Transcript Another Hepatosplenomegaly? More than one is needed!

The Art
of
Breaking
Bad
News
Breaking Bad News




Why is breaking bad news an important
issue for doctors?
The experience of a life threatening illness is
devastating for most patients and their families
They have a need for information and emotional
support
Information should be delivered in an optimal
manner so as to provide support for them
Communication Skills
Preparedness

1.
2.
To characterize and compare incoming
residents' self-reported
amount and sufficiency of medical school
training in clinical communication for patients
of different ages
training experience and anticipated comfort
level when breaking news of serious
diagnoses with patients of different ages
Dubé et al, Ambul Pediatr. 2003 May-Jun
Are the Residents Prepared?





143 residents self-assessments
Estimates of training time with adult patients
were greater than any other patient age
category and were rated most sufficient.
12% reported no formal training in pediatric skills
> Half reported: never observed a pediatric or
adolescent "bad news" interaction.
Half of the respondents had personally informed
a patient or family of a serious diagnosis, most
often concerning middle-aged or elderly.
Dubé et al, Ambul Pediatr. 2003 May-Jun
Residents Feel Less Prepared
Respondents had their greatest discomfort
discussing serious illness in younger
patients compared to adults.
 Residents feel less prepared for and
receive less training in general
communications skills, particularly skills
required for delivering bad news, in
pediatric clinical interactions compared to
interactions with adult patients.

Dubé et al, Ambul Pediatr. 2003 May-Jun
Talk to Your Patients


“A five-year-old may not understand science but
will understand an explanation of how they will
feel and what they will experience going through
a diagnostic procedure,”
The authors recommend that residencies create
as many opportunities as possible for new
doctors to develop communication skills for
breaking bad news to children, teens and loved
ones.
Dubé et al, Ambul Pediatr. 2003 May-Jun
General Principles
Who should tell patients?
 One person only should be responsible for
breaking bad news, and usually this
should be the primary physician.
 Make sure that the patient knows your
name, role and designation.

What to tell?
The patient has a legal and moral right to
accurate, reliable information
 Primary responsibility is to the individual
patient & parents.
 Responsibility to relatives is important but
secondary.
 Ensure that the patient understands
treatment options and the reasons for any
future investigations.

Different ways of coping
Some cope by learning as much as
possible about a situation so they can feel
more in control.
 Others prefer not to know and cope by
avoiding thinking about it.

When to tell?
The patient should be prepared for the
possibility of bad news as early as
possible in the diagnostic process, by the
doctor of first contact.
 If a number of investigations are being
performed, do not give results of each test
individually: Plan a consultation when all
results are available.

Where to Tell?
Make every effort to ensure privacy and
make the patient feel comfortable.
In a hospital setting
Avoid giving the patient the news during
ward rounds.
 Find a private room.
 If possible, both the Senior and Junior
Medical Staff should be present to ensure
that the information given is reinforced at a
later point by the relevant Junior Medical
Practitioner.

Cont. Where to Tell
Close the curtains around a patient’s bed.
 Sit at the bedside at eye level with the
patient rather than stand over the patient.
 Ensure the patient is clothed.
 Ensure that interruptions such as beepers
and telephone calls do not occur.

Others
Where possible arrange for other health
professionals, such as a nurse or social
worker, to be present when breaking bad
news.
 This person should be someone to whom
the family have access after you have left,
to provide support and supplement
information.

Non Verbal Communication
Use non verbal cues to convey warmth,
sympathy, encouragement or reassurance
to the patient.
 In most cultural groups, this involves
making eye contact, facing the patient, not
interrupting when the patient is speaking,
nodding encouragingly, and giving full
attention to the patient.

Cont. Non Verbal Communication
It is critical that the patient feels that you
have time to talk and listen.
 Hence, avoid writing notes, reading the
patient’s files, or looking elsewhere when
the patient is talking to you.
 In some cases, touch can be very
reassuring for the patient, and in other
cases it may not be appreciated.

