1. EPECEPECEPECEPEC EPECEPECEPECEPEC Communicating Bad News Communicating Bad News Module 2 The Education in Palliative and End-of-life Care Project at Northwestern University’s Feinberg School of Medicine, created with the support of the American Medical Association and the Robert Wood Johnson Foundation

2. Objectives l Know why communication of “bad” news is important l Understand the 6-step protocol for delivering bad news l Know why communication of “bad” news is important l Understand the 6-step protocol for delivering bad news

3. Importance l Most people want to know l Strengthens physician-patient relationship l Fosters collaboration l Permits patients, families to plan, cope l Most people want to know l Strengthens physician-patient relationship l Fosters collaboration l Permits patients, families to plan, cope

4. 6-step protocol... 1. Getting started 2. What does the patient know? 3. How much does the patient want to know? Adapted from Robert Buckman 1. Getting started 2. What does the patient know? 3. How much does the patient want to know? Adapted from Robert Buckman

5. ... 6-step protocol 4. Sharing the information 5. Responding to patient, family feelings 6. Planning and follow-up Adapted from Robert Buckman 4. Sharing the information 5. Responding to patient, family feelings 6. Planning and follow-up Adapted from Robert Buckman

6. Step 1: Getting started... l Plan what you will say confirm medical facts don’t delegate l Create a conducive environment l Plan what you will say confirm medical facts don’t delegate l Create a conducive environment

7. ... Step 1: Getting started l Allot adequate time prevent interruptions l Determine who else the patient would like present if child, patient’s parents l Allot adequate time prevent interruptions l Determine who else the patient would like present if child, patient’s parents

8. Step 2: What does the patient know? l Establish what the patient knows child’s parents l Assess ability to comprehend new bad news l Reschedule if unprepared l Establish what the patient knows child’s parents l Assess ability to comprehend new bad news l Reschedule if unprepared

9. Step 3: How much does the patient want to know?... l Recognize, support various patient preferences decline voluntarily to receive information designate someone to communicate on his or her behalf l Recognize, support various patient preferences decline voluntarily to receive information designate someone to communicate on his or her behalf

10. ... Step 3: How much does the patient want to know? l People handle information differently race, ethnicity, culture, religion, socioeconomic status age and developmental level l People handle information differently race, ethnicity, culture, religion, socioeconomic status age and developmental level

11. When family says “don’t tell”... l Legal obligation to obtain informed consent from the patient l Promote congenial family alliance l Honesty with a child promotes trust l Legal obligation to obtain informed consent from the patient l Promote congenial family alliance l Honesty with a child promotes trust

12. ... When family says “don’t tell” l Ask the family: Why not tell? What are you afraid I will say? What are your previous experiences? Is there a personal, cultural, or religious context? l Talk to the patient together l Ask the family: Why not tell? What are you afraid I will say? What are your previous experiences? Is there a personal, cultural, or religious context? l Talk to the patient together

13. Step 4: Sharing the information... l Say it, then stop avoid monologue, promote dialogue avoid jargon, euphemisms pause frequently check for understanding use silence, body language l Say it, then stop avoid monologue, promote dialogue avoid jargon, euphemisms pause frequently check for understanding use silence, body language

14. ... Step 4: Sharing the information l Don’t minimize severity avoid vagueness, confusion l Implications of “I’m sorry” l Don’t minimize severity avoid vagueness, confusion l Implications of “I’m sorry”

15. Step 5: Responding to feelings... l Affective response tears, anger, sadness, love, anxiety, relief, other l Cognitive response denial, blame, guilt, disbelief, fear, loss, shame, intellectualization l Basic psychophysiologic response fight-flight l Affective response tears, anger, sadness, love, anxiety, relief, other l Cognitive response denial, blame, guilt, disbelief, fear, loss, shame, intellectualization l Basic psychophysiologic response fight-flight

16. Step 5: Responding to feelings... l Be prepared for outburst of strong emotion broad range of reactions l Give time to react l Be prepared for outburst of strong emotion broad range of reactions l Give time to react

17. ... Step 5: Responding to feelings l Listen quietly, attentively l Encourage descriptions of feelings l Use nonverbal communication l Listen quietly, attentively l Encourage descriptions of feelings l Use nonverbal communication

18. Step 6: Planning, follow-up... l Plan for the next steps additional information, tests treat symptoms, referrals as needed l Discuss potential sources of support l Plan for the next steps additional information, tests treat symptoms, referrals as needed l Discuss potential sources of support

19. ... Step 6: Planning, follow-up l Give contact information, set next appointment l Before leaving, assess: safety of the patient supports at home l Repeat news at future visits l Give contact information, set next appointment l Before leaving, assess: safety of the patient supports at home l Repeat news at future visits

20. When language is a barrier... l Use a skilled interpreter familiar with medical terminology comfortable translating bad news l Consider telephone translation services l Use a skilled interpreter familiar with medical terminology comfortable translating bad news l Consider telephone translation services

21. ... When language is a barrier l Avoid family as primary translators confuses family members how to translate medical concepts modify news to protect patient supplement the translation l Speak directly to the patient l Avoid family as primary translators confuses family members how to translate medical concepts modify news to protect patient supplement the translation l Speak directly to the patient

22. Communicating prognosis... l Some patients want to plan l Others are seeking reassurance l Some patients want to plan l Others are seeking reassurance

23. Communicating prognosis... l Inquire about reasons for asking “What are you expecting to happen?” “How specific do you want me to be?” “What experiences have you had with: others with same illness? others who have died?” l Inquire about reasons for asking “What are you expecting to happen?” “How specific do you want me to be?” “What experiences have you had with: others with same illness? others who have died?”

24. Communicating prognosis... l Patients vary “planners” want more details those seeking reassurance want less l Avoid precise answers hours to days … months to years average l Patients vary “planners” want more details those seeking reassurance want less l Avoid precise answers hours to days … months to years average

25. ... Communicating prognosis l Limits of prediction hope for the best, plan for the worst better sense over time can’t predict surprises, get affairs in order l Reassure availability, whatever happens l Limits of prediction hope for the best, plan for the worst better sense over time can’t predict surprises, get affairs in order l Reassure availability, whatever happens

26. Caregiver communication l Maintain common chart or log book goals for care treatment choices what to do in an emergency likes, dislikes things to do / not to do contact information l Maintain common chart or log book goals for care treatment choices what to do in an emergency likes, dislikes things to do / not to do contact information

27. EPECEPECEPECEPEC EPECEPECEPECEPEC Communicating Bad News Summary Summary