Communicating Bad News to Cancer Patients

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Communicating Bad Newsto Cancer Patients

• Joel S. Policzer, MD, FACP, FAAHPM
• Sr. VP National Medical Director
• VITAS Innovative Hospice Care
• Miami, FL

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Bad News

• any news that drastically and negatively alters
  the patients view of their future

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Bad News

• any news that drastically and negatively alters
  the patients view of their future

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Bad News

• any news that drastically and negatively alters
  the patients view of their future

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Do You Tell?

• 50 90 of patients want the truth
• So the issue is not do you?
• Issue is how?

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Do You Tell?

• In reality, patients who are dying, know they are
  dying
• They want confirmation of their status
• They want a time frame
• YOU would want a time frame when your time
  approaches

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Time Frames

• Study looked at prognostication of three groups
• cancer patients
• chemo nurses
• oncologists
• Looked at accuracy of estimated survival

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Time Frames

• Patients were very accurate in when they expected
  death to occur
• Chemo nurses closely tracked the patients
  estimates
• Oncologists were off by months, usually
  estimating many months of survival in patients
  that were close to death

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Time Frames

• Take home message
• if an oncologist tells you that you have months
  to live, youll probably be dead in a week

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Time Frames

• Patients do not expect
• 534 PM on July 21
• People want
• a few months
• a few weeks
• days
• hours

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Time Frames

• As physicians and oncologists, if weve taken
  care of enough patients, we know in our gut, with
  our clinical instinct, where a patient is in
  their trajectory
• People want to know to be able to plan
• Maybe they want to live the next month in
  Tuscany or Provence instead of wretching in your
  chemo room

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Why is this Difficult?

• Social factors
• Our society values youth, health, wealth
• Elderly, sick and poor are marginalized
• Sick and dying have less social value

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Why is this Difficult?

• Physician factors
• Fear of causing pain
• Uncomfortable in uncomfortable situations
• Sympathetic pain due to patients distress

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Why is this Difficult?

• Fear of being blamed
• Physicians have authority, control, privilege and
  status
• When medical care fails patient
• its physicians fault
• blame the messenger

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Why is this Difficult?

• Fear of therapeutic failure
• Medical system reinforces idea that poor outcome
  and death are failures of system
• and by extension, our failure
• all disease is fixable
• better living through chemistry
• We are trained to feel this way if only

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Why is this Difficult?

• Fear of medico-legal system
• Everyone has right to be cured
• If no cure happens, someone is to blame

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Why is this Difficult?

• Fear of not knowing
• we dont do what we dont do well
• Good communication is a skill that is not highly
  valued, therefore not taught

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Why is this Difficult?

• Fear of eliciting reaction
• dont do anything unless you know what to do if
  it goes wrong
• Not trained to handle reactions
• Not trained to allow emotion to come out

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Why is this Difficult?

• Fear of saying I dont know
• We are never rewarded for lack of knowledge
• Cant know or control everything

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Why is this Difficult?

• Fear of expressing emotions
• Viewed as unprofessional
• Suppressing emotions increases distance
• between ourselves and patients

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Why is this Difficult?

• Ambiguity of Im sorry
• Two meanings
• Im sorry for you
• Im sorry I did this
• Easily misinterpreted

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Why is this Difficult?

• Fear of ones own illness and death
• Cannot be honest with the dying unless you accept
  you will die

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• So How Do We Do This??

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Never, never, never, ever

• NEVER assume
• To assume to make an ASS
• of U
• and ME

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• If you need to know something
• If you want to know something

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• If you need to know something
• If you want to know something
• ASK!!

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Six Step Protocol

• -arrange physical context
• -find out what patient knows
• -find out what patient wants to know
• -share information
• -respond to patients feelings
• -plan follow-through

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Arrange physical context

• Always in person, face to face
• NEVER on telephone
• Assure privacy
• Verify who is present
• Verify who should be present
• ASK

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Arrange physical context

• Remove physical barriers
• Sit down
• patient-physician eyes at same level
• appear relaxed, not casual
• (avoid open 4)
• Touch patient (appropriately)
• above the waist, handshake, shoulder

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Find out what patient knows

• Not just knows, but understands
• Use open questions
• closed questions excellent for history-taking
• prevent discussion

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Find out what patient knows

• Listen effectively to response
• tells understanding, ability to understand
• Repeat back what patient says
• Do not interrupt
• Make encouraging cues
• Maintain eye contact

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Find out what patient knows

• Tolerate silences
• Listen for buried question
• question asked while you are speaking

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Find out what patient wants to know

• Ask!!
• Do not allow families to run interference
• If patient chooses not to know now, may ask later

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Share the information

• Plan agenda
• know beforehand what information has to get
  across
• eg diagnosis, treatment, prognosis, support
• Start by aligning with what patient knows

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Share the information

• Allow patients to get ready
• Impart information in small packets
• best case retention 50
• Speak English, not Doctor
• Verify message is received

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Respond to feelings

• Acknowledge emotions
• strong emotions prevent communication
• identify and acknowledge them
• Learn to be comfortable with silence and with
  emotion

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Respond to feelings

• Range of normal reaction is wide
• give latitude as much as possible
• stay calm, speak softly
• be gentle, yet firm
• stick to basic rules of interview
• question-listen-hear-respond

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Respond to feelings

• Distinguish between adaptive and maladaptive
  behaviors
• Adaptive Maladaptive
• anger rage
• crying collapse
• bargaining manipulation
• fulfilling an ambition
  impossible quest
• fear anxiety/panic
• hope unrealistic hope

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Respond to feelings

• Respond with empathic responses
• it must be very hard to
• you sound angry (afraid, depressed)

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Respond to feelings

• In the face of true conflict act, dont react
• If you cannot change behavior, get help

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Planning follow-through

• Have plan of action
• Make certain patients understand what is fixable
  and what is not
• Always be honest
• Patient leaves with contract
• what will happen, who to call, how to call,
  when to return

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• You have one chance to get this conversation
  right
• Patient/family will remember this always
• How do you want to be remembered?

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• How to Break Bad News A Guide for Health Care
  Professionals
• Robert Buckman, M.D.
• Johns Hopkins University Press, 1992
• ISBN 0-8018-4491-6