community MedicineKing Saud University ,Riyadh, Saudi Arabia
2 Breaking Bad News Learning Objectives for Students/Trainees: To understand why this is an important part of communication skills.To understand the definition of bad news.The students/trainees should become aware of:What to do?How to do it?What not to do?Students/Trainees should also become familiar with certain illnesses/ problems which may require giving bad news.
3 Breaking Bad NewsA difficult but fundamentally important task for all health care professionalsPhysicians feel uncertain & uncomfortable while breaking bad news, leading to being distant & disengaged from their patients.
4 Breaking Bad News 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 )Focused training in communication skills & techniques to facilitate breaking of bad news has been demonstrated to improve patients satisfaction & physicians comfort.
5 What is bad news?“any news that drastically and negatively alters the patients view towards his future.”Buckman R. BMJ1984It alters one’s self-image : “I left my house as one person & came home another.”Professional cyclist Lance Armstrong’s recollection
6 Examples reported by clinical consultants Examples of Conditions Requiring Breaking of Bad NewsCancer related diagnosesIntra uterine foetal demiseLife long illness: Diabetes, EpilepsyPoor prognosis related to chronic diseases: loss of independenceInforming parents about their child’s serious mental/physical handicapGiving diagnosis of serious sexually transmitted disease …catastrophic psychosocial resultsNon clinical situations like giving feedback to poorly performing trainees or colleagues
7 Psychosocial ContextPatients response is influenced by previous experiences & current social circumstances---inappropriate timingEven simple diagnosis being incompatible with one’s profession---tremors in cardiac surgeon.Varying needs of patient & family---patient wishes to know more himself & less information to pass on to family, family wishes vice versa.
8 Barriers to effective disclosure It is referred by some physicians like “dropping the bomb”Baile W F, oncologist 2000Common Barriers includePhysician’s fears of :Being blamed by patientNot knowing all the answersInflicting pain & sufferingsOwn illness & deathLack of trainingLack of timeMultiple physicians---who should perform the task
9 Patient’s perspective Most important factors for patients include:Physician’s competence, honesty & attentionThe time allowed for questionsStraightforward & understandable diagnosisThe use of clear languageParker PA, Baile WF j.clinical onc 2001
10 Family's perspective Family members prefer: privacy Good attitude of the person who gives the bad newsClarity of messageCompetency of physiciansTime for questionsJurkovich GJ, et al. J Trauma 200
11 Delivering Bad News“It is not an isolated skill but a particular form of communication.”Frank A. Eur J of Palliat care 1997Rabow & Mcphee (West J. Med 1999) described: “Clinicians focus often on relieving patients’ bodily pain, less often on their emotional distress & seldom on their suffering.”
12 Delivering Bad NewsRabow & Mcphee (West J. Med 1999) synthesized a simple mnemonic of ABCDE:Advance PreparationBuild a therapeutic environment/relationshipCommunicate wellDeal with patient & family reactionsEncourage and validate emotions
13 Advance PreparationFamiliarize yourself with the relevant clinical information (investigations, hospital report)Arrange for adequate time in private, comfortable environmentInstruct staff not to interruptBe prepared to provide at least basic information about prognosis and treatment options (so do read it up)
14 Advance PreparationMentally rehearse how you will deliver the news. You may wish to practice out loudScript specific words & phrases to use or to avoidBe prepared emotionally
15 Build a therapeutic environment/relationship Introduce yourself to everyone presentSummarise where things have got to date, check with patient/relativeDiscover what has happened since last seenJudge how the patient is feeling/thinkingDetermine the patient’s preferences for what and how much he/she wants to know
16 Build a therapeutic environment/relationship (contd) Warning shot “I’m afraid it looks more serious than we had hoped”Use touch where appropriatePay attention to verbal & non verbal cuesAvoid inappropriate humourAssure patient that you will be available
17 Communicate well Speak frankly but compassionately Avoid medical jargonAllow silence & tears; proceed at patient’s paceHave the patient describe his/her understanding of the information givenEncourage questionsWrite things down & provide written informationConclude each visit with a summary & follow up plan
18 Deal with patient and family reactions Assess & respond to emotional reactionsBe aware of cognitive coping (denial, blame, guilt, disbelief, acceptance, intellectualization)Allow for “shut down”, when patient turns off & stops listeningBe empathetic; it is appropriate to say “I’m sorry or I don’t know. Crying may be appropriateDon’t argue or criticize colleagues
19 Encourage and validate emotions Offer realistic hopeGive adequate information to facilitate decision makingExplore what the news means to the patient & inquire about spiritual needsInquire about the support systems in place
20 Encourage and validate emotions Attend to your own needs during and following the delivery of bad news (counter-transference can be harmful)Use multidisciplinary services to enhance patient care ( hospice)Formal or informal debriefing session with concerned team members may be appropriate
21 What to do? Introduce yourself Look to comfort and privacy Determine what the patient already knowsWarn the patient that bad news is comingBreak the Bad NewsIdentify the patient’s main concernSummarize and check understandingOffer realistic hopeArrange follow up and make sure that some one is with the patient when he leaves
22 How to do it ? Be sensitive Be empathic and consider appropriate touchingMaintain eye contactGive information in small chunksRepeat and clarifyRegularly check understandingDo not be afraid of silence or tearsExplore patient’s emotions and give him time to respondBe honest if you are unsure about something
23 What not to do ? Hurry Give all the information in one go Give too much informationUse medical jargon or unclear language/wordsLie or be economical with the truthBe blunt. Words can be like loaded pistols/gunsGuess the prognosis (She has got 6 months, may be 7)
24 QuotationThe greatest revolution of our generation is the discovery that human beings, by changing the inner attitudes of their minds , can change the outer aspects of their lives.William JamesAmerican Psychologist & Philosopher
25 Angry Patient WHAT TO DO? Introduce yourself Acknowledge the person’s angerTry to find out the reason for his anger, e.g. frustration, fear or guiltValidate his feelingsLet him ventilate his anger or any feelings that led to his angerOffer to do something or for him to do something
26 Angry Patient HOW TO DO IT? Sit at the same level as the patient, not too close and not too far, with eye contactSpeak calmly without raising your voiceAvoid dismissive or threatening body languageEncourage the person to speak with open ended questionsEmpathize as much as you can with verbal and non verbal cuesBe aware of your own safety
27 Angry patient WHAT NOT TO DO? Glare at the person Confront him or interrupt himPatronize him or touch himPut the blame on others/seek to exonerate yourselfMake unreasonable promisesBlock his exitIf the person is a patient’s relative, be mindful about confidentiality
28 SCENARIO Tariq, a 55-year-old chain smoker taxi driver with persistent cough for 3 months, attends your clinic to find out the biopsy report of a lesion shown on a chest x-ray and CT scan. He is rather anxious, that he has a serious condition. His biopsy report confirms that he has a Bronchogenic Carcinoma of right lung. You are required to proceed with this consultation.
29 Scenario No 2 Proceed with this consultation. A 54-year-old lady attends your clinic to find out the result of an MRI of her spine. She has had constant pain all over her spine for the last 2 months. She also has a history of Breast cancer, which was treated 5 years ago.Her report shows that she has secondaries all over her spineProceed with this consultation.(Examination not required)