1. COMMUNICATING BAD NEWS Michael Marschke, MD Medical Director of Horizon Hospice in Chicago

2. BAD NEWS Most Americans want to know Most Americans want to know If done right: If done right: Improves doctor-patient relationshipImproves doctor-patient relationship Helps patient and family to copeHelps patient and family to cope Fosters a collaborative relationFosters a collaborative relation

3. 6 STEP APPROACH 1. Prepare 2. Find out what the patient knows 3. Find out what the patient wants to know 4. Share the information 5. Respond to emotions 6. Plan follow-up * from How to Break Bad News: A Guide for Health Care Professionals, by Robert Buckman

4. 1. PREPARE Confirm facts yourself; gather necessary data Confirm facts yourself; gather necessary data Get the setting right – privacy, pull up the chairs, tissues… Get the setting right – privacy, pull up the chairs, tissues… Allow adequate time; prevent interruptions Allow adequate time; prevent interruptions Who else needs to be there? Who else needs to be there?

5. 2. HOW MUCH DO THEY KNOW? What do you think is going on? What do you think is going on? Establish if they are able to comprehend Establish if they are able to comprehend If unprepared or appears to need support, reschedule (soon!) If unprepared or appears to need support, reschedule (soon!) Can be done in advanced during the initial assessment Can be done in advanced during the initial assessment

6. 3. HOW MUCH DO THEY WANT TO KNOW? If this condition turns out to be something serious, do you want to know? How much do you want to know? If this condition turns out to be something serious, do you want to know? How much do you want to know? If not, establish who is to be told If not, establish who is to be told

7. When family says Dont tell them anything. You are legally and ethically obligated to get this request from the patient You are legally and ethically obligated to get this request from the patient Ask them why, what are they afraid of Ask them why, what are they afraid of Discuss this directly with the patient with the family present Discuss this directly with the patient with the family present

8. 4. SHARE INFORMATION Communication skills: Eye level, eye contact Eye level, eye contact Comfortable Comfortable Interested body language Interested body language Use language patient understands Use language patient understands Promote dialogue, open-ended questions, check for understanding Promote dialogue, open-ended questions, check for understanding Empathy Empathy Silence Silence

9. 4. SHARE INFORMATION Deliver news in a sensitive but straight-forward way Deliver news in a sensitive but straight-forward way Avoid vagueness; well-intentioned efforts to soften the blow may lead to misunderstanding Avoid vagueness; well-intentioned efforts to soften the blow may lead to misunderstanding Pause frequently Pause frequently Im sorry may confer aloofness or your responsibility Im sorry may confer aloofness or your responsibility

10. 5. RESPOND TO EMOTIONS Tears, anger, anxiety are normal reactions Tears, anger, anxiety are normal reactions Cognitively, patients may express denial, blame, guilt, fear, shame. Cognitively, patients may express denial, blame, guilt, fear, shame. Rarely, one may experience a panic attack Rarely, one may experience a panic attack Let the emotion express itself, acknowledge it, be attentive Let the emotion express itself, acknowledge it, be attentive Silence, touch, comfort Silence, touch, comfort Assess safety, need for support Assess safety, need for support

11. 6. FOLLOW-UP Establish what the next steps are; treat symptoms right away Establish what the next steps are; treat symptoms right away If detailed, may want to do on a second visit soon If detailed, may want to do on a second visit soon Remember, they may only retain 10- 25% of what you said Remember, they may only retain 10- 25% of what you said Re-visit soon; re-address facts/understanding/emotions Re-visit soon; re-address facts/understanding/emotions

12. OTHER ISSUES LANGUAGE BARRIERS: Need skilled translator, not family Need skilled translator, not family Speak directly to patient Speak directly to patient Verify understanding Verify understanding GOALS/ADVANCED DIRECTIVES SHARE INFO WITH PRIMARY CAREGIVERS

13. COMMUNICATING PROGNOSIS Ask why they want to know/what are they expecting Ask why they want to know/what are they expecting Avoid precise answers/give ranges Avoid precise answers/give ranges Hope for the best BUT plan for the worst – be prepared/get affairs in order – offer help with this Hope for the best BUT plan for the worst – be prepared/get affairs in order – offer help with this

14. FINAL HOURS In many cases can be recognized In many cases can be recognized Compassionate honesty Compassionate honesty Re-focus on patient goals Re-focus on patient goals Emphasize little things for comfort – oral swabs, open communication, light touching, gentle positioning Emphasize little things for comfort – oral swabs, open communication, light touching, gentle positioning Empathetic support Empathetic support Evaluate family need for support Evaluate family need for support

15. DEATH NOTIFICATION Try to do in person Try to do in person Be honest Be honest Be there; silence support Be there; silence support Ask about viewing/body care/bathing, cultural/religious rituals, others that need to be informed. Take as much time as needed. Ask about viewing/body care/bathing, cultural/religious rituals, others that need to be informed. Take as much time as needed. Watch for abnormal grief reactions Watch for abnormal grief reactions Elicit support system Elicit support system Be sensitive about asking about funeral/autopsy Be sensitive about asking about funeral/autopsy Set up follow-up Set up follow-up