BREAKING BAD NEWS

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BREAKING BAD NEWS

• Dr.Weaam M. Al-Eid
• Pediatric Rheumatologist
• MCH-Dammam

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Breaking Bad News(BBN)

• Most emotionally laden responsibilities
• Many patients can recall in details how their
  diagnosis was disclosed

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BBN

• Communication is a major component of the medical
  management
• We still have much to learn about talking to our
  patients
• Physicians dont want to take hopes away from
  their patients
• Most of the physicians are not train on how to
  discuss bad news
• The need for developing the skills of
  communications

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What Is Bad News??

• Any news that drastically negatively alters the
  patients view of her / his future
• 
  (BMJ 1984)

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Response To Bad News

• Psychosocial context
• Inopportune time!!

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Tendering The Truth

• The life of a sick person can be shortened not
  only by the acts,but also by the words or the
  manner of a physician
• (American medical associations 1847)

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BBN is so Difficult???

• Unpleasant task
• Challenge of individualizing the manner of BBN
• 50-90 of pts. Desire full disclosure
• 40 of pts.do not want full disclosure
• Fearful of the pts / familys reactions
• Clinicians focus on relieving body pain not on
  emotional distress

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1 GETTING STARTED!

• Physical setting
• Private comfortable
• Sits down with no barrier
• Adequate time
• no interruptions

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GETTING STARTED

• Attendance
• The patient
• Ask who else want
• to join

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GETTING STARTED

• Clinicians
• Who will break the news ?
• Introduce yourself
• Familiarize yourself with
• the clinical data
• Prepare emotionally!

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2 FIND OUT!

• How much the pt /family know
• What have you already been told about
• your illness?

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3FIND OUT

• How much the pt.want to know?
• What level of details should cover
  (individualization)
• How are you feeling? (two way affair)

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4COMMUNICATE WELL

• Speak frankly but compassionately
• Foreshadow the bad news
• ( I am sorry but I have bad news )
• Avoid medical jargon
• Dont cover every thing

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4COMMUNICATE WELL

• Use silence
• Respond to the family cues
• Encourage questions
• Be sure that the other team member know
• Professional translator

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5RESPONDING TO PTS. FEELINGS
Can you tell me about what you are feeling?

• Avoid inappropriate humor or comments
• Be sensitive to cultural differences personal
  preference
• Empathetic

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5 RESPONDING TO PTS. FEELINGS

• Avoid defensiveness
• Silence,tears proceed at pt.pace
• Realistic hope
• Interdisciplinary
• services

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6PLANNING FOLLOW UP

• Step by step plan
• Collaborative terms
• Ensure pt.safety

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Breaking the Bad News When The Word is
( Cancer )
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THE ART OF ONCOLOGY
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The Pt.Reaction
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The Reaction of Physicians

• Reassure the pt.
• Permission to react
• Evaluate pt.reaction
• - Pt.cries
• - Accept anger
• - Avoid defensiveness

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Next Step

• The general plan
• Suggest to bring a family member/ friend
• Paternalistic approach

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Suggestions

• Identify common stresses in dealing with the
  patient family at the end of life
• Develop strategy for dealing with emotion
• bridging cultural gaps
• Develop a strategy for conveying hope to the
  patient

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REFERENCES
1- Annlas of Oncology 2003 , 1448 2- Clinical
Oncology 2002 , 203674 3- American Family
Physician 2001, 461975 4- Oncologist 2000 ,
5302
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Thank you
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Break The news Over The Phone

• Best avoided
• Face-face meeting
• Connected to
• the right number!
• Patient time privacy

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BBN Over The Phone

• Simply straight forward
• Give warning
• Wait,listen answer questions
• Support

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DENILE

• It is primitive defense mechanism enables
  individuals to cope with very distressing events
  or thoughts it is likely to be temporarily

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DENILE

• Find out
• Healthy or un healthy
• What issues pt. Is avoiding?
• How long has this been present?
• Do other family member deny?

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ACTION

• Give opportunity to discussion
• Healthy denial no intervention
• Unhealthy denial ---explore how
• confrontational strategies

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When language is a barrier

• Translator understand medical
• terminology
• Avoid using family members

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COLLUSION

• (It is important to consider the pt. the
  family together)
• Patient is the primary concern
• The patient right to be confidential
• Always tell the truth if asked

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CULTURALLY DIVERSE SETTING

• 3 Basic Ground-Rules
• Be aware that there may be a cultural
• differences
• Accept that individuals may not be typical
• of their own culture
• Respect cultural norm

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Thank you