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The FACES Foundation Lecture Series Delivering Bad News Howard Beckman, MD, FACP, FAACH Clinical Professor of Medicine and Family Medicine University of.

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Presentation on theme: "The FACES Foundation Lecture Series Delivering Bad News Howard Beckman, MD, FACP, FAACH Clinical Professor of Medicine and Family Medicine University of."— Presentation transcript:

1 The FACES Foundation Lecture Series Delivering Bad News Howard Beckman, MD, FACP, FAACH Clinical Professor of Medicine and Family Medicine University of Rochester School of Medicine November 15, 2012

2 Objectives Promote an approach centered on understanding and responding to the patient & family Emphasize the importance of listening Provide a stepped approach to delivering bad news that begins with clarity about the key message to be shared Incorporate the principle that only the patient/family can decide which news is bad

3 Delivering Bad News Recall an experience of delivering bad news that is memorable to you. Why does that particular experience come to mind? Turn to another person and share the story and why you chose to share it.

4 Historical Approaches to DBN...conceal most things from the patient while you are attending him. Give orders with cheerfulness and serenity, turning attention away from what is being done to him [because] a forecast of what is to come can cause a turn for the worse. Hippocrates, Decorum

5 Historical Approaches to DBN Promise health to the patient who is hanging on your lips but intentionally exaggerate the peril of the illness to the family. If the patient recovered, the physician was assured you will be praised more for your art; should he die his friend will testify that you had given him up. Arnaud of Villanova - (14th Century Physician)

6 Historical Approaches to DBN The life of a sick person can be shortened not only by the acts, but also by the words or the manner of a physician. It is, therefore, a sacred duty to guard himself carefully in this respect, and to avoid all things which have a tendency to discourage the patient and to depress his spirits. First Code of Medical Ethics Am. Med. Assn., 1847

7 Historical Approaches to DBN #13 In my practice, Im doing heart surgery all the time so I talk to families. I always tell the nurses and tell everybody, paint the gloomiest pictures you can because if they do ok, I look like a hero. And if things dont go so well, then there is kind of a respect in that, you know. I may know that the case went fine, the patient is going to be fine, there are not going to be any problems. But I never ever say that to the patient or to the family. Always say, well, it was a tough case and I think hell pull through. Levinson, et al, 1993

8 Defining Bad News Information that Significantly Alters a Persons View of the Future Kelly CK, Bearing Bad Tidings. ACP-ASIM Observer. Jan. 2003

9 Common Fears About Delivering Bad News Causing pain and/or suffering Being wrong or giving incorrect information Extinguishing hope Confronting ones own mortality Eliciting profound emotions: ones own or the patients Fear of saying, I dont know

10 Common Errors in Delivering Bad News Not attending to the need for privacy Failing to solicit patients understanding of the issue in question before delivering the news Not asking about the depth of information the patient or family wants to know Delivering excessive information–the lecture Giving premature reassurance, Its going to be fine… Id worry about something else

11 Common Errors in Delivering Bad News Trivializing emotions :Many patients have struggled with this. I know how youre feeling Prioritizing physical over emotional concerns Failing to respond to intense emotions; missing empathic opportunities (Suchman et. al.) or missing clues (Levinson et al)

12 Common Errors in Delivering Bad News Failing to assess changes in the patient/familys attitude or desire for information over time Assuming the valence of the news on the patient/ family Failing to coordinate with other teams… I didnt realize the ICU nurse suggested hospice Arguing or bargaining with a person or family in denial or anger; missing the patients/familys stage of change

13 Stages of Change June 1, 2014©2011 Focused Medical Analytics, LLC13 H. Beckman, MD. et al. AJMQ, 2006. Adapted from E. Kubler-Ross

14 Guidelines for Delivering Bad News: Preparing 1.Review the record: whats previously been discussed? 2.Solicit staffs view of the patients understanding of the problem 3.Determine if the patient has expressed how information s/he wants to know at this time 4.Learn the details of the case

15 Guidelines for Delivering Bad News: Setting Up the Environment Choose a comfortable, quiet, private location Avoid physical barriers like desks & tray tables Schedule enough time for content & emotion Formulate the message you want the patient/family to remember

16 Select the Message Carefully

17 Guidelines for Delivering Bad News: Opening the Interaction Determine who the patient wants involved Check for patients/ familys understanding of the issue before beginning Elicit how much information the patient or family wants to know at this time Identify the message you want the patient or family to remember Say that message FIRST: You have a treatable condition… We will make you as comfortable as possible… Were here for you

18 Guidelines for Delivering Bad News: Delivering the News Then deliver the news you think is bad Wait for the response; do not fill the silence with your opinion or reassurance Remember, often the patient/ family hears nothing after the news is delivered What is most remembered by the patient or family is your response to their emotions

19 Guidelines for Delivering Bad News: Leading the Interaction Let the patient/family decide if the news is bad Reactions vary depending on age, education religious/ cultural values, previous expectations Wait for the patient/family to digest the information and the valence of the news

20 Guidelines for Delivering Bad News: Creating Meaning Give the patient control over timing and quantity of information – observe NVB, listen Tailor the discussion to the concerns expressed by the patient or family Encourage questions and thoughts Avoid lengthy explanations When unsure, say so, Im not sure, let me look into that and get back to you

21 Guidelines for Delivering Bad News: Concluding the Interaction Ask how the patient/family is doing Work towards a mutually agreed upon plan Summarize follow-up tasks to achieve the plan Follow up time will be needed; agree on a plan for providing access

22 Leave room for hope Encourage patient or family to write down questions as they arise Repeat the core message Emphasize that there will be follow-up opportunities to talk Guidelines for Delivering Bad News: Concluding the Interaction

23 Check back with patient/family a short time after the meeting Take care of yourself – seek support, acknowledge your feelings Guidelines for Delivering Bad News: Following Up

24 Delivering Bad News Now apply the principles from this session to the interaction you described earlier. 1.What is the message you want to deliver? 2.Deliver the news 3.Rather than speak after the news, wait and listen for your partners response(s). 4.Respond to any emotion expressed.

25 Contact Information Howard Beckman, MD Clinical Professor of Medicine and Family Medicine University of Rochester School of Medicine Howard_Beckman@urmc.rochester.edu 585-341-6775


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