Presentation on theme: "Understanding “breaking bad news”"— Presentation transcript:
1Understanding “breaking bad news” Clare WarnockPractice development sisterWPH
2What is breaking bad news How would you describe breaking bad newsWho does itWhat is bad news
3What is breaking bad news Traditional viewthe moment when a doctor provides significant information about diagnosis, prognosis or treatment to patients and their families in a one to one consultationthe role of the HCP is to be presentas a witness to what has been said andproviding support once the consultation is over“Modern view”A wide range of HCPs are involved in BBNOther information can be classified as bad newsBBN is a processThere may be multiple episodes of information provisionoften “ad hoc” and not part of a pre-planned consultationIt also includes activities that take place before, during and after bad news is given
4Popular definitionany bad, sad or significant information that negatively alters a person’s expectation or perception of their present or future (Fallowfield and Jenkins 2004)Key itemsANY informationIndividual expectationIndividual perception
5What do you think could classify as bad news Examples informing relatives of a patient’s deterioration or death,advising a patient that they need to move into a residential home,explaining the details of arduous treatment such as renal dialysis or chemotherapy,providing daily updates to family members when a patient’s condition is not improvingexplaining transitions in care for example from curative to palliative to end of lifefailed discharge plansTelling someone they can’t drive any more
6What is bad news – it depends! the same information could be interpreted as good, bad or neutral by different peopleinfluenced by subjective factorspatient’s expectations, values, life experiences and social situationthe events leading up to and surrounding the moment that the information is givenHow might different people react to being told they need to have surgery?
7Breaking bad news as a process BBN is not about a single consultationDewar’s early work in spinal injury unitInitial momentFollowed by multiple episodes of potential bad newsRealising the implications of spinal injury over timeIt also involves the activities that take place before, during and after bad news is given
8What activities are carried out around bad news? Assessing the needs of patients and relatives for further information; recognising their cues and promptsWorking with the patient and family to achieve consensus when there are issues about who should be informedIdentifying and prioritising the patient’s preferences for informationLiaising with the appropriate members of the healthcare team to initiate discussions where the need is identified or requestedCoaching and supporting patients and relatives who find it difficult to ask questions or talk to the doctors
9Other activities around BBN Helping patients ask questions when they appear to be confused or reluctant to do soSupporting others who are providing the information to find alternative words or explanations if the patient appears not to understand or needs clarificationCommunicating what has been said in the consultation to the rest of the healthcare teamEliciting patient and relatives’ feelings about the information they have receivedListening to and acknowledging the emotional reactions of patients and relatives to bad newsExplaining and discussing the information received and its implications
10Other activities around BBN? Answering questions as they arise, identifying and clarifying misunderstanding and explaining complex medical terminologyProviding information about the next steps in the care pathwayHelping the patient and relatives make decisions about careHelping patients and relatives address complex issues e.g. what is meant by DNAR, informed consent, advanced care directivesSupporting patients and relatives when they realise the implications of their situation or the information they have been givenHelping the family reach a consensus when there is disagreement between them about the plan of careActing as an intermediary between patients, relatives and the healthcare team
11Why is BBN important? Patient preference – research consistently shows Most patients want to be informedvariations in the depth and level of knowledge desired Other potential positive outcomesbuilding a sense of trust between patients and the healthcare teamenabling patients and relatives to make appropriate decisions and plans based on a realistic insight into their situation
12What are the negative consequences of not providing patients with bad news?
13Consequences of not BBN Impact on treatment and decision makingPatients receiving burdensome, inappropriate and unnecessary treatmentFalse optimism and being unable to marry what is happening with the information receivedMisunderstanding and confusion over the intention and aim of treatmentDenying patients the opportunity to participate in decision makingUnnecessary anxiety in worrying about the unknown
14Impact on end of life care Depriving patients and families of essential time before the patient’s condition deterioratesPreventing the discussion of end of life preferencesDenying patients the opportunity to get their affairs in orderImpact if relatives informed and the patient isn’tFeeling isolated and unable to communicate with each otherUnnecessary strain on family relationshipsFamilies carrying the burden of deception
15Poor job and role satisfaction Impact on the healthcare teamJob stress and burnoutPoor job and role satisfactionDisagreement and fractured relationships if not all agree with the information provided
16Word of cautionSome patients prefer not to receive some or all of the facts as this is how they cope with their illnessCultural differencespreferences and behaviours around information relating to particular diagnoses, such as cancer, prognosis and end of life decisionsin some cultures it can be common for the family to be given the information while the patient is shielded from the full facts.Individual patient’s preferences for information should guide the content, timing and delivery of information
17Does being honest destroy hope? research reveals that providing honest information does not remove hopehonest information can support patients in their efforts to maintain hopereduces fear of the unknownenables patients to match their hopes with the reality of their experienceIs this a contradiction?
18Reframing hopes and goals (Campbell 2010) “When we worry about destroying hope we are generally referring to a very specific hope of getting better or living longer.But hope is a complex, multi-dimensional and above all flexible construct...One can shift from hoping for a cure...to hoping to go home from the hospital.Such a shift in the things one hopes for requires a reframing of goals to meet the realities at hand...(a reality) that none of us would wish for”
19Reframing hopes - examples Hopes described by patients with a life-limiting illness include:living longer than expectedgood symptom managementgetting the most out of the time that is leftmaking it to certain events or achieving certain goalsmending damaged relationshipsspending special time with family and friendsThis doesn’t mean people want to be in that situation (or that they won’t be sad/angry/upset)It is a way of coping that can be used over time
20Summary – what have we learnt about BBN? Bad news includes many different types of informationInformation is defined as “bad news” by individuals and cannot always be determined in advanceBBN is a process with multiple episodes of information provisionas people experience the implications of their situation and raise questions and concernsIt also includes the activities before, during and after the news is givenHCPs carry out a wide range of diverse roles in relation to BBN
21Final notesThe way that bad, sad and significant information is given is importantThe consequences are long-lastingHow it is done can influenceexperiences and satisfaction with treatmentrelationships with the healthcare team.adherence and compliance with treatmentcoping with the consequences of illnessProviding information in a way that helps the patient understand and cope with what they are told requires skills and knowledgeGuidelines and good practice advice have been developed to support staffThese will be explored in the next section of the study day