Communication Skills in Medicine Delivering Bad News An

Communication Skills in Medicine - Delivering Bad News An Introduction to Internet Resources in English Podzim ’ 02 - Špindlerův Mlýn Pavel Kurfürst, ÚCJ LF UP

BAD NEWS • any news that drastically and negatively alters the patient’s view of his or her future (Vandekieft) • it results in a cognitive, behavioral, or emotional deficit in the person receiving the news that persists for some time after the news is received (Back – Curtis)

BAD NEWS • many health care professionals tend to define 'bad news' as worst case scenarios (eg. telling a patient they have cancer or that their loved one has died) • but a knee cartilage problem requiring rest for a waitress may mean no pay (RFC handbook)

SITUATIONS • terminal diagnosis • death in an out-ofhospital setting • communicating sensitive subjects to parents and children • fetal death verified by an ultrasound • multiple sclerosis confirmed by MRI • onset of diabetes in an adolescent

THE PAST AND THE PRESENT • Hippocrates advised concealing most things from the patient • older physicians, who trained during the 1950 s and 60 s, were taughtto "protect" patients from disheartening news (Easton) • in the past decades traditional paternalistic models of patient care have given way to an emphasis on patient autonomy

FACTS • 50 -90% of patients desire full disclosure of a terminal diagnosis (Vandekieft) • 95% of cancer patients want the physician to be fully honest with them about the outcome of their illness (Thomas)

FACTS • over the course of a 40 -year career, an oncologist may conduct up to 200, 000 interviews with patients, caregivers and/or families; if as few as 10% of those interviews involve the disclosure of bad news, that is still 20, 000 interviews in which you have to be the bearer of bad news (Buckman)

EDUCATION • clinicians are responsible for delivering bad news, this skill is rarely taught in medical schools, clinicians are generally poor at it (Rabow – Mc. Phee) • breaking bad news is one of a physician’s most difficult duties • medical education typically offers little formal preparation for this task (Vandekieft)

EDUCATION • 1997 -1998 AMA survey: only 4 of 126 US medical schools required a separate course on caring for the dying (Acevedo) • many medical graduates have persisting interpersonal difficulties when confronted with terminally ill patients, death and dying (Barrington – Murrie)

EDUCATION • historically, the emphasis on the biomedical model in medical training places more value on technical proficiency than on communication skills

• in ancient times, the bearer of the news that a battle had been lost was often killed; in a similar fashion, reacting to bad news, some patients blame their clinicians (Rabow – Mc. Phee) • death represents a failure of the medical system, our failure as physicians, and even our failure as human beings (West)

• clinicians focus often on relieving patients' bodily pain, less often on their emotional distress, seldom on their suffering • they may view suffering as beyond their professional responsibilities • if clinicians feel unable to, or simply do not want to, address the powerful issue of patient suffering, it is appropriate to refer the patient to another professional on the healthcare team who is more comfortable in this arena (Rabow – Mc. Phee)

• breaking bad news is not as much a delivery as it is a dialogue between two people (Rabow – Mc. Phee) • the patients needs to given an opportunity to express his emotions and to articulate his fears (Thomas)

• the physician’s caring attitude is more important than the information provided during the clinical encounter (Back – Curtis) • clinicians can deliver bad news well and manage its consequences (Rabow – Mc. Phee)

COMMUNICATE AS A TEAM • • patient family physician other health care providers • • • psychologist chaplain nurse social worker translator

GUIDELINES • several professional groups have published consensus guidelines on how to discuss bad news • few of those guidelines are evidencebased • the clinical efficacy of many standard recommendations has not been empirically demonstrated (Vandekieft)

S-P-I-K-E-S • a six-step approach by R. Buckman • proposed by the Project to Educate Physicians on End-of-life Care (EPEC) - supported by the American Medical Association and the Robert Wood Johnson Foundation

S-P-I-K-E-S • • • setting perception invitation knowledge empathy strategy and Summary (Buckman; Maicki; Acevedo; Payne; EPEC materials; Michigan PG)

ABCDE • • • advance preparation build a therapeutic environment/relationship communicate well deal with patient and family reactions encourage and validate emotions (reflect back emotions) (Rabow – Mc. Phee; Vandekieft; Dyer)

OTHER GUIDELINES • • • preparation place people position pronouncement post-event follow up (Rodgers)

OTHER GUIDELINES • preparation • introduction • achieving understanding • pacing and shared control (Rodgers) • responding to emotions • honesty • support • closure

OTHER GUIDELINES • • • preparation setting delivery emotional Support information closure (Gordon)

OTHER GUIDELINES • • prepare for the encounter assess the patient’s understanding discuss the news respond to the patient’s emotions offer to discuss implications of the news summarize the discussion arrange a follow-up time for patient and family questions and concerns • document the discussion in the medical record (Back – Curtis)

OTHER GUIDELINES • the World Health Organisation (WHO) Guidelines on Communicating Bad News • WHO/MNH/PSF/93. 2. B (WHO Guidelines on Communicating Bad News - adapted abstract)

REMEMBER people handle information differently depending on their • educational level • ethnicity and culture • religion, beliefs • socioeconomic status • age (Michigan Physician Guide)

REMEMBER • technical language usually misunderstood by the patient (73% of women with breast cancer do not understand the term MEDIAN when told about prognosis and survival) (Back - Curtis) • • avoid euphemisms do not minimize the severity of the situation (Michigan Physician Guide)

REMEMBER never give bad news on a Friday! (RFC handbook)

KEY WORDS • communicating / delivering / breaking / giving bad news • communication skills / communication issues / doctor-patient communication • end-of-life care / palliative medicine • end-of-life communication

RESOURCES see a separate list of resources click here (*. rtf file)

CONTACT kurfurst@seznam. cz www. ucjlf. upol. cz/svoc