1. Breaking Bad News Do we know how to be helpful? Dr. Grant MacLean

2. Cecilia came to you complaining of nausea, epigastric pain and weight loss. You have the results of the biopsy done at gastroscopy a few days ago. Her new partner had left a message that if it is bad news please dont tell her. She is sitting in the office waiting for you with her partner. Are you ready?

3. Three key parts to successfully breaking bad news: Is it bad? How to tell the bad news Knowing what to tell

4. Coming to see you is Vicki, a 37 year old woman who had presented with a left supraclavicular lymph node mass ? Lymphoma – may have a good outcome

5. Unfortunately she also had a very large hard irregular mass in the pelvis. ? Ovarian cancer – may respond well to chemotherapy Her question: Can you cure me?

6. Next is Ken, 55, who looks well but recently had a hemicolectomy for colon cancer. He had a CT scan and wants the results – it shows widespread metastatic disease in his liver and his lungs. Can you cure me…Im scared…..and Im not sure I want to know…..but….. … how long have I got?

7. And then you are asked to see Jack, 83, with severe heart disease, presenting with painless vomiting. Yesterday he was told he had pancreatic cancer. He hates his nasogastric tube, and he wants to know: How soon are we going to start chemotherapy?

8. In two separate studies Peter Kirk and Jean Kutner have found that patients and families want: 1. Prognostic information & honesty 2. Hope Isnt there a conflict?

9. If you struggle with this conflict, you are not alone: Baile, Buckman et al described an informal study of 500 oncologists at ASCO in 1998, in which they looked at the difficulties in breaking bad news.

10. Nearly 50% admitted no training in responding to patients emotions. Nearly 50% admitted they were not comfortable dealing with patients emotions. Nearly 50% admitted difficulty discussing the transition from active therapy to palliative care.

11. Rob Buckman gave us SPIKES To help us break bad news. What are the key points?

12. Can we avoid the horror tales. Like the young woman who was waiting in the hospital entrance for her ride home when she saw her surgeon leaving: When will I get the results of the biopsy? I felt like crying and throwing up – and had nowhere to go…

13. A Buddhist teaching is the wine glass is already broken. Enjoy the wine glass and accept that one day it will break. Some of our patients have already accepted this philosophy.

14. If you break your partners favorite wine glass you may both be upset or angry… But if there was an earthquake and all the glasses broke but the kids were OK, it may not be important. When is bad news not so bad?

15. A few years ago I investigated Colleen for chest pain. She was on Tamoxifen for breast cancer with bone mets. The bone scan was much worse. She was relieved – I was scared it was my heart – I know you can die suddenly from heart disease.

16. We need to check with our patients – e.g. What do you worry about? or even what is the worst thing that could happen to you? I am afraid of nausea… I hope I will not be in pain… I dont want to be hooked up to a machine… As long as I dont have a stroke… Id rather not spend my valuable time at the cancer clinic…

17. Do you know we have a reputation for interrupting patients before they can say why they have come to see us or what troubles them most?

18. Beckman & Frankel (1984): in 69% of visits, the patient was interrupted by the physician before being able to say why they were seeing the physician!

19. How can we respond to the patients needs if we dont know them?

20. Kutner, 1999: What needs to be discussed, what might be discussed, what should be discussed and what ought to be kept silent, are issues that require negotiation between the patient and the physician.

21. Gattellari: …many patients cannot make informed decisions, because they lack knowledge of their prognosis and alternatives to anti-cancer treatment.

22. An important message from Kutners study: > 90% wanted prognostic information to help with decision making. Only 50% wanted to know when they would die.

23. A modification of Rob Buckmans SPIKES that can help us know what to say, as well as and how to break bad news is the strategy RELATE

24. RELATERELATE In the right place, appear relaxed enquire listen patients agenda tell the truth respond to emotions with empathy

25. R – the Right time & place Looking at your watch, or your hand on the door knob sends the wrong message Is now the time? Who should be present? Sit down. Relax and focus.

26. E - enquire You cannot know what is important to me unless you ask. My values may differ from yours, my fears may differ from yours. IF you dont enquire, you will not know.

27. L – and the most important is LISTEN One of Rob Buckmans Ground Rules To support a patient you do not have to agree with the patients point of view, but you do have to listen to it and identify what the patient is saying.

28. A – the patients agenda If you want to help the patient, acknowledge and focus on the patients agenda. The patient may not care about the size of the lesion on the CT…..

29. T – tell the truth There are cultural differences that we need to be sensitive to, but in our culture the majority of our patients expect HONESTY (Kutner - >90% expect the doctor to be honest) which may include I dont know!

30. E – respond to the patients emotions with empathy even if you are exhausted or feeling pressured for time, this may be a pivotal time in the life of the patient.

31. One of our problems may be not understanding what hope can be & that hope can be refocussed Contrary to modern oncology literature, not all patients measure success in life by how many days they live!

32. The oncologist: I assume you hope to live longer The patient: I hope I do not have to have chemotherapy – if it is not going to add years, then I want to avoid nausea and fatigue. I hope I can preserve quality…

33. Ronna Jevne offers this definition: Hope is not about everything turning out OK; it is about being OK with how things are.

34. When Vicki asked whether I could cure her, it was tough for us all. She knew her cancer had spread, but she was young, with children, and she wanted to live. What would you offer?

35. Unfortunately her primary was neither lymphoma nor ovarian cancer. She had widespread cancer arising from the esophagus.

36. Telling the truth can be painful for us all, but in Vickis situation it helped us move to discussion about palliative care; She had a lot of pain, and her hope was to be free of pain.

37. Ken knew I could not predict when he would die. He is a mathematician, and he explained the probability of my being wrong. So with how long? what did he want to know?

38. He knew his cancer was not curable. He wanted information so he could make decisions, and he wanted hope.

39. Ken was afraid to ask how long but when given a chance to amplify, he wanted to know: will it hurt? this may sound silly to you, but will I be alive next week - my son is coming…

40. And then there is Jack Frail Serious heart disease With pancreatic cancer – which cannot be cured. In fact chemotherapy is unlikely to shrink his cancer or significantly impact his disease course.

41. Jack is wondering when chemotherapy will start. What would you offer him?

42. Jack was relieved that he didnt have to go through chemotherapy, as were his family. They were enthusiastic about meeting the palliative care team and focussing on quality of life issues.

43. Lauren is in her mid thirties. Three years ago she had RT for locally advanced ca cervix. She complains of sacral pain, vaginal bleeding and difficulty with voiding. She wants the CT scan results and wants to get on quickly with chemotherapy as she wants to be cured.

44. Pat is 50, on Carboplatin for ovarian cancer. She is terrified of her disease. She has come to see if it is worth continuing the chemotherapy after three courses. She doesnt know the results, but her CA 125 has fallen from 1200 to 45; and the CT shows complete clearing of the previously noted masses and nodes.

45. Your colleague has seemed a little forgetful lately. A CT of his brain, that you ordered for him, has not been reported but you have seen it with the radiologist. He has what appear to be two metastases or tumors.