Dealing with language and cultural
differences
Employ a trained health interpreter
whenever there is a language difference
between the doctor and patient.
 Be sensitive to the person’s culture, race,
religious beliefs and social background.
 If appropriate, consult a health
professional who has detailed knowledge
and experience of that culture.

Meet the Family
Tell the patient his/her diagnosis as soon
as it is certain.
 Make every attempt to tell the family in
person, almost never by phone.
 Make sure sufficient time is allocated for
this consultation.

10 Steps in Breaking Bad News
1- Ensure privacy and adequate
time
Give the patient the bad news in a place
which is quiet ad private.
 Allow enough uninterrupted time during
the initial meeting for the family to think
about what you are going to tell, so that
they can discuss it with you and ask you
questions.
 Ensure that interruptions, such as beepers
and telephones, do not occur.

2- Assess Understanding
Assess the patient’s understanding of the
situation.
 The patient may already be quite aware
that the prognosis is likely to be bad, or
they may have very little awareness of
this.
 Their response will provide an appropriate
starting point for you.

Assess Understanding

eg ‘I know the last few weeks of waiting
must have been quite difficult for you. How
much do you know about your condition?’
3- Provide information simply and
honestly
Tell the patient the diagnosis and
prognosis honestly and in simple
language, though not bluntly.
 Avoid technical jargon, which obscure the
truth.
 If the patient has cancer, then use this
word.
 Give the facts which are relevant to the
diagnosis and for management.

Provide information simply and
honestly



As the family may still be adjusting to the news,
the facts may need to be repeated or revised
several times and on different occasions.
Were relevant, write the information down, or
use pamphlets and diagrams.
eg. ‘Yes, the tests show your child has . ..(type
of disease). It is certain because all the tests
indicate the same result...’
4- Encourage patients to express
feelings






Allow and encourage the family to express their
feelings, such as crying.
Some immediate reactions may be dumbness,
disbelief, anger or acute distress.
Accept these feelings and concerns by letting
them know that it is quite normal to feel this way.
This helps the patient feel accepted and to
discuss their concerns.
Have tissues available!
Respond to the family’s feelings with empathy.
Encourage patients to express feelings


eg ‘This is obviously bad news and it is
understandable that you are very upset about it.
Many patients feel upset or even angry when
they receive this kind of news. However, it is
important not to jump to any conclusions.
Although you have . ..(disease) it is far too early
to say what will happen to you.’
(NB: the latter part of this statement may not be
relevant in clearly terminal cases)
5- Give a broad time frame


Avoid giving a prognosis with a definite time
scale, but, if possible, give the patient a broad,
realistic time frame which will allow them to
arrange their life & personal affairs.
eg ‘this obviously comes as a shock, but it is
important not to jump to the wrong conclusions.
No one can tell you exactly what will happen, but
many patients with this disease have survived
for . . . . . . . (realistic time).’
6- Avoid the notion of ‘nothing more
can be done’



Even if the disease is too far advanced for
curative treatment, try to reassure the patient
that you will provide support (medical and non
medical) for as long as is needed to make the
patient’s remaining life as comfortable as
possible.
Where the treatment is palliative, do not pretend
that it is likely to cure the disease.
eg ‘A lot of things can be done to make your life
as normal and comfortable as possible. We will
do all we can to help you through this difficult
time.’
7- Arrange Review
At the end of the consultation, arrange a
time in the immediate future (preferably
within the next 24 hours) to review the
situation with the family.
 In the interim period, either be personally
available or nominate someone else if the
family has any questions or concerns.
 Write this information down.

