Tips for Bad News Bearers

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Tips for Bad News Bearers

• A Critical Clinical Skill
• Dr. Jeff Sisler
• Department of Family Medicine
• CancerCare Manitoba
• Issues and Updates 2007

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Learning Objectives

• After this session, you will
• Recognize the challenge of sharing bad news
  effectively
• Be able to describe an effective six step
  process for sharing bad news--SPIKES
• Be committed to improving your skills in breaking
  bad news to patients

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What is Bad News?

• Any news that seriously and negatively alters the
  patients view of his or her future.
• Buckman

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The Goal

• Help the patient and family understand the
  condition
• Support the patient and family
• Minimize the risk of overwhelming distress or
  prolonged denial

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Why is it a critical skill?

• The Patients Perspective
• Patients often have vivid memories of receiving
  bad news
• Negative experiences can have lasting effects on
  anxiety and depression
• Can facilitate adaptation to illness and deepen
  the patient-doctor relationship

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Why is it a critical skill?

• The Physicians Perspective
• High degree of difficulty
  
  Physician anxiety
• High risk of performing poorly

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What do patients want?

• For themselves
• more time to talk
• and show feelings
• From the doctor
• more information, caring,
• hopefulness, confidence
• a familiar face
• Strauss 1995

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What do you do?

• What have you have found helpful in making bad
  news visits go as well as possible?

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• S etting up the interview
• P erception of the patient re their
  illness
• I nvitation from patient to share info
• K nowledge and Information conveyed
• E motions responded to empathically
• S ummary and Strategy for follow-up

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1. Setting up the interview

• Anticipate the possibility of bad news, and
  arrange a follow-up visit after significant
  scans, biopsies etc.
• Avoid telephone
• Private setting, sitting down
• Turn off beeper, no interruptions
• Ensure adequate time

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1. Setting up the interview

• Lab reports, X-rays present
• Support person present , if desired
• Review the condition, basic prognosis and
  treatments before the visit
• HOPEFUL TONE

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The one-stop cancer website for Manitoba Family
Physicians www.cancercare.mb.ca Info for Doctors
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Assessing the patients 2. Perception

• ASK then TELL
• Important if the patient is not well known to you
  OR if visits to consultants have occurred
• Assess the Gap between what the patient knows
  and the diagnosis
• What have you already been told about might be
  going on?
• What is your understanding of why the CT scan
  was ordered?

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Obtaining the patients3. Invitation

• Preferably before the visit
• Easier if patient is well- known
• Listen to patient cues
• Are you the sort of person who likes to know all
  the details of your condition?
• Would you like me to discuss the results of the
  CT scan with you?

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Giving 4. Knowledge and Information

• Align yourself with the patients understanding
  and vocabulary
• Start with a warning shot Im afraid that the
  scan shows that the problem is fairly serious.
• Give diagnosis simply, avoid euphemisms or
  excessive bluntness
• Provide information in small chunks
• Check frequently for understanding

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Giving 4. Knowledge and Information

• Check for knowledge or experience with condition
• Allow for pauses, use repetition
• Will usually want basic but clear information re
  treatment plan and prognosis
• BUT
• Tune into patient readiness to hear more, and
  know when to stop

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Balancing Truth and Hope The Skillful Use of
Indirect Language S Healing et al 2006

• It looks like. not You have.
• there are tumours in the liver not you have
  tumours in your liver
• Emphasize on maintaining the relationship as well
  as communicating the news

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Respond to 5. Emotions empathically

• Observe for and allow emotional reactions
• Kleenex handy, use of touch
• N aming the feeling I know this is
  upsetting
• U nderstanding It would be for anyone
• R especting Youre asking all the right
  questions
• S upporting Ill do everything I can to
  help you through this.

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6. Summary and Strategy for follow-up

• Summarize discussion
• Clear follow-up plan re referral, tests, next
  contact (in lt48 hrs)
• Provide written summary or brochures
• Refer to community resources
• Invite support person for next visit if not
  present

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6. Summary and Strategy for follow-up

• End on note of hope and partnership
• AFTER document well
• assess your own reaction

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Six Steps for Breaking Bad News

• S etting up the interview
• P erception of the patient re their illness
• I nvitation from patient to share info
• K nowledge and Information conveyed
• E motions responded to empathically
• S ummary and Strategy for follow-up

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Discrepancies in Ratings

• Patients rated the following much higher than
  doctor and nurses
• receiving bad news in a quiet, private place
• arranging a follow-up visit soon to review with
  patient and family
• inform patient about support services
• Girgis, Behavioural Medicine 1999

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Follow-up

• Please take a handout outlining the SPIKES steps
  in sharing bad news
• Try out one or two of the suggestions next time
  you have bad news to share

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• The task of breaking bad news is a testing
  ground for the entire range of our professional
  skills and abilities. If we do it badly, the
  patients or family members may never forgive us
  if we do it well, they will never forget us.
• Robert Buckman

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Thank you!