Breaking Bad News Dr. Riaz Qureshi Distinguished Professor Family Medicine Dept. of Family & Community Medicine King Saud University ,Riyadh, Saudi Arabia

Breaking Bad News Learning Objectives for Students/Trainees: To understand why this is an important part of communication skills. To understand the definition of bad news. The students/trainees should become aware of: What to do? How to do it? What not to do? Students/Trainees should also become familiar with certain illnesses/ problems which may require giving bad news.

Breaking Bad News A difficult but fundamentally important task for all health care professionals Physicians feel uncertain & uncomfortable while breaking bad news, leading to being distant & disengaged from their patients.

Breaking Bad News Recent studies have shown that: Patients generally (50-90%) desire full & frank disclosure, though a sizeable minority still may not want the full disclosure. (Ley p. Giving information to patients. New York: Wiley, 1982 ) Focused training in communication skills & techniques to facilitate breaking of bad news has been demonstrated to improve patients satisfaction & physicians comfort.

What is bad news? “any news that drastically and negatively alters the patients view towards his future.” Buckman R. BMJ1984 It alters one’s self-image : “I left my house as one person & came home another.” Professional cyclist Lance Armstrong’s recollection

Examples reported by clinical consultants Examples of Conditions Requiring Breaking of Bad News Cancer related diagnoses Intra uterine foetal demise Life long illness: Diabetes, Epilepsy Poor prognosis related to chronic diseases: loss of independence Informing parents about their child’s serious mental/physical handicap Giving diagnosis of serious sexually transmitted disease …catastrophic psychosocial results Non clinical situations like giving feedback to poorly performing trainees or colleagues

Psychosocial Context Patients response is influenced by previous experiences & current social circumstances---inappropriate timing Even simple diagnosis being incompatible with one’s profession---tremors in cardiac surgeon. Varying needs of patient & family---patient wishes to know more himself & less information to pass on to family, family wishes vice versa.

Barriers to effective disclosure It is referred by some physicians like “dropping the bomb” Baile W F, oncologist 2000 Common Barriers include Physician’s fears of : Being blamed by patient Not knowing all the answers Inflicting pain & sufferings Own illness & death Lack of training Lack of time Multiple physicians---who should perform the task

Patient’s perspective Most important factors for patients include: Physician’s competence, honesty & attention The time allowed for questions Straightforward & understandable diagnosis The use of clear language Parker PA, Baile WF j.clinical onc 2001

Family's perspective Family members prefer: privacy Good attitude of the person who gives the bad news Clarity of message Competency of physicians Time for questions Jurkovich GJ, et al. J Trauma 200

Delivering Bad News “It is not an isolated skill but a particular form of communication.” Frank A. Eur J of Palliat care 1997 Rabow & Mcphee (West J. Med 1999) described: “Clinicians focus often on relieving patients’ bodily pain, less often on their emotional distress & seldom on their suffering.”

Delivering Bad News Rabow & Mcphee (West J. Med 1999) synthesized a simple mnemonic of ABCDE: Advance Preparation Build a therapeutic environment/relationship Communicate well Deal with patient & family reactions Encourage and validate emotions

Advance Preparation Familiarize yourself with the relevant clinical information (investigations, hospital report) Arrange for adequate time in private, comfortable environment Instruct staff not to interrupt Be prepared to provide at least basic information about prognosis and treatment options (so do read it up)

Advance Preparation Mentally rehearse how you will deliver the news. You may wish to practice out loud Script specific words & phrases to use or to avoid Be prepared emotionally

Build a therapeutic environment/relationship Introduce yourself to everyone present Summarise where things have got to date, check with patient/relative Discover what has happened since last seen Judge how the patient is feeling/thinking Determine the patient’s preferences for what and how much he/she wants to know

Build a therapeutic environment/relationship (contd) Warning shot “I’m afraid it looks more serious than we had hoped” Use touch where appropriate Pay attention to verbal & non verbal cues Avoid inappropriate humour Assure patient that you will be available

Communicate well Speak frankly but compassionately Avoid medical jargon Allow silence & tears; proceed at patient’s pace Have the patient describe his/her understanding of the information given Encourage questions Write things down & provide written information Conclude each visit with a summary & follow up plan

Deal with patient and family reactions Assess & respond to emotional reactions Be aware of cognitive coping (denial, blame, guilt, disbelief, acceptance, intellectualization) Allow for “shut down”, when patient turns off & stops listening Be empathetic; it is appropriate to say “I’m sorry or I don’t know. Crying may be appropriate Don’t argue or criticize colleagues

Encourage and validate emotions Offer realistic hope Give adequate information to facilitate decision making Explore what the news means to the patient & inquire about spiritual needs Inquire about the support systems in place

Encourage and validate emotions Attend to your own needs during and following the delivery of bad news (counter-transference can be harmful) Use multidisciplinary services to enhance patient care ( hospice) Formal or informal debriefing session with concerned team members may be appropriate

What to do? Introduce yourself Look to comfort and privacy Determine what the patient already knows Warn the patient that bad news is coming Break the Bad News Identify the patient’s main concern Summarize and check understanding Offer realistic hope Arrange follow up and make sure that some one is with the patient when he leaves

How to do it ? Be sensitive Be empathic and consider appropriate touching Maintain eye contact Give information in small chunks Repeat and clarify Regularly check understanding Do not be afraid of silence or tears Explore patient’s emotions and give him time to respond Be honest if you are unsure about something

What not to do ? Hurry Give all the information in one go Give too much information Use medical jargon or unclear language/words Lie or be economical with the truth Be blunt. Words can be like loaded pistols/guns Guess the prognosis (She has got 6 months, may be 7)

Quotation The greatest revolution of our generation is the discovery that human beings, by changing the inner attitudes of their minds , can change the outer aspects of their lives. William James American Psychologist & Philosopher

Angry Patient WHAT TO DO? Introduce yourself Acknowledge the person’s anger Try to find out the reason for his anger, e.g. frustration, fear or guilt Validate his feelings Let him ventilate his anger or any feelings that led to his anger Offer to do something or for him to do something

Angry Patient HOW TO DO IT? Sit at the same level as the patient, not too close and not too far, with eye contact Speak calmly without raising your voice Avoid dismissive or threatening body language Encourage the person to speak with open ended questions Empathize as much as you can with verbal and non verbal cues Be aware of your own safety

Angry patient WHAT NOT TO DO? Glare at the person Confront him or interrupt him Patronize him or touch him Put the blame on others/seek to exonerate yourself Make unreasonable promises Block his exit If the person is a patient’s relative, be mindful about confidentiality

SCENARIO Tariq, a 55-year-old chain smoker taxi driver with persistent cough for 3 months, attends your clinic to find out the biopsy report of a lesion shown on a chest x-ray and CT scan. He is rather anxious, that he has a serious condition. His biopsy report confirms that he has a Bronchogenic Carcinoma of right lung. You are required to proceed with this consultation.

Scenario No 2 Proceed with this consultation. A 54-year-old lady attends your clinic to find out the result of an MRI of her spine. She has had constant pain all over her spine for the last 2 months. She also has a history of Breast cancer, which was treated 5 years ago. Her report shows that she has secondaries all over her spine Proceed with this consultation. (Examination not required)