Bad News[1] Intro To Clinics

Regie A. Layug, MD Department of Family & Community Medicine Colegio de San Beda Medicina

At the end of the session, the student learners are expected to: 1. Identify situations considered as bad news 2. Learn a practical method of breaking bad news to patients 3. Know the components of the SPIKES protocol 4. Formulate and design ways on how to personally convey bad news to particular patients



Any news that adversely and seriously affects an individual’s view of his or her future

 Imparting

information to patients that will have serious adverse consequences to them and their families

 Disclosing

the diagnosis of cancer  Discussing cancer recurrence or failure of treatment to impact disease progression  Disclosing metastatic disease  Discussing the presence of irreversible disease or serious treatment toxicity

 Transitions

in care objectives  Disclosing positive results of genetic tests

 Feeling

of helplessness  Physician’s unwanted need to confront own feelings about death and the dying process  Feeling of sadness for the patient

A

strategy, not a script  Highlights the most important features of the bad news interview  Suggests methods of assessing the situation as it evolves and responding constructively to what happens

 Privacy  Patient’s

mistrust and antagonism may result simply from a poorly chosen location

 Find

a private location  Close door  Curtains drawn around a hospital bed  Ask the patient to turn off the TV or radio to minimize distractions  If you have just examined the patient, allow him of her to dress before the discussion

 Involve  Family

significant others

members or friends  Ask the patient who will act as spokesperson for the family during the discussion

 Sit

down

 Pull

up a chair  Ask permission to sit on the edge of the bed  Avoid sitting behind physical barriers like desks  Undo your coat or blazer  Put down any items that are not critical to the discussion

 Look

attentive and calm

 Psychotherapy

neutral position  Maintain eye contact  Have a box of tissues or handkerchief nearby  Adopt other friendly gestures to lessen tension

 Listening

mode

 Appropriate

use of silence  Repetition and use of active listening skills

 Availability  Give

your patient a clear indication of your time restraints  Make arrangements to avoid frequent interruptions during the encounter  In the hospital, check with the nurse working with your patient to ensure this is a good time for the discussion

 “Before

you tell, ask”  Find out if your patient has an idea of the seriousness of the problem

“What do you think was going on with you when you felt the lump?” “What have you been told about all this so far?” “Are you worried that this might be something serious?”

 Take

note of the language and vocabulary he or she is using  Do not confront denial at the first interview

 Obtain

overt permission respects the patient’s right to know (or not to know)  Offer to answer any immediate questions that the patient has and make sure he or she knows that additional questions can be answered in subsequent interviews  Ask if the patient wants you to talk to a family member instead

“Are you the kind of person who prefers to know all the details about what is going on?” “How much information would you like me to give you about your diagnosis and treatment?” “Would you like me to give you details of what is going on or would you prefer that I just tell you about treatments I am proposing?”

 Before

you break bad news, give your patient a warning that bad news is coming

Use the same language your patient uses  Avoid technical, scientific language  Give information in small chunks and clarify that the patient understands what you have said at the end of each chunk  Tailor the rate at which you provide the information to your patient  Acknowledge and respond to the patient’s emotions and reactions as they unfold in the discussion 

 Empathic  Listen

Response

for and identify the emotion. If you are not sure which emotion, use an exploratory response

 Empathic  Identify

Response

the cause or source of the emotion (most likely to be the bad news that the patient has just heard)

 Empathic  Show

Response

your patient that you have identified both the emotion and its origin

 Validate

your patient’s feelings and relate the response to you  Let your patient know that showing emotion is perfectly normal, to minimize feelings of embarrassment and isolation

 Ensure

that the patient understands the information you have provided  Check frequently to make sure that you are both on the same page

 Summarize

the information in your discussion  Give opportunity for the patient to voice any major concerns or questions