Breaking bad news

breaking bad news in medical care

1. BREAKING BAD NEWS DR MOHAMMMED LUKMAN ABOLAJI, DEPARTMENT OF FAMILY MEDICINE , AMINU KANO TEACHING HOSPITAL KANO. 2/11/2021 1

2. OUTLINE INTRODUCTION DEFINATION OF BAD NEWS/EXAMPLES APPROACH TO BREAKING BAD NEWS SPIKES PROTOCOL KEY POINTS/ CONCLUSION PRACTICAL DEMOSTRATION OF BREAKING BAD NEWS 2/11/2021 2

3. INTRODUCTION Breaking bad news to patients has been a subject of professional concern for many years, interest growing alongside a culture of increasing medical disclosure of diagnosis and prognosis [Buckman,1992 ]. The life of a sick person can be shortened not only by the act, but also by the words or the manner of a physician. It is, therefore, a sacred duty to guard himself carefully in this respect, and to avoid all things which have tendency to discourage the patient and to depress the spirit [American medical association]. 2/11/2021 3

4. INTRODUCTION Breaking bad news demands a great deal of professionalism, patience, and energy. It requires the twofold complex process of finding Appropriate kind words and understandable terminology. The secondary task of assessing how the patient and family are reacting. The degree of distress that the conversation is inducing . The subsequent tailoring of information as the FP responds to the assessment process. 2/11/2021 4

5. 2/11/2021 5 An expert in breaking bad news is not someone who gets it right every time – he or she is merely someone who gets it wrong less often. - R Buckman

6. What is bad news? Any news that seriously and adversely changes the patient’s views of his/her future. Buckman,1992. Situations where there is either a feeling of no hope , a threat to persons mental or physical wellbeing, risk of upsetting an established life style , or where a message is given which conveys to an individual fewer choices in his or her life. Bor et al.,1993 Any information that is not welcome. Arber and gallagher , 2003. 2/11/2021 6

7. Examples of bad news These include: Cancer diagnosis Intra uterine foetal death Life long illnesses e.g. Diabetes, hypertension, HIV, infective hepatitis, Poor prognosis related to chronic diseases e.g. heart failure, stroke Informing parents about their child’s serious mental/physical handicap Disease recurrence Spread of disease Failure of treatment to affect disease progression The presence of irreversible side effects Results of genetic tests Death 2/11/2021 7

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9. WHY SHOULD IT BE DONE ? Improve the patient’s and family’s ability to plan and cope, Encourage realistic goals and autonomy, Support the patient emotionally, Strengthen the doctor-patient relationship, Foster collaboration among the patient, family, doctors and other professionals. Reduces stress in doctors Facilitates open discussion among patient, relatives and doctors Empowers patient by allowing them a greater say in treatment 2/11/2021 9

10. WHAT MAKES IT DIFFICULT? The physician’s perspective: Uncertainty about the patient's condition & expectations Fear of destroying the patient's hope Fear of their inadequacy in the face of uncontrollable disease. Fear of patient’s anticipated emotional reactions. Embarrassment at having previously painted too optimistic a picture for the patient Cultural constraints and language barriers Lack of training in breaking bad news 2/11/2021 10

11. WHAT MAKES IT DIFFICULT ? Cont ’ The patient’s perspective: Patient often have vivid memories of receiving bad news Negative experiences can have lasting effects on anxiety and depression Fears of social stigma and impact of disability and illness 2/11/2021 11

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13. OTHER MODELS FOR BREAKING BAD NEWS SAAIQ Approach S ET the scene as soon as possible A SSESS the understanding of the attendant A LERT them that I have bad news I NFORM in clear, understandable words Q UICKLY repeat summary of the situation COMFORT MODEL C ommunication O rientation M indfulness F amily O ngoing R eiterative T eam SAD NEWS Approach S et up & Sit down A sk , don’t tell D eliver the news N o fancy lingo E xpect , permit & respond to emotion W ait S upport & Summarise CONES C ontext O pening shot N arrative E motion S trategy and summary FOUR Cs C ompassion C ompetence C onfession C harting 2/11/2021 13

14. SPIKES Six-Step Protocol SPIKES Six-step protocol S etting 1 . Set the stage. P erception 2 . What does the patient know? I nvitation 3 . How much does the patient w want to know? K nowledge 4 . Share the information. E motion 5 . Respond to feelings. S ubsequent 6 . Plan next steps and follow-up 2/11/2021 14

