1. Delivering Bad News Matthew Butteri, MD. Assistant Professor of Medicine UCI School of Medicine

2. Impressions

3. Media Reference Think what Dr. House would do and then simply do the opposite. Bonus topic: What about his cane?

4. Include the key players Ask the patient who they want involved in the discussion of important issues Don’t violate HIPPA

5. SPIKES Setting up the interview Perceptions Invitation Knowledge Emotions Strategy/Summary

6. Setting up Arrange for privacy Involve significant others Sit down and appear un-hurried Make an emotional connection Make arrangements to avoid interruptions - eg. Hand off your pager if possible

7. Perceptions Use open ended questions to assess the patient and their families perception of the medical situation. Careful not to talk down or above What is your understanding of your … What have you been told so far?

8. Invitation Explore if the patient wants all the facts or (as you know in some cultures) they may say my daughter or son will take care of everything. How would you like me to give the information about test results?

9. Knowledge A brief warning shot may help Warning that bad news is coming may help lessen the shock. Unfortunately I have some bad news to share then say it clear and concisely. Avoid medical jargon: - say “spread” instead of metastasis

10. The Patient’s Emotions Expect anything: - silence - disbelief - crying - denial - anger - shock

11. Your Emotions Sit and listen, connect with your eyes, hold their hand - whatever is natural I wish the news were different Can empathy be learned?

12. Strategy and Summary Make sure “the emotion part” has cleared enough for this step When ready in “broad strokes” talk about the various treatment options Remind them that many specialists will likely be involved in their care Leave them with some kind of realistic hope. Let them know you will support them through this process.

13. case # 1 The family says do not tell mom that she has pancreatic cancer because the news will destroy her and she will give up hope. How do you proceed?

14. case # 2 A patient with severe dementia has a massive CVA and the only daughter lives out of state. How do you proceed?

15. case # 3 You diagnose metastatic cancer in a patient who can not speak for themselves and there is no DPOA or POLST. The oldest of many children says ok to shock and do CPR but do not put my dad on a breathing machine. How do you proceed?

16. case # 4 You just updated the family about some devastating news. The son slams his first on the table says “I’m going to bust some heads if anything bad happens to mom” then storms out of the room slamming the door on the way out. What are your next steps?

17. case # 5 It’s 3am and you are the night float and one of your 50 patients goes into PEA and dies after a 20 minute code. You learn from a colleague that their was a delay in care that might have lead to this outcome. The husband is at the bedside and wants to know what happened? How do you proceed?

18. Spikes Setting up the interview Perceptions Invitation Knowledge Emotions Strategy/Summary

19. Final Thoughts Resolve key issues before delivering bad news Obtain relevant information before giving news Choose the appropriate setting Have support staff available Be compassionate and empathetic Be direct (don’t avoid the topic or break it slow) Be available

20. Provide Hope That is realistic and honest.

21. Thank you