Breaking Bad News

1. Breaking Bad News Dr. Riaz Qureshi Distinguished Professor Family Medicine Dept. of Family & Community Medicine King Saud University ,Riyadh, Saudi Arabia

2. Breaking Bad News 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.

3. Breaking Bad News • A 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.

4. Breaking Bad News • Recent 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.

5. What is bad news? • “any news that drastically and negatively alters the patients view towards his future.” • Buckman R. BMJ1984 • It alters one’s self-image : “I left my house as one person & came home another.” • Professional cyclist Lance Armstrong’s recollection

6. Examples reported by clinical consultants Examples of Conditions Requiring Breaking of Bad News • Cancer related diagnoses • Intra uterine foetal demise • Life long illness: Diabetes, Epilepsy • Poor prognosis related to chronic diseases: loss of independence • Informing parents about their child’s serious mental/physical handicap • Giving diagnosis of serious sexually transmitted disease …catastrophic psychosocial results • Non clinical situations like giving feedback to poorly performing trainees or colleagues

7. Psychosocial Context • Patients response is influenced by previous experiences & current social circumstances---inappropriate timing • Even simple diagnosis being incompatible with one’s 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.

8. Barriers to effective disclosure • It is referred by some physicians like “dropping the bomb” • Baile W F, oncologist 2000 Common Barriers include Physician’s fears of : • Being blamed by patient • Not knowing all the answers • Inflicting pain & sufferings • Own illness & death • Lack of training • Lack of time • Multiple physicians---who should perform the task

9. Patient’s perspective Most important factors for patients include: • Physician’s competence, honesty & attention • The time allowed for questions • Straightforward & understandable diagnosis • The use of clear language • Parker PA, Baile WF j.clinical onc 2001

10. Family's perspective Family members prefer: • privacy • Good attitude of the person who gives the bad news • Clarity of message • Competency of physicians • Time for questions • Jurkovich GJ, et al. J Trauma 200

11. 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.”

12. Delivering Bad News Rabow & Mcphee (West J. Med 1999) synthesized a simple mnemonic of ABCDE: • Advance Preparation • Build a therapeutic environment/relationship • Communicate well • Deal with patient & family reactions • Encourage and validate emotions

13. Advance Preparation • Familiarize 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)

14. Advance Preparation • Mentally 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

15. Build a therapeutic environment/relationship • Introduce 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 patient’s preferences for what and how much he/she wants to know

16. Build a therapeutic environment/relationship (contd) • Warning shot “I’m 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

17. Communicate well • Speak frankly but compassionately • Avoid medical jargon • Allow silence & tears; proceed at patient’s pace • Have the patient describe his/her understanding of the information given • Encourage questions • Write things down & provide written information • Conclude each visit with a summary & follow up plan

18. 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 listening • Be empathetic; it is appropriate to say “I’m sorry or I don’t know. Crying may be appropriate • Don’t argue or criticize colleagues

19. 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

20. Encourage and validate emotions • Attend 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

21. What to do? • Introduce yourself • Look to comfort and privacy • Determine what the patient already knows • Warn the patient that bad news is coming • Break the Bad News • Identify the patient’s main concern • Summarize and check understanding • Offer realistic hope • Arrange follow up and make sure that some one is with the patient when he leaves

22. How to do it ? • Be sensitive • Be empathic and consider appropriate touching • Maintain eye contact • Give information in small chunks • Repeat and clarify • Regularly check understanding • Do not be afraid of silence or tears • Explore patient’s emotions and give him time to respond • Be honest if you are unsure about something

23. What not to do ? • Hurry • Give all the information in one go • Give too much information • Use medical jargon or unclear language/words • Lie or be economical with the truth • Be blunt. Words can be like loaded pistols/guns • Guess the prognosis (She has got 6 months, may be 7)

24. Quotation • The 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

25. Angry Patient WHAT TO DO? • Introduce yourself • Acknowledge the person’s anger • Try to find out the reason for his anger, e.g. frustration, fear or guilt • Validate his feelings • Let him ventilate his anger or any feelings that led to his anger • Offer to do something or for him to do something

26. Angry Patient HOW TO DO IT? • Sit at the same level as the patient, not too close and not too far, with eye contact • Speak calmly without raising your voice • Avoid dismissive or threatening body language • Encourage the person to speak with open ended questions • Empathize as much as you can with verbal and non verbal cues • Be aware of your own safety

27. Angry patient WHAT NOT TO DO? • Glare at the person • Confront him or interrupt him • Patronize him or touch him • Put the blame on others/seek to exonerate yourself • Make unreasonable promises • Block his exit • If the person is a patient’s relative, be mindful about confidentiality

28. 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.

29. Scenario No 2 • A 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)