1. DISCUSSING SERIOUS NEWS
MODULE 1:
DISCUSSING SERIOUS NEWS
Goals of Care Communication Curriculum
Alpert Medical School of Brown University

2. Objectives
At the conclusion of this session, the participant should be able to:
Use curiosity and good listening skills to understand patient coping styles
Describe empathic and effective approaches to discussing serious news
Identify strategies for discussing prognosis

3. Assessing Patient Coping Styles and Understanding
Illness understanding
Prognostic integration
Will need assess how patient copes with new and potentially upsetting information. Many patients may want a spouse, family member or friend present to support them during and after the conversation.
All of these discussions must begin by assessing the patient’s understanding of their illness. Misunderstandings can then be addressed.
An understanding of prognosis will ultimately be critical to determining goals of care and is reviewed in more detail later in the presentation.

4. Patient-Physician Goals
Helping patient understand trajectory of disease
Integrate this understanding with their goals
Patients will often need education as to what to expect as their illness progresses. Survival and level of function will both need to be understood to be able to develop goals of care that are possible given the limitations of the disease.

5. Pendulum of Information Integration
Unrealistic
Hope
Reality
Worrisome to clinicians
This is normal
Part of developmental tasks that patient need to do to fully understand and integrate prognostic information
A. Weisman
Slide: V. Jackson, 2011

6. Integration is not Instantaneous
Integration happens over time
Can be difficult to achieve integration if they are at either extreme
These discussions should be viewed as a process and understanding and integration of the information may require several meetings.
Information may need to be reviewed and repeated.

7. Use Open-Ended Questions
What is your understanding of your illness?
What are you hoping for?
What are you worried about?

8. Curiosity Approach CAUTION: Use curiosity to figure it out
If you think you know what they are feeling and thinking, you most likely don't
Use curiosity to figure it out
Become aware of your internal voice
Manage your internal voice
The curiosity approach relies on asking open ended questions. Try not to reach premature judgments or conclusion and be open to learning more about the patients understanding and emotions.
D Stone, Difficult Conversation

10. How could curiosity have helped?
Role Play #1

11. How could curiosity have helped?
What might the doctor be thinking?
What might the patient be thinking?
What could have been done differently?

12. Basic Techniques for
Good Listening

13. 3 Steps to Good Listening
Inquire
Paraphrase
Acknowledge
D Stone, Difficult Conversation

14. Take out the Trash http://www.youtube.com/watch?v=p-3aHEhML5Q
A slavish approach to asking the “right “ question and missing the emotion and the needs of the patient can end up with a conversation that leaves the patient and physician frustrated.

15. Inquire to Learn Shows that you are invested
Open-ended questions to avoid bias
“Tell me more”
“Help me better understand”
D Stone, Difficult Conversation

16. Paraphrase for Clarity
Shows that you are processing what has been said
Gives pt opportunity to clarify
Repeat in your own words
“It sounds like...”
D Stone, Difficult Conversation

17. Acknowledge their Feelings
Shows that they are being heard
Name the emotion
Acknowledge emotion before jumping into problem-solving
“I can see that you're ___”
D Stone, Difficult Conversation

18. Good Listening Role Play

19. Questions? How was the second conversation different?
What was an example of inquiring?
What was an example of paraphrasing?
What was an example of acknowledging?

20. Discussing Serious News

21. Talking About Serious News
Not “breaking bad news”
CAUTION:
Don't ignore emotion
The news may not be as “bad” as the patient was expecting. The patient may already have a good sense of what is going on. In many cases it is a discussion not a “news flash”.
Back A, et al. Mastering Communication with Seriously Ill Patients

23. Discussing Serious News
Role Play #3

24. Talking about Serious News
Prepare
Assess
“How much have your doctors told you?”
Negotiate
“How much do you want to know?”
Disclose
Acknowledge emotion
“I can see this is difficult”
Summarize plan
Back A, et al. Mastering Communication with Seriously Ill Patients

25. Talking about Serious News
Role play #4

26. Talking about Serious News
How are the 2 scenarios different?
What was an example of assessing?
What was an example of acknowledgement?
What was an example of negotiating?
What was an example of disclosure?
What was an example of summarizing?

27. Discussing Prognosis

28. Discussing Prognosis CAUTION
Don't assume you know what the patient wants to hear

30. Discussing Prognosis
Role Play #5

31. Discussing Prognosis Negotiate content Disclose Acknowledge
Assess understanding

32. Start by Negotiating Discussion
“How much do you want to know?”
3 Types of Patient answers:
“Yes”
“No”
“I don't know”
Back A, et al. Mastering Communication with Seriously Ill Patients

33. “Yes, I want to know” Negotiate content:
“What kind of information do you want?”
Examples:
Stats: Average life expectancy
Best and worst case scenario
Making it to a specific date
Back A, et al. Mastering Communication with Seriously Ill Patients

34. “Yes, I want to know” Provide Information Speak slowly
Pause (allows information to sink in)
Back A, et al. Mastering Communication with Seriously Ill Patients

35. “Yes, I want to know” Acknowledge reaction
“I can see this is upsetting”
Acknowledging gives safe space for expression and exploration of emotion
Caution: silence, touch, tissues
Back A, et al. Mastering Communication with Seriously Ill Patients

36. “Yes, I want to know” Check for understanding
“Tell me what you understand from our discussion.”
Back A, et al. Mastering Communication with Seriously Ill Patients

37. Discussing Prognosis
Role Play #6

38. Discussing Prognosis Questions
How are the 2 scenarios different?
Did you identify some communications strategies in the second role play?

39. “No, I don't want to know” Assess why Acknowledge concerns
Ask permission to revisit
?Surrogate decison-maker
Private assessment (will prognostic information change outcome today). If yes, then renegotiate
“I understand you'd rather not talk about this today, and I want to honor your decision. But I also think it would be important to discuss some of these issues so that we can figure out what decision might make the most sense for you now. How would you feel about that?”
Back A, et al. Mastering Communication with Seriously Ill Patients

40. “I don't know if I want to know”
Name the ambivalence
Explore pros and cons
Acknowledge difficulty
Outline options if appropriate
Back A, et al. Mastering Communication with Seriously Ill Patients

41. Summary: Fundamentals of good communication
have the same basic principles.

42. 3 Steps to Good Listening
Inquire
Paraphrase
Acknowledge

43. Talking about Serious News
Prepare
Assess
Negotiate
Disclose
Acknowledge emotion
Summarize plan

44. Discussing Prognosis Negotiate content Disclose Acknowledge
Assess understanding

45. Role-Playing
You've been asked to see a woman in her 70s for Palliative Care initial inpt consultation by the Medicine team. She has Stage IV colon cancer diagnosed 1 year ago. She is s/p second line chemo and her oncologist wants to offer further chemo. The Medicine team feels like further chemo may not be in the pt's best interest and have asked you to speak to her.
In reviewing her case, you are worried that further chemo will shorten the pt's life and have discussed this with the oncologist who has said, “This is the only chance she has, so why wouldn't I offer it?” The oncologist has not discussed prognosis with the patient though the pt has asked. You assess her prognosis to be days to weeks.

46. Summary
Use good listening techniques to assess patient and family understanding and coping styles
Use PANDAs technique for communicating bad news
Use strong negotiating skills to address prognosis

47. Acknowledgments Original Contribution by: Jensy Stafford, MD
Revised by:
Edward Martin, MD
Lynn McNicoll, MD
Supported by:
Donald W. Reynolds Foundation Grant