Breaking Bad News Ahmer A. Karimuddin September 5 th, 2003

Introduction Concepts Doctors Dilemma Medical Education Leading up Interview Cultural Factors Prognosis Sudden Death Debriefing Support Anger & Blame Depression, Despair & Hope

Introduction Yet the first bringer of unwelcome news Hath but a losing office, and his tongue Sounds ever after as a sullen bell Remembered knolling a departing friend King Henry IV, Part 2, Ii

Introduction Physician Patient relationship Breaking bad news Common intervention Common intervention Testing ground Testing ground Consequences are immense

Concepts Perception of news as good or bad is a belief, value judgment or affective response from the provider or receiver of the information, in a given context (Bor, et al., 1996)

Concepts Patient must make value judgment Indirect pressure Patient autonomy? Never assume or anticipate a reaction Bad news does not equal death Change in quality of life Change in quality of life Ending of hope Ending of hope Cannot withhold information

Doctors Dilemma A lack of skills in what to say and how to say it Fear of blame Patient emotion Personal emotion Fear of death, illness, mortality Fear of death, illness, mortality Helplessness Helplessness Premature advice or reassurance is implied insensitivity or rejection

Doctors Dilemma Dosanjh et al. (Med. Educ. 2001) Significant barriers exist to breaking bad news Significant barriers exist to breaking bad news Lack of emotional support Lack of emotional support Available time Available time Personal fears about the delivery process Personal fears about the delivery process Lack of communication skills Lack of communication skills Lack of feedback on prior attempts Lack of feedback on prior attempts Personal feelings, after event Personal feelings, after event

Methods 1.Directly, bluntly and with insensitivity 2.Kindly, sadly without overt support and encouragement 3.Positive with understanding, empathy, reassurance and flexibility Patients overwhelmingly prefer which option? Brevin et al. (Lancet, 1999)

Medical Education Dent et al. (BMJ, 1990) 75% of housestaff never received adequate training 75% of housestaff never received adequate training General lack of evidence in the literature Campbell et al. (Behav. Med, 1998) 35% of residents feel competent in breaking bad news 35% of residents feel competent in breaking bad news Girgis et al. (NZJS, 1999) 80% of surgeons feel breaking bad news well is as important as technical surgical skills 80% of surgeons feel breaking bad news well is as important as technical surgical skills

Medical Education Multiple studies demonstrate education works now and later: Undergraduate training Undergraduate training Video & Audio taping Video & Audio taping Feedback Feedback Gordon et al. (AGIM, 1993) Communication and detection skills deteriorate during internship Communication and detection skills deteriorate during internship

Medical Education Observe & practice new behaviours Structured experiences Systematic feedback Goal oriented evaluation

Medical Education Methods have no impact on long term patient adjustment Disclosure brings: Gratitude Gratitude Peace of mind Peace of mind Positive attitude Positive attitude Reduced anxiety Reduced anxiety Adjustment Adjustment Tactics should mainly be employed to ensure physician comfort and ability (Persaud, 1993)

Leading up Know the history well Acknowledge social circumstances Understand the prognosis Quality of life issues Privacy Comfortable environment Time Availability of a person of choice BE CERTAIN

Interview Simple clear language Minimal to no medical jargon Match verbal and emotional cues Team approach

Interview I am sorry, I have some bad news to tell you Discuss reason for being here Tell patient first Small doses Ask if patient understands frequently Repeat and summarize

Interview Alllow time to assimilate How do you feel? List of questions InformationHope Positive approach Positive approach Sincere, controlled optimism Sincere, controlled optimism Hope leads to a will to live, does it increase longevity? Hope leads to a will to live, does it increase longevity? Probabilities & Absolutes

Reaction Most distressing aspect for physician Outpouring of emotion Silence Inappropriate response Do not break the silence

Reaction QuestioningDenial Inability to cope Inability to cope Repeat Repeat Ask to explain Ask to explainAnger Defensiveness DefensivenessAcceptance I notice you are taking the news calmly, many people react differently I notice you are taking the news calmly, many people react differently

Reaction LonelinessBurden To family To family To system To system Manner of dying Suffocation, choking, bleeding Suffocation, choking, bleeding Loneliness, povery Loneliness, poveryAbandonment Confirmation of suspicion 88% of patients suspect bad news before they are told 88% of patients suspect bad news before they are told

Cultural Factors English speaking countries Full disclosure Full disclosure Asian and Hispanic communities Family centered model of decision making Family centered model of decision making Patients should be asked if they wish to delegate treatment decisions to families or be informed of full story

How long do I have? Productive quality of life Expected survival – Admission of failure Gloomy prognosis may lead patient elsewhere Process of dying Avoid details Avoid details Ensure patient wants to know expected survival Be honest, not overly optimistic or pessimistic

Sudden Death Death = Shock Over the telephone? 64% NO 64% NO 26% YES 26% YES Privacy with other staff members Medical trauma to Family trauma Feelings of failure, inadequacy, guilt Contradict self recrimination Allow silence and emotion

Sudden Death ReviewPrivacyViewing Avoid disturbing images Avoid disturbing imagesAutopsy? Sensitivity Sensitivity Time Time Broken Heart Syndrome

Debriefing Caregiver reactions Sadness, anger, guilt, self reproach Sadness, anger, guilt, self reproach Avoidance Avoidance Overactivity Overactivity Grief of rescuers Critical Incident debriefing Critical responsibility Critical responsibility Health education Health education Should occur after every CPR attempt

Support for Patient & Families Support Time spent listening and acknowledging emotions Time spent listening and acknowledging emotions Frame their fears Frame their fears Answer their questions Answer their questions Acceptance vs. denial Acceptance vs. denial Denial of diagnosis Denial of implications Denial of death

Anger & Blame Overt vs. subtle Against health care professionals Overwhelming Overwhelming Negative response Negative response Against disease, loss of control, God, self, friends, family Identify the cause of the anger Fear? Fear? Guilt = problem

Depression, Despair & Hope Depression Identify Identify Diagnose Diagnose Treat TreatSuicidality Hope vs. despair Undeliverable promises Undeliverable promises Abandonment Abandonment

Conclusions Difficult task Part of patient care Patients are dissatisfied with the quality of information Clinicians are uncomfortable with providing information Lack of empirical data Medical education