COMMUNICATING BAD NEWS Communicating bad news to patients

COMMUNICATING BAD NEWS

Communicating bad news to patients and families is one of the most important and difficult challenges that health care providers face. Naturally, it’s a somewhat easier task in bad times when bad news is all around

The Ten Elements 1. Describe the news in a clear and straightforward manner. n Do not lie, hide the message, sugarcoat, use jargon, minimize, or downplay. n Do not make promises about the future that may not hold true. n Do not overreact. n Do not avoid adding honest perspective— “Although this is by no means a good situation, it is not as bad as…”

2. Explain why the action is being taken. • What is the logic behind the action? • How does the action support the benefits the patient health? • What was being done wrong? • How will the action help solve the patient health problem?

3. Explain how the decisions and actions that are made will benefit the patient. n If there’s no absolute. But we are waiting for positive results. n The test of “success” is reactions such as, “I don’t like it, and it may be the best for the patient is but I see it the best considering the situation. ” n We have done all the possible action we believe is right and all the health team is involved in assuring how the action is going to change the meanwhile situation. ”

4. Involve a high-status messenger in delivering the message. n Who sends the message says a lot about how much the whole health team cares about the patient. n The health team (all health team) is involved.

5. Deliver the message in a timely manner. n Reactive communication is usually defensive and apologetic. n Do the patient and families believe that they have enough time to react properly, to share in the decision made, to change their decision if they wanted?

6. Identify who made the decision and what process was used. Who was involved in the final decision making process? n What decision-making process was followed? n

7. Describe the effort that went into the decision. n What actions, procedures, consultations, . . etc were conducted behind the scenes? n How painful, and satisfactory was the process of making the decision?

8. Outline some of the alternatives that were considered. n What other creative and thoughtful ideas were considered? n Why were they not implemented?

9. Show that the health care providers cares about patient. n How the health care providers behaves in communicating bad news shows its “true colors. ”

10. Describe what action is required and what, if anything, can be done to change the decision or help avoid the problem in the future. A. To change action: n Output …. must increase to X. B. To avoid the problem in the future: n new direction must be taken. n new findings appeared.

6 -Step Protocol 1. 2. 3. 4. 5. 6. Getting started What does the patient know? How much does the patient want to know? Sharing the information Responding to patient and family feelings Planning and follow-up

Step 1: Getting started n n n n Plan what will be discussed. Confirm the medical facts of the case. Ensure that all the needed information is available. Create an environment conducive to effective communication. Ensure privacy and adequate seating. Allow adequate time for the discussion. Do not slip this into a short interval between other critical tasks. Prevent interruptions. Arrange to hold telephone calls and pages. Determine who else the patient would like to have present for the discussion. This might include family, significant others, surrogate decision makers, and/or key members of the

Step 2: What does the patient know? Start the discussion by establishing what the patient and family know about the patient’s health. Questions might include: n What do you understand about your illness? n How would you describe your medical situation? n When you first had symptom X, what did you think it might be? n What did Doctor X tell you when he sent you here? n Did you think something serious was going on when…? n

Step 3: How much does the patient want to know? n Each person has the right to voluntarily decline to receive any information and may designate someone else to communicate on his or her behalf. Ask the patient and family how they would like to receive information. Possible questions include the following: n If this condition turns out to be something serious, do you want to know? n Would you like me to tell you the full details of your condition?

Step 4: Sharing the information n n Deliver the information in a sensitive but straightforward manner. Say it, then stop. Avoid delivering all of the information in a single, steady monologue. Use simple language that is easy to understand. Avoid technical jargon or euphemisms. Pause frequently. Check for understanding. Use silence and body language as tools to facilitate the discussion. Do not minimize the severity of the situation. Well-intentioned efforts to “soften the blow” may lead to vagueness and confusion.

n n Step 5: Responding to feelings Patients and families respond to bad news in a variety of ways. Some respond emotionally with tears, anger, sadness, love, anxiety, relief, or other strong emotions. Others experience denial, blame, guilt, disbelief, fear, or a sense of loss or shame, or may even intellectualize why the situation is happening. A few may demonstrate reflexive psychophysiologic responses such as “fight or flight” and may even try to bolt from the room or totally withdraw into themselves. Parents may become very emotional when thinking about actually telling their child the diagnosis.

Ask them to describe their feelings: n I imagine this is difficult news… n You appear to be angry. Can you tell me what you are feeling? n Does this news frighten you? n Tell me more about how you are feeling about what I just said. n What worries you most? n What does this news mean to you?

Step 6: Planning and followup n Gather additional information or performing further tests. n Arrange for appropriate referrals. n Explain plans for additional treatment. n Discuss potential sources of emotional and practical support, eg, family, significant others, friends, social worker, n spiritual counselor, peer support group, professional therapist.