Transcript Communication Skills in Medicine: Delivering Bad News – An

Communication Skills in Medicine
- Delivering Bad News
An Introduction to Internet
Resources in English
Podzim ’02 - Špindlerův Mlýn
Pavel Kurfürst, ÚCJ LF UP
BAD NEWS
• any news that drastically and negatively
alters the patient’s view of his or her future
(Vandekieft)
• it results in a cognitive, behavioral,
or emotional deficit in the person
receiving the news that persists for some
time after the news is received
(Back – Curtis)
BAD NEWS
• many health care professionals tend
to define 'bad news' as worst case
scenarios (eg. telling a patient they have
cancer or that their loved one has died)
• but a knee cartilage problem requiring rest
for a waitress may mean no pay
(RFC handbook)
SITUATIONS
• terminal diagnosis
• death in an out-ofhospital setting
• communicating
sensitive subjects to
parents and children
• fetal death verified
by an ultrasound
• multiple sclerosis
confirmed by MRI
• onset of diabetes
in an adolescent
THE PAST AND THE PRESENT
• Hippocrates advised concealing most
things from the patient
• older physicians, who trained during
the 1950s and 60s, were taughtto "protect"
patients from disheartening news
(Easton)
• in the past decades traditional paternalistic
models of patient care have given way
to an emphasis on patient autonomy
FACTS
• 50-90% of patients desire full disclosure
of a terminal diagnosis
(Vandekieft)
• 95% of cancer patients want the physician
to be fully honest with them about
the outcome of their illness
(Thomas)
FACTS
• over the course of a 40-year career,
an oncologist may conduct up to 200,000
interviews with patients, caregivers
and/or families;
if as few as 10% of those interviews
involve the disclosure of bad news,
that is still 20,000 interviews in which
you have to be the bearer of bad news
(Buckman)
EDUCATION
• clinicians are responsible for delivering bad
news, this skill is rarely taught in medical
schools, clinicians are generally poor at it
(Rabow – McPhee)
• breaking bad news is one of a physician’s most
difficult duties
• medical education typically offers little formal
preparation for this task
(Vandekieft)
EDUCATION
• 1997-1998 AMA survey: only 4 of 126 US
medical schools required a separate
course on caring for the dying
(Acevedo)
• many medical graduates have persisting
interpersonal difficulties when confronted
with terminally ill patients, death and dying
(Barrington – Murrie)
EDUCATION
• historically, the emphasis on the biomedical
model in medical training places more
value on technical proficiency than
on communication skills
• in ancient times, the bearer of the news
that a battle had been lost was often killed;
in a similar fashion, reacting to bad news,
some patients blame their clinicians
(Rabow – McPhee)
• death represents a failure of the medical
system, our failure as physicians,
and even our failure as human beings
(West)
• clinicians focus often on relieving patients' bodily
pain, less often on their emotional distress,
seldom on their suffering
• they may view suffering as beyond their
professional responsibilities
• if clinicians feel unable to, or simply do not want
to, address the powerful issue of patient
suffering, it is appropriate to refer the patient
to another professional on the healthcare team
who is more comfortable in this arena
(Rabow – McPhee)
• breaking bad news is not as much
a delivery as it is a dialogue between
two people
(Rabow – McPhee)
• the patients needs to given an opportunity
to express his emotions and to articulate
his fears
(Thomas)
• the physician’s caring attitude is more
important than the information provided
during the clinical encounter
(Back – Curtis)
• clinicians can deliver bad news well and
manage its consequences
(Rabow – McPhee)
COMMUNICATE AS A TEAM
•
•
•
•
patient
family
physician
other health care
providers
•
•
•
•
•
psychologist
chaplain
nurse
social worker
translator
GUIDELINES
• several professional groups have
published consensus guidelines on
how to discuss bad news
• few of those guidelines are evidencebased
• the clinical efficacy of many standard
recommendations has not been
empirically demonstrated
(Vandekieft)
S-P-I-K-E-S
• a six-step approach by R. Buckman
• proposed by the Project to Educate
Physicians on End-of-life Care (EPEC)
- supported by the American Medical
Association and the Robert Wood
Johnson Foundation
S-P-I-K-E-S
•
•
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•
•
•
setting
perception
invitation
knowledge
empathy
strategy and Summary
(Buckman; Maicki; Acevedo; Payne; EPEC materials; Michigan PG)
ABCDE
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•
•
•
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advance preparation
build a therapeutic environment/relationship
communicate well
deal with patient and family reactions
encourage and validate emotions
(reflect back emotions)
(Rabow – McPhee; Vandekieft; Dyer)
OTHER GUIDELINES
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•
•
•
•
•
preparation
place
people
position
pronouncement
post-event follow up
(Rodgers)
OTHER GUIDELINES
• preparation
• introduction
• achieving
understanding
• pacing and shared
control
(Rodgers)
• responding
to emotions
• honesty
• support
• closure
OTHER GUIDELINES
•
•
•
•
•
•
preparation
setting
delivery
emotional Support
information
closure
(Gordon)
OTHER GUIDELINES
•
•
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•
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prepare for the encounter
assess the patient’s understanding
discuss the news
respond to the patient’s emotions
offer to discuss implications of the news
summarize the discussion
arrange a follow-up time for patient and family
questions and concerns
• document the discussion in the medical record
(Back – Curtis)
OTHER GUIDELINES
• the World Health Organisation (WHO)
Guidelines on Communicating Bad News
• WHO/MNH/PSF/93.2.B
(WHO Guidelines on Communicating Bad News - adapted abstract)
REMEMBER
people handle information differently
depending on their
• educational level
• ethnicity and culture
• religion, beliefs
• socioeconomic status
• age
(Michigan Physician Guide)
REMEMBER
•
technical language usually misunderstood
by the patient
(73% of women with breast cancer
do not understand the term MEDIAN
when told about prognosis and survival)
(Back - Curtis)
•
•
avoid euphemisms
do not minimize the severity of the situation
(Michigan Physician Guide)
REMEMBER
never give bad news on a Friday!
(RFC handbook)
KEY WORDS
• communicating / delivering / breaking /
giving bad news
• communication skills / communication
issues / doctor-patient communication
• end-of-life care / palliative care / palliative
medicine
• end-of-life communication
RESOURCES
see a separate list of resources
click here (*.rtf file)
CONTACT
[email protected]
www.ucjlf.upol.cz/svoc