15. SETTING: Set the stage Plan what you will say Confirm medical facts Don’t delegate Create a conducive environment physician’s office, quiet room in a hospital setting, the patient’s home or a private hospital room) Draw curtains, close the door, sit down (and not behind a big desk) Allot adequate time Prevent interruptions Introduce self & greet Determine who else the patient would like present 2/11/2021 15

16. PERCEPTION: What Does the Patient Know? Ask patient what they know, feel, fear, etc Establish what the patient knows Assess ability to comprehend new bad news Reschedule if unprepared 2/11/2021 16

17. INVITATION: How Much Does the Patient Want to Know ? Ask patient if she/he wishes to know the details of the condition and/or treatment Accept patient’s right not to know Offer to answer questions later if she/he wishes Elicit and address the patient’s concerns Recognize , support various patient preferences Decline voluntarily to receive information Designate someone to communicate on his or her behalf 2/11/2021 17

18. KNOWLEDGE: Sharing the Information Give a warning shot “unfortunately, I have got some bad news to tell you” (may lessen the shock that can follow the disclosure of bad news) Say it, then stop Avoid monologue; promote dialogue Use plain language Pause frequently Check for understanding Don’t minimize severity Avoid vagueness, confusion 2/11/2021 18

19. EMPATHY/EMOTION : Responding to Feelings Be prepared for Outburst of strong emotion Broad range of reactions ( fear, anger, sadness, denial, guilt) Give time to react Listen quietly, attentively Encourage descriptions of feelings Use nonverbal communication Empathize with the patient “Hearing the result of the test is clearly a major shock to you ” “Obviously, this piece of news is very upsetting” “Clearly, this is very distressing” 2/11/2021 19

20. Responding to Feelings, cont. If patient cries allow some time to cry Offer tissue if it is available Could touch the patient if appropriate After a few moments you should continue talking even if patient continues to cry 2/11/2021 20

21. If Patient refuses to accept the diagnosis? Explore reasons for Patient denial Get family members involved Do not be combative Check if the Patient has a clear understanding Appreciate that there is an information gap and try to educate the Patient 2/11/2021 21

22. SUBSEQUENT: Planning, Follow-up Plan for next steps Additional information, tests, treat symptoms, referrals as needed Discuss potential sources of support ( emotional and spiritual needs and other support systems) Multidisciplinary involvement (social work, palliative care, religious bodies when appropriate) to provide further support to the patient Acknowledge & answer questions Summarize plan (Use “teach back” technique) Give contact information ( phone number or email) Set next appointment Before leaving, assess patient safety and home supports Repeat news at future visits 2/11/2021 22

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24. DO’S AND DON’T’S DO’S Ensure privacy and confidentiality Respect Honest Simple language Listen Sensitive to the nonverbal language Allow for silence, tears and other patient reactions Document and liaise with the multidisciplinary team DON’T’S Overload with information Distort the truth Give false reassurance Feel obliged to keep talking all the time Withhold information Assume that you know what is of most concern to the patient Criticize Make judgments 2/11/2021 24

25. When Language is a Barrier Use a skilled translator Familiar with medical terminology Comfortable translating bad news Avoid family as primary translators Speak directly to the patient 2/11/2021 25

26. CONCLUSION Breaking bad news is an important clinical skill that can be frequently utilized in the context of routine practice. Following an established protocol while integrating empathetic communication makes the difficult task of breaking bad news more comfortable for the FP and helps improve the communication between the patient and family . These skills can be learned in continuing education programs or easily integrated into FP curriculum 2/11/2021 26

27. REFFRENCES Dr Zainab Abdulazeez’S Breaking bad news hospital presentation Dr Fawziya Shehu Malami’s Breaking bad news departmental presentation Baile , W., Buckman , R., Lenzi , E., Glober , G., Beale, E., & Kudelka , A. SPIKES – a six-step protocol for delivering bad news: Application to the Patient with Cancer. Oncologist 2000; 5(4):302-311 . Scoles PV, Hawkins RE, LaDuca A. Assessment of clinical skills in medical practice. J Contin Educ Health Prof. 2003;23(3):182–190. [PubMed] [Google Scholar] Aled J. Putting practice into teaching: an exploratory study of nursing undergraduates’ interpersonal skills and the effects of using empirical data as a teaching and learning resource. J Clin Nurs . 2007;16(12):2297–2307. [PubMed] [Google Scholar ] Charlton CR, Dearing KS, Berry JA, Johnson MJ. Nurse practitioners’ communication styles and their impact on patient outcomes: an integrated literature review. J Am Acad Nurse Pract . 2008;20(7):382–388. [PubMed] [Google Scholar] 2/11/2021 27

28. THANK YOU FOR YOUR ATTENTION 2/11/2021 28