1. Tips for Bad News Bearers A Critical Clinical Skill Dr. Jeff Sisler Department of Family Medicine CancerCare Manitoba Issues and Updates 2007

2. Learning Objectives After this session, you will: zRecognize the challenge of sharing bad news effectively zBe able to describe an effective six step process for sharing bad news--SPIKES zBe committed to improving your skills in breaking bad news to patients

3. What is Bad News? Any news that seriously and negatively alters the patients view of his or her future. Buckman

4. The Goal zHelp the patient and family understand the condition zSupport the patient and family zMinimize the risk of overwhelming distress or prolonged denial

5. Why is it a critical skill? The Patients Perspective zPatients often have vivid memories of receiving bad news zNegative experiences can have lasting effects on anxiety and depression zCan facilitate adaptation to illness and deepen the patient-doctor relationship

6. Why is it a critical skill? The Physicians Perspective High degree of difficulty + Physician anxiety = High risk of performing poorly

7. What do patients want? For themselves… zmore time to talk zand show feelings From the doctor… zmore information, caring, hopefulness, confidence za familiar face Strauss 1995

8. What do you do? zWhat have you have found helpful in making bad news visits go as well as possible?

9. S etting up the interview P erception of the patient re their illness I nvitation from patient to share info K nowledge and Information conveyed E motions responded to empathically S ummary and Strategy for follow-up

10. 1. Setting up the interview zAnticipate the possibility of bad news, and arrange a follow-up visit after significant scans, biopsies etc. Avoid telephone Private setting, sitting down Turn off beeper, no interruptions Ensure adequate time

11. 1. Setting up the interview Lab reports, X-rays present Support person present, if desired Review the condition, basic prognosis and treatments before the visit HOPEFUL TONE

12. The one-stop cancer website for Manitoba Family Physicians www.cancercare.mb.ca Info for Doctors

13. Assessing the patients 2. Perception zASK then TELL zImportant if the patient is not well known to you OR if visits to consultants have occurred zAssess the Gap between what the patient knows and the diagnosis zWhat have you already been told about might be going on? zWhat is your understanding of why the CT scan was ordered?

14. Obtaining the patients 3. Invitation zPreferably before the visit zEasier if patient is well- known zListen to patient cues z Are you the sort of person who likes to know all the details of your condition? zWould you like me to discuss the results of the CT scan with you?

15. Giving 4. Knowledge and Information zAlign yourself with the patients understanding and vocabulary zStart with a warning shot: Im afraid that the scan shows that the problem is fairly serious. zGive diagnosis simply, avoid euphemisms or excessive bluntness zProvide information in small chunks zCheck frequently for understanding

16. Giving 4. Knowledge and Information zCheck for knowledge or experience with condition zAllow for pauses, use repetition zWill usually want basic but clear information re treatment plan and prognosis BUT zTune into patient readiness to hear more, and know when to stop

17. Balancing Truth and Hope: The Skillful Use of Indirect Language S Healing et al 2006 zIt looks like…. not You have…. zthere are tumours in the liver… not you have tumours in your liver… zEmphasize on maintaining the relationship as well as communicating the news

18. Respond to 5. Emotions empathically zObserve for and allow emotional reactions zKleenex handy, use of touch N aming the feeling I know this is upsetting U nderstanding It would be for anyone R especting Youre asking all the right questions S upporting Ill do everything I can to help you through this.

19. 6. Summary and Strategy for follow-up zSummarize discussion zClear follow-up plan re: referral, tests, next contact (in <48 hrs) zProvide written summary or brochures zRefer to community resources zInvite support person for next visit if not present

20. 6. Summary and Strategy for follow-up End on note of hope and partnership AFTER: document well assess your own reaction

21. Six Steps for Breaking Bad News S etting up the interview P erception of the patient re their illness I nvitation from patient to share info K nowledge and Information conveyed E motions responded to empathically S ummary and Strategy for follow-up

22. Discrepancies in Ratings Patients rated the following much higher than doctor and nurses: zreceiving bad news in a quiet, private place zarranging a follow-up visit soon to review with patient and family zinform patient about support services Girgis, Behavioural Medicine 1999

23. Follow-up zPlease take a handout outlining the SPIKES steps in sharing bad news zTry out one or two of the suggestions next time you have bad news to share

24. The task of breaking bad news is a testing ground for the entire range of our professional skills and abilities. If we do it badly, the patients or family members may never forgive us; if we do it well, they will never forget us. Robert Buckman

25. Thank you!