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Breaking Bad News. Dr. Riaz Qureshi Distinguished Professor Family Medicine Dept. of Family & Community Medicine King Saud University ,Riyadh, Saudi Arabia. Breaking Bad News. Learning Objectives for Students/Trainees: To understand why this is an important part of communication skills. - PowerPoint PPT Presentation

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  • Dr. Riaz QureshiDistinguished Professor Family MedicineDept. of Family & Community MedicineKing Saud University ,Riyadh, Saudi Arabia

  • Learning Objectives for Students/Trainees:

    To understand why this is an important part of communication skills. To understand the definition of bad news. The students/trainees should become aware of: What to do? How to do it? What not to do?

    Students/Trainees should also become familiar with certain illnesses/ problems which may require giving bad news.

  • Breaking Bad NewsA difficult but fundamentally important task for all health care professionals

    Physicians feel uncertain & uncomfortable while breaking bad news, leading to being distant & disengaged from their patients.

  • Breaking Bad NewsRecent studies have shown that:Patients generally (50-90%) desire full & frank disclosure, though a sizeable minority still may not want the full disclosure.(Ley p. Giving information to patients. New York: Wiley, 1982 )

    Focused training in communication skills & techniques to facilitate breaking of bad news has been demonstrated to improve patients satisfaction & physicians comfort.

  • What is bad news?any news that drastically and negatively alters the patients view towards his future.Buckman R. BMJ1984

    It alters ones self-image : I left my house as one person & came home another.Professional cyclist Lance Armstrongs recollection

  • Examples reported by clinical consultants

    Examples of Conditions Requiring Breaking of Bad News

    Cancer related diagnosesIntra uterine foetal demiseLife long illness: Diabetes, EpilepsyPoor prognosis related to chronic diseases: loss of independenceInforming parents about their childs serious mental/physical handicapGiving diagnosis of serious sexually transmitted disease catastrophic psychosocial resultsNon clinical situations like giving feedback to poorly performing trainees or colleagues

  • Psychosocial ContextPatients response is influenced by previous experiences & current social circumstances---inappropriate timing Even simple diagnosis being incompatible with ones profession---tremors in cardiac surgeon.

    Varying needs of patient & family---patient wishes to know more himself & less information to pass on to family, family wishes vice versa.

  • Barriers to effective disclosureIt is referred by some physicians like dropping the bomb Baile W F, oncologist 2000

    Common Barriers includePhysicians fears of :Being blamed by patientNot knowing all the answersInflicting pain & sufferingsOwn illness & deathLack of trainingLack of time Multiple physicians---who should perform the task

  • Patients perspectiveMost important factors for patients include: Physicians competence, honesty & attention The time allowed for questionsStraightforward & understandable diagnosisThe use of clear language

    Parker PA, Baile WF j.clinical onc 2001

  • Family's perspectiveFamily members prefer:privacyGood attitude of the person who gives the bad newsClarity of message Competency of physiciansTime for questions

    Jurkovich GJ, et al. J Trauma 200

  • Delivering Bad News It is not an isolated skill but a particular form of communication.Frank A. Eur J of Palliat care 1997

    Rabow & Mcphee (West J. Med 1999) described: Clinicians focus often on relieving patients bodily pain, less often on their emotional distress & seldom on their suffering.

  • Delivering Bad NewsRabow & Mcphee (West J. Med 1999) synthesized a simple mnemonic of ABCDE:Advance PreparationBuild a therapeutic environment/relationshipCommunicate wellDeal with patient & family reactionsEncourage and validate emotions

  • Advance PreparationFamiliarize yourself with the relevant clinical information (investigations, hospital report)

    Arrange for adequate time in private, comfortable environment

    Instruct staff not to interrupt

    Be prepared to provide at least basic information about prognosis and treatment options (so do read it up)

  • Advance PreparationMentally rehearse how you will deliver the news. You may wish to practice out loud

