How to Break Bad News in a Clinical Setting Presented to UC Irvine FM Scholars March 16, 2009

1. How to Break Bad News in a Clinical SettingPresented to UC Irvine FM Scholars March 16, 2009 Kristin Kleppe, Psy.D. Director of Behavioral Science Dept of Family Medicine UC Irvine Types of bad news family physician might encounter: diagnosis such as cancer or diabetes or a pregnant patient�s ultrasound reveals a fetal demise, others? Bad news is any information that produces a negative alternation to a person�s expectations about their present and future� it is subjective � dependent on a person�s life experiences, personality, spiritual beliefs, philosophy about life, perceived social supports, and emotional hardiness. Recognition has grown of the need to integrate appropriate communication skills training in medical school and residency programs. Research has shown that if bad news is communicated badly it can cause confusion, long lasting distress, resentment and - if done well, it can assist understanding, acceptance and adjustment, patient satisfaction, enhanced adherence to treatment and decreased litigation (Barclay). Have they ever received any bad news? Memories of? Types of bad news family physician might encounter: diagnosis such as cancer or diabetes or a pregnant patient�s ultrasound reveals a fetal demise, others? Bad news is any information that produces a negative alternation to a person�s expectations about their present and future� it is subjective � dependent on a person�s life experiences, personality, spiritual beliefs, philosophy about life, perceived social supports, and emotional hardiness. Recognition has grown of the need to integrate appropriate communication skills training in medical school and residency programs. Research has shown that if bad news is communicated badly it can cause confusion, long lasting distress, resentment and - if done well, it can assist understanding, acceptance and adjustment, patient satisfaction, enhanced adherence to treatment and decreased litigation (Barclay). Have they ever received any bad news? Memories of?

2. Objectives Identify and dispute irrational beliefs related to death, disease, and your role as a physician Identify basics of effective communication skills Identify optimal protocols for giving bad news to patients or their families

3. Objective #1 Identify and dispute irrational beliefs related to death, disease, and your role as a physician

4. Fear of Death and Dying Death anxiety will create fear and therefore create an obstacle; to discuss life/death issues, you must have resolved personal issues related to death and dying. Existentiality is not a subject taught in medical school but it can give great impact to physician's ability to deliver bad news and manage anxiety/feelings following. (Friedrichsen). Contributes to physician burn-out and depression especially in fields like oncology where physician might have 35 sessions a month where he/she is required to give bad news. Death anxiety will create fear and therefore create an obstacle; to discuss life/death issues, you must have resolved personal issues related to death and dying. Existentiality is not a subject taught in medical school but it can give great impact to physician's ability to deliver bad news and manage anxiety/feelings following. (Friedrichsen). Contributes to physician burn-out and depression especially in fields like oncology where physician might have 35 sessions a month where he/she is required to give bad news.

6. Borrowing from Cognitive Therapy Epictetus (Epik-tee-tus) around 2,000 years ago: "Men are disturbed not by events, but by the views which they take of them." REBT (Albert Ellis) Antecedent, Belief (about event), Consequence (A does not cause C; B causes C), Dispute (also acceptance)Epictetus (Epik-tee-tus) around 2,000 years ago: "Men are disturbed not by events, but by the views which they take of them." REBT (Albert Ellis) Antecedent, Belief (about event), Consequence (A does not cause C; B causes C), Dispute (also acceptance)

7. Small Group Exercise Identify irrational beliefs related to giving patients or their families bad news Dire need to help, guilt feelings, feelings of incompetency, countertransference, over identification with patient's suffering. (�I must ease the pain; I cannot tolerate it if �. ; I have to be successful with all my patients all the time; I must be able to answer all questions such as �How much time does my mother have left?�; I must not lose control.� Include existential fears.Dire need to help, guilt feelings, feelings of incompetency, countertransference, over identification with patient's suffering. (�I must ease the pain; I cannot tolerate it if �. ; I have to be successful with all my patients all the time; I must be able to answer all questions such as �How much time does my mother have left?�; I must not lose control.� Include existential fears.

9. Disputing Irrational Beliefs Where is the evidence? Is it logical? Is it consistent with reality? Can I really NOT tolerate it? How is the belief serving me? What do I risk by letting go? Consider IB as hypothesis that needs to be challenged, tested and then surrendered if not proven. Re-examine feelings of helplessness not as failure and weakness but as a normal response; humanity of helplessness. Consider IB as hypothesis that needs to be challenged, tested and then surrendered if not proven. Re-examine feelings of helplessness not as failure and weakness but as a normal response; humanity of helplessness.

10. Learning Objective #2 Identify basics of effective communication skills Non-verbal Para-verbal Verbal

11. Non-verbal Communication Position, proximity, posture, touch, facial expressions, eye contact, gestures active listening skills Position, proximity, posture, touch, facial expressions, eye contact, gestures active listening skills

12. Para-verbal Communication

13. Verbal Communication Be genuine! Facilitative listening Empathic, reflective and summarizing statements �I�m sorry�� but for what? Avoid clich�s and platitudes Presaging Facilitating Listening: 1) echoing, repeating key words or phrases, 2) reflecting content (summarizing or making an interpretation) 3) reflecting feeling (helps person label the emotions they are feeling) Presaging: preparing patient for expected negative outcome: �The doctors are doing all that they can but I�m sorry it does not look good.� Gradual build-up to what is expected to be bad news. Facilitating Listening: 1) echoing, repeating key words or phrases, 2) reflecting content (summarizing or making an interpretation) 3) reflecting feeling (helps person label the emotions they are feeling) Presaging: preparing patient for expected negative outcome: �The doctors are doing all that they can but I�m sorry it does not look good.� Gradual build-up to what is expected to be bad news.