Arrange Review

eg ‘I know this is a lot to take in at this stage, so
why don’t we meet again tomorrow after you’ve
had a chance to think about it more clearly and
to discus it with your family / friends. You will
probably think of a lot of questions in the
meantime. Just write them down so you won’t
forget them, and I will do my best to answer
them at our next meeting. In the meantime, if
you have any concerns, don’t hesitate to contact
either me on . . . . . . . or Dr Mohammad . . . ...’
8- Discuss treatment options




Discuss the possible treatment options and their side
effects with the family at this stage.
Make it clear to the patient that a treatment
recommendation will be made to them, but that they will
be involved in the final decision about it.
As far as possible, ensure that there is consensus
amongst the health care providers about the treatment
options prior to discussing these with the patient.
eg ‘There are a number of things we maybe able to do,
including . . . . . . .(eg. chemotherapy, radiotherapy,...).
Where possible, we will ensure that you are involved in
deciding on the treatment.’
9- Offer assistance: to tell others




Ask the family who they would like to tell about
the situation, and then offer assistance and
support in telling these people.
These may include children, other family
members or employers.
Encourage family meetings to discuss issues
which arise over time and answer questions
honestly.
If there are children involved, then involve a
health professional used to dealing with children.
Offer assistance to tell others

eg ‘There are people who will want to
know what is happening to you. Are there
particular people you would like me to tell
specifically? Are there people you would
not wish to have the information? I would
be happy to talk with anyone, either on the
phone or in a general discussion with your
family or other special friends.’
Offer assistance: Provide information
about support services
Give the patient information about the
availability of various support services,
such as religious scholars, cancer support
groups, palliative care services,
bereavement counseling, internet groups
& websites
 Suggest referral to these if desired
 Reinforce that the general practitioner will
also be an important support all the time

Support services
Eg ‘there are a number of different people
and support groups who you and your
family may find it helpful to talk to.
 Talking about your situation with others
who have been through a similar
experience may help you to cope with it.
 Your general practitioner will also be there
for you.’

10- Document information given



Document what the patient has been told, which
family/other members have been told, who is
permitted to know about the patient’s situation,
and the patient’s reaction to the news.
Be concise and include this on their medical
record.
Include this information on the discharge
summary which goes to the patient’s general
practitioner and to any others involved.
Summary: Steps in breaking bad news







Give bad news in a quiet, private place.
Allow enough uninterrupted time in initial
meeting.
Assess patient’s understanding.
Provide information simply and honestly.
Encourage patients to express feelings.
Respond to patients’ feelings with empathy.
Give a broad time frame for the prognosis.
Cont. Steps
Avoid the notion of ‘I know how you
feel’ or ‘nothing more can be done’
 Arrange a time to review the situation.
 Discuss treatment options.
 Offer assistance to tell others.
 Provide information about support
services.
 Document information given.

Techniques to aid patient recall of
information

The following assist in
the recall and
comprehension of
information, and maybe
used when this seems
appropriate, and not
necessarily in the first
consultation:
Techniques to aid patient recall of
information
1.
2.
3.
4.
5.
Make information simple, clear and
specific.
Avoid technical terms, use layperson’s
terms.
Speak slowly and clearly.
Present your advice in categories.
Repeat important pieces of information.
Techniques to aid patient recall of
information
6.
7.
8.
9.
10.
Audiotape the consultation.
Use simple diagrams or models.
Write down important information.
At the end: Ask the family to convey to
you their understanding of what you have
told them.
Make sure there are no questions left
unanswered.
Take Home Message
“‫”وما أرسلناك إال رحمة للعالمين‬
107 ‫ اآلية‬،‫سورة األنبياء‬
“And We have sent you
(O Muhammad) not but
as a mercy for the
mankind & all that
exists”
The Holy Qur’an 21:107
Please:
Following these
Break that
steps ensure
patientsBad
who are
diagnosed with a life
News
threatening illness
are informed
Gently!of their
diagnosis in an
optimal manner,
and are provided with
the support required
to deal with the
news.
Good Luck!
Ref.

NSW Cancer Council: How to Break Bad
News
 Communicating
 A Reading
Bad News
Model, Education for Physicians
on End-of-life Care (EPEC) curriculum, Final
version 9/17/04

Pub-Med Search
! ‫شكراً لحُسن اصغائكم‬
Thank You For Your Good Attention !
www
“Communicating Bad News: A Reading Module” on:
www.geocities.com/kkuh_pedia/
Your comments & feedback are welcome!
[email protected]