Another Hepatosplenomegaly? More than one is needed!

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The Art of Breaking Bad News
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Breaking Bad News

• 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

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Communication Skills Preparedness

• 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

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Are the Residents Prepared?

• 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
• gt 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

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Residents Feel Less Prepared

• Respondents had their greatest discomfort
  discussing serious illness in younger patients
  compared to adults.
• 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.
• Dubé et al, Ambul Pediatr. 2003 May-Jun

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Talk to Your Patients

• 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

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General Principles

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

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What to tell?

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

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Different ways of coping

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

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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.
• If a number of investigations are being
  performed, do not give results of each test
  individually Plan a consultation when all
  results are available.

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Where to Tell?

• Make every effort to ensure privacy and make the
  patient feel comfortable.

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In a hospital setting

• Avoid giving the patient the news during ward
  rounds.
• Find a private room.
• 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.

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Cont. Where to Tell

• Close the curtains around a patients bed.
• Sit at the bedside at eye level with the patient
  rather than stand over the patient.
• Ensure the patient is clothed.
• Ensure that interruptions such as beepers and
  telephone calls do not occur.

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Others

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

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Non Verbal Communication

• Use non verbal cues to convey warmth, sympathy,
  encouragement or reassurance to the patient.
• 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.

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Cont. Non Verbal Communication

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

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Dealing with language and cultural differences

• Employ a trained health interpreter whenever
  there is a language difference between the doctor
  and patient.
• Be sensitive to the persons culture, race,
  religious beliefs and social background.
• If appropriate, consult a health professional who
  has detailed knowledge and experience of that
  culture.

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Meet the Family

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

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10 Steps in Breaking Bad News
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1- Ensure privacy and adequate time

• Give the patient the bad news in a place which is
  quiet ad private.
• 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.
• Ensure that interruptions, such as beepers and
  telephones, do not occur.

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2- Assess Understanding

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

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Assess Understanding

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

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3- Provide information simply and honestly

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

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Provide information simply and honestly

• 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...

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4- Encourage patients to express feelings

• 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 familys feelings with empathy.

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Encourage patients to express feelings

• 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)

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5- Give a broad time frame

• 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).

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6- Avoid the notion of nothing more can be done

• 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
  patients 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.

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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.
• In the interim period, either be personally
  available or nominate someone else if the family
  has any questions or concerns.
• Write this information down.

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Arrange Review

• eg I know this is a lot to take in at this
  stage, so why dont we meet again tomorrow after
  youve 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 wont forget them, and I will do my best
  to answer them at our next meeting. In the
  meantime, if you have any concerns, dont
  hesitate to contact either me on . . . . . . . or
  Dr Mohammad . . . ...

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8- Discuss treatment options

• 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 are 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.

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9- Offer assistance to tell others

• 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.

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Offer assistance to tell others

• 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.

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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
• Suggest referral to these if desired
• Reinforce that the general practitioner will also
  be an important support all the time

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Support services

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

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10- Document information given

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

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Summary Steps in breaking bad news

• Give bad news in a quiet, private place.
• Allow enough uninterrupted time in initial
  meeting.
• Assess patients 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.

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Cont. Steps

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

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Techniques to aid patient recall of information

• The following assist in the recall and
  comprehension of information, and maybe used when
  this seems appropriate, and not necessarily in
  the first consultation

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Techniques to aid patient recall of information

1. Make information simple, clear and specific.
2. Avoid technical terms, use laypersons terms.
3. Speak slowly and clearly.
4. Present your advice in categories.
5. Repeat important pieces of information.

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Techniques to aid patient recall of information

1. Audiotape the consultation.
2. Use simple diagrams or models.
3. Write down important information.
4. At the end Ask the family to convey to you their
   understanding of what you have told them.
5. Make sure there are no questions left unanswered.

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Take Home Message
??? ??????? ??? ???? ???????? ???? ?????????
????? 107 And We have sent you (O Muhammad) not
but as a mercy for the mankind all that
exists The Holy Quran 21107
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Please Break Bad News Gently!
Following these steps ensure that patients who
are diagnosed with a life threatening illness are
informed of their diagnosis in an optimal manner,
and are provided with the support required to
deal with the news. Good Luck!
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Ref.

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

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Thank You For Your Good Attention !

• ????? ????? ??????? !

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• Communicating Bad News A Reading Module on
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• Your comments feedback are welcome!
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