Communication Skills in Medicine - Delivering Bad News An Introduction to Internet Resources in English

1
Communication Skills in Medicine - Delivering Bad
NewsAn Introduction to Internet Resources in
English

• Podzim 02 - Špindleruv Mlýn
• Pavel Kurfürst, ÚCJ LF UP

2
BAD NEWS

• any news that drastically and negatively alters
  the patients view of his or her
  future(Vandekieft)
• it results in a cognitive, behavioral, or
  emotional deficit in the personreceiving the
  news that persists for some time after the news
  is received(Back Curtis)

3
BAD NEWS

• many health care professionals tendto define
  'bad news' as worst case scenarios (eg. telling a
  patient they have cancer or that their loved one
  has died)
• but a knee cartilage problem requiring rest for a
  waitress may mean no pay(RFC handbook)

4
SITUATIONS

• terminal diagnosis
• death in an out-of-hospital setting
• communicating sensitive subjects to parents and
  children

• fetal death verifiedby an ultrasound
• multiple sclerosis confirmed by MRI
• onset of diabetesin an adolescent

5
THE PAST AND THE PRESENT

• Hippocrates advised concealing most things from
  the patient
• older physicians, who trained duringthe 1950s
  and 60s, were taughtto "protect" patients from
  disheartening news(Easton)
• in the past decades traditional paternalistic
  models of patient care have given wayto an
  emphasis on patient autonomy

6
FACTS

• 50-90 of patients desire full disclosureof a
  terminal diagnosis (Vandekieft)
• 95 of cancer patients want the physician to be
  fully honest with them aboutthe outcome of their
  illness (Thomas)

7
FACTS

• over the course of a 40-year career,an
  oncologist may conduct up to 200,000 interviews
  with patients, caregiversand/or familiesif as
  few as 10 of those interviews involve the
  disclosure of bad news, that is still 20,000
  interviews in whichyou have to be the bearer of
  bad news (Buckman)

8
EDUCATION

• clinicians are responsible for delivering bad
  news, this skill is rarely taught in medical
  schools, clinicians are generally poor at
  it(Rabow McPhee)
• breaking bad news is one of a physicians most
  difficult duties
• medical education typically offers little formal
  preparation for this task(Vandekieft)

9
EDUCATION

• 1997-1998 AMA survey only 4 of 126 US medical
  schools required a separate course on caring for
  the dying(Acevedo)
• many medical graduates have persisting
  interpersonal difficulties when confronted with
  terminally ill patients, death and dying
  (Barrington Murrie)

10
EDUCATION

• historically, the emphasis on the biomedical
  model in medical training places more value on
  technical proficiency thanon communication
  skills

11

• in ancient times, the bearer of the news that a
  battle had been lost was often killedin a
  similar fashion, reacting to bad news, some
  patients blame their clinicians(Rabow McPhee)
• death represents a failure of the medical system,
  our failure as physicians,and even our failure
  as human beings (West)

12

• clinicians focus often on relieving patients'
  bodily pain, less often on their emotional
  distress, seldom on their suffering
• they may view suffering as beyond their
  professional responsibilities
• if clinicians feel unable to, or simply do not
  want to, address the powerful issue of patient
  suffering, it is appropriate to refer the
  patientto another professional on the healthcare
  team who is more comfortable in this arena(Rabow
  McPhee)

13

• breaking bad news is not as mucha delivery as it
  is a dialogue betweentwo people (Rabow
  McPhee)
• the patients needs to given an opportunity to
  express his emotions and to articulate his
  fears(Thomas)

14

• the physicians caring attitude is more important
  than the information provided during the clinical
  encounter(Back Curtis)
• clinicians can deliver bad news well and manage
  its consequences(Rabow McPhee)

15
COMMUNICATE AS A TEAM

• patient
• family
• physician
• other health care providers

• psychologist
• chaplain
• nurse
• social worker
• translator

16
GUIDELINES

• several professional groups have published
  consensus guidelines onhow to discuss bad news
• few of those guidelines are evidence-based
• the clinical efficacy of many standard
  recommendations has not been empirically
  demonstrated(Vandekieft)

17
S-P-I-K-E-S

• a six-step approach by R. Buckman
• proposed by the Project to Educate Physicians on
  End-of-life Care (EPEC)- supported by the
  American Medical Association and the Robert
  WoodJohnson Foundation

18
S-P-I-K-E-S

• setting
• perception
• invitation
• knowledge
• empathy
• strategy and Summary
• (Buckman Maicki Acevedo Payne EPEC materials
  Michigan PG)

19
ABCDE

• advance preparation
• build a therapeutic environment/relationship
• communicate well
• deal with patient and family reactions
• encourage and validate emotions(reflect back
  emotions)
• (Rabow McPhee Vandekieft Dyer)

20
OTHER GUIDELINES

• preparation
• place
• people
• position
• pronouncement
• post-event follow up
• (Rodgers)

21
OTHER GUIDELINES

• preparation
• introduction
• achieving understanding
• pacing and shared control
• (Rodgers)

• respondingto emotions
• honesty
• support
• closure

22
OTHER GUIDELINES

• preparation
• setting
• delivery
• emotional Support
• information
• closure
• (Gordon)

23
OTHER GUIDELINES

• prepare for the encounter
• assess the patients understanding
• discuss the news
• respond to the patients emotions
• offer to discuss implications of the news
• summarize the discussion
• arrange a follow-up time for patient and family
  questions and concerns
• document the discussion in the medical record
• (Back Curtis)

24
OTHER GUIDELINES

• the World Health Organisation (WHO) Guidelines on
  Communicating Bad News
• WHO/MNH/PSF/93.2.B
• (WHO Guidelines on Communicating Bad News -
  adapted abstract)

25
REMEMBER

• people handle information differently
• depending on their
• educational level
• ethnicity and culture
• religion, beliefs
• socioeconomic status
• age
• (Michigan Physician Guide)

26
REMEMBER

• technical language usually misunderstoodby the
  patient(73 of women with breast cancerdo not
  understand the term MEDIANwhen told about
  prognosis and survival) (Back - Curtis)
• avoid euphemisms
• do not minimize the severity of the
  situation(Michigan Physician Guide)

27
REMEMBER

• never give bad news on a Friday!
• (RFC handbook)

28
KEY WORDS

• communicating / delivering / breaking / giving
  bad news
• communication skills / communication issues /
  doctor-patient communication
• end-of-life care / palliative care / palliative
  medicine
• end-of-life communication

29
RESOURCES

• see a separate list of resources
• click here (.rtf file)

30
CONTACT

• kurfurst_at_seznam.cz
• www.ucjlf.upol.cz/svoc