The Art of Breaking Bad News Breaking Bad

The Art of Breaking Bad News

Breaking Bad News l l Why is breaking bad news an important issue for doctors? The experience of a life threatening illness is devastating for most patients and their families They have a need for information and emotional support Information should be delivered in an optimal manner so as to provide support for them

Communication Skills Preparedness l 1. 2. To characterize and compare incoming residents' self-reported amount and sufficiency of medical school training in clinical communication for patients of different ages training experience and anticipated comfort level when breaking news of serious diagnoses with patients of different ages Dubé et al, Ambul Pediatr. 2003 May-Jun

Are the Residents Prepared ? l l l 143 residents self-assessments Estimates of training time with adult patients were greater than any other patient age category and were rated most sufficient. 12% reported no formal training in pediatric skills > Half reported: never observed a pediatric or adolescent "bad news" interaction. Half of the respondents had personally informed a patient or family of a serious diagnosis, most often concerning middle-aged or elderly. Dubé et al, Ambul Pediatr. 2003 May-Jun

Residents Feel Less Prepared Respondents had their greatest discomfort discussing serious illness in younger patients compared to adults. l Residents feel less prepared for and receive less training in general communications skills, particularly skills required for delivering bad news, in pediatric clinical interactions compared to interactions with adult patients. l Dubé et al, Ambul Pediatr. 2003 May-Jun

Talk to Your Patients l l “A five-year-old may not understand science but will understand an explanation of how they will feel and what they will experience going through a diagnostic procedure, ” The authors recommend that residencies create as many opportunities as possible for new doctors to develop communication skills for breaking bad news to children, teens and loved ones. Dubé et al, Ambul Pediatr. 2003 May-Jun

General Principles Who should tell patients? l One person only should be responsible for breaking bad news, and usually this should be the primary physician. l Make sure that the patient knows your name, role and designation. l

What to tell? The patient has a legal and moral right to accurate, reliable information l Primary responsibility is to the individual patient & parents. l Responsibility to relatives is important but secondary. l Ensure that the patient understands treatment options and the reasons for any future investigations. l

Different ways of coping Some cope by learning as much as possible about a situation so they can feel more in control. l Others prefer not to know and cope by avoiding thinking about it. l

When to tell? The patient should be prepared for the possibility of bad news as early as possible in the diagnostic process, by the doctor of first contact. l If a number of investigations are being performed, do not give results of each test individually: Plan a consultation when all results are available. l

Where to Tell? Make every effort to ensure privacy and make the patient feel comfortable.

In a hospital setting Avoid giving the patient the news during ward rounds. l Find a private room. l If possible, both the Senior and Junior Medical Staff should be present to ensure that the information given is reinforced at a later point by the relevant Junior Medical Practitioner. l

Cont. Where to Tell Close the curtains around a patient’s bed. l Sit at the bedside at eye level with the patient rather than stand over the patient. l Ensure the patient is clothed. l Ensure that interruptions such as beepers and telephone calls do not occur. l

Others Where possible arrange for other health professionals, such as a nurse or social worker, to be present when breaking bad news. l This person should be someone to whom the family have access after you have left, to provide support and supplement information. l

Non Verbal Communication Use non verbal cues to convey warmth, sympathy, encouragement or reassurance to the patient. l In most cultural groups, this involves making eye contact, facing the patient, not interrupting when the patient is speaking, nodding encouragingly, and giving full attention to the patient. l

Cont. Non Verbal Communication It is critical that the patient feels that you have time to talk and listen. l Hence, avoid writing notes, reading the patient’s files, or looking elsewhere when the patient is talking to you. l In some cases, touch can be very reassuring for the patient, and in other cases it may not be appreciated. l

Dealing with language and cultural differences Employ a trained health interpreter whenever there is a language difference between the doctor and patient. l Be sensitive to the person’s culture, race, religious beliefs and social background. l If appropriate, consult a health professional who has detailed knowledge and experience of that culture. l

Meet the Family Tell the patient his/her diagnosis as soon as it is certain. l Make every attempt to tell the family in person, almost never by phone. l Make sure sufficient time is allocated for this consultation. l

10 Steps in Breaking Bad News

1 - Ensure privacy and adequate time Give the patient the bad news in a place which is quiet ad private. l Allow enough uninterrupted time during the initial meeting for the family to think about what you are going to tell, so that they can discuss it with you and ask you questions. l Ensure that interruptions, such as beepers and telephones, do not occur. l

2 - Assess Understanding Assess the patient’s understanding of the situation. l The patient may already be quite aware that the prognosis is likely to be bad, or they may have very little awareness of this. l Their response will provide an appropriate starting point for you. l

Assess Understanding l eg ‘I know the last few weeks of waiting must have been quite difficult for you. How much do you know about your condition? ’

3 - Provide information simply and honestly Tell the patient the diagnosis and prognosis honestly and in simple language, though not bluntly. l Avoid technical jargon, which obscure the truth. l If the patient has cancer, then use this word. l Give the facts which are relevant to the diagnosis and for management. l

Provide information simply and honestly l l l As the family may still be adjusting to the news, the facts may need to be repeated or revised several times and on different occasions. Were relevant, write the information down, or use pamphlets and diagrams. eg. ‘Yes, the tests show your child has. . . (type of disease). It is certain because all the tests indicate the same result. . . ’

4 - Encourage patients to express feelings l l l Allow and encourage the family to express their feelings, such as crying. Some immediate reactions may be dumbness, disbelief, anger or acute distress. Accept these feelings and concerns by letting them know that it is quite normal to feel this way. This helps the patient feel accepted and to discuss their concerns. Have tissues available! Respond to the family’s feelings with empathy.