14. Objective #3 Identify optimal protocols for giving bad news to patients or their families Patients and family members want empathy, respect and openness � cannot be reduced to a protocol driven response set. Excellent communication skills most important but if you don�t have strong communication skills � be genuine and speak from the heart. Patients and family members want empathy, respect and openness � cannot be reduced to a protocol driven response set. Excellent communication skills most important but if you don�t have strong communication skills � be genuine and speak from the heart.

15. A-B-C-D-E Model from Rabow and McPhee cited in Vandekieft A � Advance Preparation: arrange adequate time and privacy, confirm medical facts, review relevant clinical data emotionally prepare for the encounter. Turn off pager or leave it with a colleague. Instruct staff � no interruptions. Formulize words ahead of time if new to process. B � Build a therapeutic relationship: identify patient preferences regarding disclosure of bad news. Do they want family members present? Study on patient preferences reflected that 50-90% of patients desire full disclosure but that means small minority still do not want bad news. (Vandekieft) So � how would the patient like bad news addressed? Introduce self to everyone present and ask for names and relationship to patient. Foreshadow the news with �I�m sorry but I have bad news.� Use touch only if appropriate. Schedule follow-up meetings and/or plan. Be sensitive to cultural differences. C � Communicate well: determine the patient�s knowledge and understanding of the situation, proceed at patient�s pace, avoid medical jargon and euphemisms, allow for silence and tears, avoid the urge to talk, answer questions. Be aware much of what you said might not be remembered. Find out what patient or family they already know or understand. At conclusion, summarize and make follow-up plans. At subsequent visits, use repetition. D � Dealing with patient and family reactions: assess and respond to emotional reactions and empathize. Be aware of cognitive coping strategies such as blame, denial, intellectualization, disbelief. Be attuned to body language and assess at future visits for despondency or suicidal ideation. Do not argue with or criticize colleagues. Avoid defensiveness; be aware of counter-transference. E � Encouraging and validating emotion: offer realistic hope based on patient�s goals. Discuss treatment options. Explore what the news means to the patient. Inquire about what support systems they have in place. Offer referrals as needed. Use interdisciplinary resources as appropriate such as LCSW or chaplain. Deal with your own needs; is de-briefing session needed?Model from Rabow and McPhee cited in Vandekieft A � Advance Preparation: arrange adequate time and privacy, confirm medical facts, review relevant clinical data emotionally prepare for the encounter. Turn off pager or leave it with a colleague. Instruct staff � no interruptions. Formulize words ahead of time if new to process. B � Build a therapeutic relationship: identify patient preferences regarding disclosure of bad news. Do they want family members present? Study on patient preferences reflected that 50-90% of patients desire full disclosure but that means small minority still do not want bad news. (Vandekieft) So � how would the patient like bad news addressed? Introduce self to everyone present and ask for names and relationship to patient. Foreshadow the news with �I�m sorry but I have bad news.� Use touch only if appropriate. Schedule follow-up meetings and/or plan. Be sensitive to cultural differences. C � Communicate well: determine the patient�s knowledge and understanding of the situation, proceed at patient�s pace, avoid medical jargon and euphemisms, allow for silence and tears, avoid the urge to talk, answer questions. Be aware much of what you said might not be remembered. Find out what patient or family they already know or understand. At conclusion, summarize and make follow-up plans. At subsequent visits, use repetition. D � Dealing with patient and family reactions: assess and respond to emotional reactions and empathize. Be aware of cognitive coping strategies such as blame, denial, intellectualization, disbelief. Be attuned to body language and assess at future visits for despondency or suicidal ideation. Do not argue with or criticize colleagues. Avoid defensiveness; be aware of counter-transference. E � Encouraging and validating emotion: offer realistic hope based on patient�s goals. Discuss treatment options. Explore what the news means to the patient. Inquire about what support systems they have in place. Offer referrals as needed. Use interdisciplinary resources as appropriate such as LCSW or chaplain. Deal with your own needs; is de-briefing session needed?

16. Telling Parents Counter-transference Answering questions Suspicions about abuse Responding to guilt Allow parents to hold child, if desired Mementoes of baby Arrange F/U visit with LCSW or other Mementoes could include photo (stillborn death), lock of hair, footprint Answering Questions: did he suffer, how long did it take, was it painful, would �x� have prevented it? Explain routine involvement of the police in sudden unexpected cases such as SIDS death. Ask parent if they want to help bathe or clean child�s body. Explain why any tubes or equipment remains before they view body. Describe injuries or signs of trauma or death before they view body. Mementoes could include photo (stillborn death), lock of hair, footprint Answering Questions: did he suffer, how long did it take, was it painful, would �x� have prevented it? Explain routine involvement of the police in sudden unexpected cases such as SIDS death. Ask parent if they want to help bathe or clean child�s body. Explain why any tubes or equipment remains before they view body. Describe injuries or signs of trauma or death before they view body.

