6. Breaking-Bad-News public heath primary health care.pdf

Public heath breaking bad news

1. Breaking Bad News

2. After undergoing a routine colonoscopy, the 50-year-
old patient learned that his doctor found a tumor.
Immediately after delivering the news, the doctor and
nurse left the room. Confused by the sudden
departure—and the office staff who avoided his gaze—
the patient got the impression that the doctor and staff
were angry with him !!!

3. What is Bad News?
"any information which adversely and seriously affects
an individual's view of his or her future"

4. Why is it Important?
A Frequent but Stressful Task
Breaking bad news can be particularly stressful
when the doctor is inexperienced, the patient is
young, or there are limited prospects for successful
treatment

5. Patients Want the Truth
By the late 1970s most physicians were open about
telling cancer patients their diagnosis .
In 1982 of 1,251 Americans indicated that 96%
wished to be told if they had a diagnosis of cancer
85% wished, in cases of a grave prognosis, to be
given a realistic estimate of how long they had to
live

6. ❑The patient-centered decision-making model is
the main stay in delivering bad news.
❑Most patients prefer to know their diagnosis.

7. ❑younger patients, female patients, and patients
with higher education levels tend to desire more
detailed information.
❑Some ethnic groups favor a family-centered
medical decision model , others prefer a model
with more individual patient autonomy .

8. Ethical and Legal Imperatives
Clear ethical and legal obligations to provide
patients with as much information as they desire
about their illness and its treatment
Physicians may not withhold medical information
even if they suspect it will have a negative effect on
the patient

9. Clinical Outcomes
How bad news is discussed can affect the patient's
comprehension of information, satisfaction with
medical care, level of hopefulness, and subsequent
psychological adjustment

10. Barriers to Breaking Bad News

11. Cultural barriers
➢Patients have unrealistic expectations of health and life,
perhaps secondary to overplayed media reports of
medical advances or unrealistic television portrayals.
➢religious diversity makes it increasingly common that the
physician and patient will have different views about an
afterlife.

12. Physician fears
➢Physicians experience stress related to providing bad
news , evidence suggests that this stress does not lessen
with a physician's years in practice or experience with
delivering bad news.
➢In general, physicians fear eliciting an emotional
reaction, being blamed for the bad news, and expressing
their emotions during the process.

13. Physician fears
➢Physicians also fear that delivering truthful news about a
terminal illness will leave a patient depressed, without
hope.
➢In reality, end-of-life discussions are associated with less
aggressive medical care, earlier hospice referral, and
improved quality of life

14. ➢Physicians often withhold information or overestimate
survival.
➢The inability to effectively and truthfully deliver bad news
can lead to patient confusion.
➢Although bad news may initially increase psychological
stress, full and accurate disclosure may help the patient
and family emotionally and practically, making the time
the patient has left as meaningful as possible

15. Models for Breaking Bad News
SPIKES model
Robert Buckman
Professor of Oncology –Toronto
Trained in Cambridge
Used world wide
KAYES model

16. SPIKES Model
Six steps
S –Settingup the interview
P –assessing the patients Perception
I –obtaining the patients Invitation
K –giving Knowledge
E –addressing Emotions
S –Strategyand Summary

17. S –Settingup the interview
❖Reviewing the patient's history and situation are critical
components of the first step. Mental rehearsal may
increase physician confidence.
❖A proper setting also assures privacy, limits interruptions,
and involves family if the patient desires.
❖Tissues should be available.
❖Sitting at the bedside increases the perceived time spent in
discussion , but it is preferred to ask about patient's
preference

18. What?
Make sure you have checked all the available
information and have test results (including getting
the right patient!) Decide general terminology to be
used
* Where? Arrange for some privacy,
* Who? Should break the news, should other staff be
there or significant others?
* Starting off? Introductions and appropriate opening

19. PERCEPTION
✓Determine the patient's understanding of his or
her condition.
✓The physician should use broad, open-ended
questions, such as, “What is your understanding
of what has occurred?”
✓The physician may also identify misunderstanding,
denial, and unrealistic expectations.

20. * What have you made of the illness so far? * What did
doctor X tell you when he sent you here?
This helps you gauge how close to the medical reality
the patient’s understanding is and will tell you about
pacing. Also whether the patient is in denial.