    Script specific words & phrases to use or to avoid

    Be prepared emotionally

  • Build a therapeutic environment/relationshipIntroduce yourself to everyone present

    Summarise where things have got to date, check with patient/relative Discover what has happened since last seen Judge how the patient is feeling/thinking

    Determine the patients preferences for what and how much he/she wants to know

  • Build a therapeutic environment/relationship (contd)Warning shot Im afraid it looks more serious than we had hoped

    Use touch where appropriate

    Pay attention to verbal & non verbal cues Avoid inappropriate humour Assure patient that you will be available

  • Communicate wellSpeak frankly but compassionatelyAvoid medical jargonAllow silence & tears; proceed at patients paceHave the patient describe his/her understanding of the information givenEncourage questions Write things down & provide written information

    Conclude each visit with a summary & follow up plan

  • Deal with patient and family reactions Assess & respond to emotional reactions Be aware of cognitive coping (denial, blame, guilt, disbelief, acceptance, intellectualization)Allow for shut down, when patient turns off & stops listeningBe empathetic; it is appropriate to say Im sorry or I dont know. Crying may be appropriate Dont argue or criticize colleagues

  • Encourage and validate emotions Offer realistic hope

    Give adequate information to facilitate decision making Explore what the news means to the patient & inquire about spiritual needs

    Inquire about the support systems in place

  • Encourage and validate emotionsAttend to your own needs during and following the delivery of bad news (counter-transference can be harmful)

    Use multidisciplinary services to enhance patient care ( hospice)Formal or informal debriefing session with concerned team members may be appropriate

  • What to do?Introduce yourselfLook to comfort and privacyDetermine what the patient already knowsWarn the patient that bad news is comingBreak the Bad NewsIdentify the patients main concernSummarize and check understandingOffer realistic hopeArrange follow up and make sure that some one is with the patient when he leaves

  • How to do it ?Be sensitiveBe empathic and consider appropriate touchingMaintain eye contact Give information in small chunksRepeat and clarifyRegularly check understandingDo not be afraid of silence or tearsExplore patients emotions and give him time to respondBe honest if you are unsure about something

  • What not to do ?HurryGive all the information in one goGive too much informationUse medical jargon or unclear language/wordsLie or be economical with the truthBe blunt. Words can be like loaded pistols/gunsGuess the prognosis (She has got 6 months, may be 7)

  • QuotationThe greatest revolution of our generation is the discovery that human beings, by changing the inner attitudes of their minds , can change the outer aspects of their lives.William James American Psychologist & Philosopher

  • Angry PatientWHAT TO DO?Introduce yourselfAcknowledge the persons angerTry to find out the reason for his anger, e.g. frustration, fear or guiltValidate his feelingsLet him ventilate his anger or any feelings that led to his angerOffer to do something or for him to do something

  • Angry PatientHOW TO DO IT?Sit at the same level as the patient, not too close and not too far, with eye contactSpeak calmly without raising your voiceAvoid dismissive or threatening body languageEncourage the person to speak with open ended questionsEmpathize as much as you can with verbal and non verbal cuesBe aware of your own safety

  • Angry patientWHAT NOT TO DO?Glare at the personConfront him or interrupt himPatronize him or touch himPut the blame on others/seek to exonerate yourselfMake unreasonable promisesBlock his exitIf the person is a patients relative, be mindful about confidentiality

  • SCENARIOTariq, a 55-year-old chain smoker taxi driver with persistent cough for 3 months, attends your clinic to find out the biopsy report of a lesion shown on a chest x-ray and CT scan. He is rather anxious, that he has a serious condition.

    His biopsy report confirms that he has a Bronchogenic Carcinoma of right lung.

    You are required to proceed with this consultation.

  • Scenario No 2A 54-year-old lady attends your clinic to find out the result of an MRI of her spine. She has had constant pain all over her spine for the last 2 months. She also has a history of Breast cancer, which was treated 5 years ago. Her report shows that she has secondaries all over her spine

    Proceed with this consultation. (Examination not required)

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