Encourage patients to express feelings l l eg ‘This is obviously bad news and it is understandable that you are very upset about it. Many patients feel upset or even angry when they receive this kind of news. However, it is important not to jump to any conclusions. Although you have. . . (disease) it is far too early to say what will happen to you. ’ (NB: the latter part of this statement may not be relevant in clearly terminal cases)

5 - Give a broad time frame l l Avoid giving a prognosis with a definite time scale, but, if possible, give the patient a broad, realistic time frame which will allow them to arrange their life & personal affairs. eg ‘this obviously comes as a shock, but it is important not to jump to the wrong conclusions. No one can tell you exactly what will happen, but many patients with this disease have survived for. . . . (realistic time). ’

6 - Avoid the notion of ‘nothing more can be done’ l l l Even if the disease is too far advanced for curative treatment, try to reassure the patient that you will provide support (medical and non medical) for as long as is needed to make the patient’s remaining life as comfortable as possible. Where the treatment is palliative, do not pretend that it is likely to cure the disease. eg ‘A lot of things can be done to make your life as normal and comfortable as possible. We will do all we can to help you through this difficult time. ’

7 - Arrange Review At the end of the consultation, arrange a time in the immediate future (preferably within the next 24 hours) to review the situation with the family. l In the interim period, either be personally available or nominate someone else if the family has any questions or concerns. l Write this information down. l

Arrange Review l eg ‘I know this is a lot to take in at this stage, so why don’t we meet again tomorrow after you’ve had a chance to think about it more clearly and to discus it with your family / friends. You will probably think of a lot of questions in the meantime. Just write them down so you won’t forget them, and I will do my best to answer them at our next meeting. In the meantime, if you have any concerns, don’t hesitate to contact either me on. . . . or Dr Mohammad. . . ’

8 - Discuss treatment options l l Discuss the possible treatment options and their side effects with the family at this stage. Make it clear to the patient that a treatment recommendation will be made to them, but that they will be involved in the final decision about it. As far as possible, ensure that there is consensus amongst the health care providers about the treatment options prior to discussing these with the patient. eg ‘There a number of things we maybe able to do, including. . . . (eg. chemotherapy, radiotherapy, . . . ). Where possible, we will ensure that you are involved in deciding on the treatment. ’

9 - Offer assistance: to tell others l l Ask the family who they would like to tell about the situation, and then offer assistance and support in telling these people. These may include children, other family members or employers. Encourage family meetings to discuss issues which arise over time and answer questions honestly. If there are children involved, then involve a health professional used to dealing with children.

Offer assistance to tell others l eg ‘There are people who will want to know what is happening to you. Are there particular people you would like me to tell specifically? Are there people you would not wish to have the information? I would be happy to talk with anyone, either on the phone or in a general discussion with your family or other special friends. ’

Offer assistance: Provide information about support services Give the patient information about the availability of various support services, such as religious scholars, cancer support groups, palliative care services, bereavement counseling, internet groups & websites l Suggest referral to these if desired l Reinforce that the general practitioner will also be an important support all the time l

Support services Eg ‘there a number of different people and support groups who you and your family may find it helpful to talk to. l Talking about your situation with others who have been through a similar experience may help you to cope with it. l Your general practitioner will also be there for you. ’ l

10 - Document information given l l l Document what the patient has been told, which family/other members have been told, who is permitted to know about the patient’s situation, and the patient’s reaction to the news. Be concise and include this on their medical record. Include this information on the discharge summary which goes to the patient’s general practitioner and to any others involved.

Summary: Steps in breaking bad news l l l l Give bad news in a quiet, private place. Allow enough uninterrupted time in initial meeting. Assess patient’s understanding. Provide information simply and honestly. Encourage patients to express feelings. Respond to patients’ feelings with empathy. Give a broad time frame for the prognosis.

Cont. Steps Avoid the notion of ‘I know how you feel’ or ‘nothing more can be done’ l Arrange a time to review the situation. l Discuss treatment options. l Offer assistance to tell others. l Provide information about support services. l Document information given. l

Techniques to aid patient recall of information l The following assist in the recall and comprehension of information, and maybe used when this seems appropriate, and not necessarily in the first consultation:

Techniques to aid patient recall of information 1. 2. 3. 4. 5. Make information simple, clear and specific. Avoid technical terms, use layperson’s terms. Speak slowly and clearly. Present your advice in categories. Repeat important pieces of information.

Techniques to aid patient recall of information 6. 7. 8. 9. 10. Audiotape the consultation. Use simple diagrams or models. Write down important information. At the end: Ask the family to convey to you their understanding of what you have told them. Make sure there are no questions left unanswered.

Take Home Message “ ”ﻭﻣﺎ ﺃﺮﺳﻠﻨﺎﻙ ﺇﻻ ﺭﺣﻤﺔ ﻟﻠﻌﺎﻟﻤﻴﻦ 107 ﺍﻵﻴﺔ ، ﺳﻮﺭﺓ ﺍﻷﻨﺒﻴﺎﺀ “And We have sent you (O Muhammad) not but as a mercy for the mankind & all that exists” The Holy Qur’an 21: 107

Please: Following these steps ensure. Break that patients who are. Bad diagnosed with a life threatening News illness are informed of their diagnosis in Gently! an optimal manner, and are provided with the support required to deal with the news. Good Luck!

Ref. l NSW Cancer Council: How to Break Bad News l Communicating l. A Bad News Reading Model, Education for Physicians on End-of-life Care (EPEC) curriculum, Final version 9/17/04 l Pub-Med Search