21. I –Invitation
While a majority of patients express a desire for full
information about their diagnosis, prognosis, and
details of their illness, some patients do not
How much information would the patient like to know

22. INVITATION
oIt is important to obtain the patient's permission before
delivering the bad news.
oA phrase such as, “Would it be okay to give you the
results of the tests right now?”engages the patient in
shared decision making.
oIf the patient declines the invitation, it is important to
determine the reason (e.g., waiting for a spouse, partner, or
other family member to provide support).

23. K –Knowledge
Warning shot:
“Well, the situation does appear to be more serious than that”
Avoid jargon
Small chunks
Use of silence
Allow time for emotions
Repeat Important Points –patients who are upset or shocked don’t hear or
remember well.
Use diagrams, written messages as an aide memoir, audiotapes or leaflets.
Check your level –try to simplify without being patronising

24. KNOWLEDGE
❑Physicians should use simple, nontechnical words and
avoid medical jargon when delivering bad news.
❑They should provide empathy by avoiding being blunt
and by allowing time for patients to express emotions.
❑Information should be provided in small amounts,
followed by a confirmation of understanding.
❑The SPIKES method advocates delivering a warning
statement before the bad news (e.g., “I'm afraid the
test results were worse than we initially hoped.”)

25. The four crucial headings are: Diagnosis, Treatment
Plan, Prognosis and Support
Listen to Patient’s Agenda: -what are their concerns
e.g. Patients may be more worried about hair loss
from chemotherapy than potential risk of the disease.
-listen to the buried questions & invite questions

26. E –Emotions
Recognise
Listen for and identify the emotion
Identify the cause of the emotion
Show the patient you have identified both the
emotion and its origin

27. EMOTIONS
oBefore providing additional information or even immediate
reassurance ,the physician should acknowledge and accept the
patient's response.
oEmpathic statements are useful during expressions of sadness
and anger.
oValidating responses helps patients realize their feelings are
important.
oSupportive statements guard against the feeling of
abandonment
oexploratory questions
oA physician can accept a patient's response (e.g., the desire to be
cured of cancer), without agreeing with it (e.g., cure is not likely).

28. S –Strategy and Summary
Understanding reduces fear
Summarise the discussion
Strategy for future care
Schedule next meeting
Allow time for questions
Leaflets

29. STRATEGY AND SUMMARY
✓Physicians should provide a summary, explore options, and
determine patient-specific goals.
✓Even with the worst prognosis, most patients prefer to
know what is coming next.
✓Follow-up should include the patient's next appointment
and a way for the patient or family to contact the physician
with questions.

30. STRATEGY AND SUMMARY
✓A second appointment in the next few days, or it may be
delayed, depending on patient preference.
✓Physicians should avoid the phrase “I'm afraid there is
nothing more we can do for you.” This leaves the patient
feeling helpless and abandoned. Instead, in the absence of
cure, the focus should be on defining and supporting the
patient's redefined hopes (e.g., less pain, more time with
family).
✓Patients should be assured that the physician will be with
them and support them.

31. Kaye’s Model
10 steps
Logical sequence
Not based on rigorous research
Can be used for any serious illness
Mixes facts with questions about feelings

32. 1. Preparation
2. What does the patient know?
3. Is more information wanted?
4. Give a warning shot
5. Allow denial
6. Explain (if requested)
7. Listen to concerns
8. Encourage ventilation of feelings
9. Summary and plan
10. Offer availability

33. 1 -Preparation
Know all the facts
Ensure privacy
Find out who the patient would like present
Introduce yourself

34. 2 –What does the patient know?
Open ended questions
Statements may make the best questions
“How did it all start?”

35. 3 –Is more information wanted?
Not forced on them
“Would you like me to explain a bit more?”

36. 4 –Warning Shots
Not straight out with it!
“I’m afraid it looks rather serious”

37. 5 –Allow Denial
Allow the patient to control the amount of
information they receive.

38. 6 –Explain if Requested
Step by step.
Detail will not be remembered but the way you explain
it will be.

39. 7 –Listen to concerns
“What are your concerns at the moment?”
Allow time and space for answers.

40. 8 –Encourage Feelings
Acknowledge the feelings.
Non-judgmental.
Vital step for patient satisfaction.

41. 9 –Summarise
Concerns.
Plans for treatment.
Foster hope.
Written information.

42. 10 –Offer Further
Availability.
Information.
Future needs will change.

43. Thank you