17. Telephone or In-Person Notification? Death Notification: Discussion Question � better to lie and get person to the hospital safely? Diagnosis Notification: Patient PreferencesDeath Notification: Discussion Question � better to lie and get person to the hospital safely? Diagnosis Notification: Patient Preferences

18. Requesting Organ & Tissue Donation Federal law Wait as long as possible after death notification Federal law requires hospitals to offer survivors opportunity to donate loved one�s organs and tissue (PL 99-5-9; Section 9318) Some people upset if asked; others upset if not asked. University of Kentucky study found that 57% agree to donate if requestors waited until family had acknowledged death. If request accompanied the death notification, less than 18% agreed. Federal law requires hospitals to offer survivors opportunity to donate loved one�s organs and tissue (PL 99-5-9; Section 9318) Some people upset if asked; others upset if not asked. University of Kentucky study found that 57% agree to donate if requestors waited until family had acknowledged death. If request accompanied the death notification, less than 18% agreed.

19. What Would you Do When�. Scenarios: Cultural implications � culture where bad news should be withheld from aging parent (consistent with past medical models in U.S that were more paternalistic. 1800�s AMA Code of Ethics included statements about not giving bad news to patients if it would cause distress that might impact their health.) Japanese speaking American patients � 23% reported bad news be disclosed in a non-verbal way or through inference and Asian patients view direct statements as insensitive , rude or uncaring (Barclay). Cultural competence is about understanding that everyone brings their own cultural context to an encounter. In recent years, U.S. physicians have emphasized respect for autonomy, individual rights, informed consent, and collaborative decision-making models. Respect for cultural differences includes recognizing that other values such as expectations for a paternalistic, directive medical model may inform the choices of some patients (Barclay). Dealing with Anger: safety first, acknowledge anger, do not raise voice, stay calm and quiet, quickly set limits if needed. Anger could manifest as a) Verbal Demands (Sense of impatience, inappropriate expectations, sense of irritation or frustration) b) Verbal Abuse (incriminations of incompetence, incriminations of neglect or abuse, slanderous comments) c) Physical Acting Out (speaking in a loud voice or screaming, throwing or striking objects or a person) Scenarios: Cultural implications � culture where bad news should be withheld from aging parent (consistent with past medical models in U.S that were more paternalistic. 1800�s AMA Code of Ethics included statements about not giving bad news to patients if it would cause distress that might impact their health.) Japanese speaking American patients � 23% reported bad news be disclosed in a non-verbal way or through inference and Asian patients view direct statements as insensitive , rude or uncaring (Barclay). Cultural competence is about understanding that everyone brings their own cultural context to an encounter. In recent years, U.S. physicians have emphasized respect for autonomy, individual rights, informed consent, and collaborative decision-making models. Respect for cultural differences includes recognizing that other values such as expectations for a paternalistic, directive medical model may inform the choices of some patients (Barclay). Dealing with Anger: safety first, acknowledge anger, do not raise voice, stay calm and quiet, quickly set limits if needed. Anger could manifest as a) Verbal Demands (Sense of impatience, inappropriate expectations, sense of irritation or frustration) b) Verbal Abuse (incriminations of incompetence, incriminations of neglect or abuse, slanderous comments) c) Physical Acting Out (speaking in a loud voice or screaming, throwing or striking objects or a person)

20. Summary Identify and dispute irrational beliefs related to death, disease, and your role as a physician Identify basics of effective communication skills Identify optimal protocols for giving bad news to patients or their families Insensitive approach in giving bad news can increase the distress of recipients, may exert a lasting negative impact, and affect their ability to adapt and adjust, can lead to anger and can increase the risk of litigation. Insensitive approach in giving bad news can increase the distress of recipients, may exert a lasting negative impact, and affect their ability to adapt and adjust, can lead to anger and can increase the risk of litigation.

21. References Barclay, J. S., Blackhall, L. J., & Tulsky, J. A. (2007). Communication strategies and cultural issues in the delivery of bad news. Journal of Palliative Medicine, 10 (4). Bendapudi, N. M., Berry, L. L., Frey, K. A., Parish, J. T., & Rayburn, W.L. (2006). Patient�s perspectives on ideal physician behaviors. Mayo Foundation for Medical Education and Research. Iserson, K. V. (1999). Grave words: Notifying survivors about sudden, unexpected deaths. Tucson, AZ: Galen Press. Fallowfield, L. & Jenkins, V. (2004). Communicating sad, bad, and difficult news in medicine. Lancet, 363, 312-19.

22. References Friedrichsen, M. & Milberg, A. (2006). Concerns about losing control when breaking bad news to terminally ill patients with cancer: Physician�s perspective. Journal of Palliative Medicine, 9 (3). Vandekieft, G. K. (2001). Breaking bad news. American Family Physician, 64, 1975-8.