1. Communicating Bad News to Cancer Patients Joel S. Policzer, MD, FACP, FAAHPM Sr. VP – National Medical Director VITAS Innovative Hospice Care Miami, FL

2. Bad News any news that drastically and negatively alters the patient’s view of their future

3. Bad News any news that drastically and negatively alters the patient’s view of their future

4. Bad News any news that drastically and negatively alters the patient’s view of their future

6. Do You Tell? 50 – 90% of patients want the truth So the issue is not “do you?” Issue is “how?”

7. Do You Tell? In reality, patients who are dying, know they are dying They want confirmation of their status They want a time frame YOU would want a time frame when your time approaches

8. Time Frames Study looked at prognostication of three groups: cancer patients chemo nurses oncologists Looked at accuracy of estimated survival

9. Time Frames Patients were very accurate in when they expected death to occur Chemo nurses closely tracked the patients’ estimates Oncologists were off by months, usually estimating many months of survival in patients that were close to death

10. Time Frames Take home message: if an oncologist tells you that you have months to live, you’ll probably be dead in a week

11. Time Frames Patients do not expect: “5:34 PM on July 21” People want: “a few months” “a few weeks” “days” “hours”

12. Time Frames As physicians and oncologists, if we’ve taken care of enough patients, we know in our gut, with our clinical instinct, where a patient is in their trajectory People want to know to be able to plan Maybe they want to live the next month in Tuscany or Provence instead of wretching in your chemo room

13. Why is this Difficult? Social factors Our society values youth, health, wealth Elderly, sick and poor are marginalized Sick and dying have less social value

14. Why is this Difficult? Physician factors Fear of causing pain Uncomfortable in uncomfortable situations Sympathetic pain due to patient’s distress

15. Why is this Difficult? Fear of being blamed Physicians have authority, control, privilege and status When medical care fails patient it’s physician’s fault “blame the messenger”

16. Why is this Difficult? Fear of therapeutic failure Medical system reinforces idea that poor outcome and death are failures of ‘system’ and by extension, our failure “all disease is fixable” “better living through chemistry” We are trained to feel this way; “if only……”

17. Why is this Difficult? Fear of medico-legal system Everyone has “right” to be cured; If no cure happens, someone is to blame

18. Why is this Difficult? Fear of not knowing “we don’t do what we don’t do well” Good communication is a skill that is not highly valued, therefore not taught

19. Why is this Difficult? Fear of eliciting reaction “don’t do anything unless you know what to do if it goes wrong” Not trained to handle reactions Not trained to allow emotion to come out

20. Why is this Difficult? Fear of saying “I don’t know” We are never rewarded for lack of knowledge Can’t know or control everything

21. Why is this Difficult? Fear of expressing emotions Viewed as unprofessional Suppressing emotions increases distance between ourselves and patients

22. Why is this Difficult? Ambiguity of “I’m sorry” Two meanings “I’m sorry for you” “I’m sorry I did this” Easily misinterpreted

23. Why is this Difficult? Fear of one’s own illness and death Cannot be honest with the dying unless you accept you will die

24. So How Do We Do This??

25. Never, never, never, ever… NEVER “assume” ASS To assume: to make an ASS U of U ME and ME

26. If you need to know something If you want to know something

27. If you need to know something If you want to know somethingASK!!

28. Six Step Protocol -arrange physical context -find out what patient knows -find out what patient wants to know -share information -respond to patient’s feelings -plan follow-through

29. Arrange physical context Always in person, face to face NEVER on telephone Assure privacy Verify who is present Verify who should be present ASK

30. Arrange physical context Remove physical barriers Sit down patient-physician eyes at same level appear relaxed, not casual (avoid ‘open 4’) Touch patient (appropriately) above the waist, handshake, shoulder

31. Find out what patient knows Not just knows, but understands Use open questions closed questions excellent for history- taking prevent discussion

32. Find out what patient knows Listen effectively to response: tells understanding, ability to understand Repeat back what patient says Do not interrupt Make encouraging cues Maintain eye contact

33. Find out what patient knows Tolerate silences Listen for “buried question” question asked while you are speaking

34. Find out what patient wants to know Ask!! Do not allow families to run interference If patient chooses not to know now, may ask later

35. Share the information Plan agenda know beforehand what information has to get across eg diagnosis, treatment, prognosis, support Start by aligning with what patient knows

36. Share the information Allow patients to ‘get ready’ Impart information in small packets best case retention = 50% Speak English, not “Doctor” Verify message is received

37. Respond to feelings Acknowledge emotions strong emotions prevent communication identify and acknowledge them Learn to be comfortable with silence and with emotion

38. Respond to feelings Range of normal reaction is wide give latitude as much as possible stay calm, speak softly be gentle, yet firm stick to basic rules of interview: question-listen-hear-respond

39. Respond to feelings Distinguish between adaptive and maladaptive behaviors AdaptiveMaladaptive anger rage crying collapse bargaining manipulation fulfilling an ambition impossible “quest” fear anxiety/panic hope unrealistic hope

40. Respond to feelings Respond with empathic responses “it must be very hard to…” “you sound angry (afraid, depressed)…”

41. Respond to feelings In the face of true conflict: act, don’t react If you cannot change behavior, get help

42. Planning follow-through Have plan of action Make certain patient’s understand what is fixable and what is not Always be honest Patient leaves with contract: what will happen, who to call, how to call, when to return

43. You have one chance to get this conversation right Patient/family will remember this always How do you want to be remembered?

44. How to Break Bad News: A Guide for Health Care Professionals Robert Buckman, M.D. Johns Hopkins University Press, 1992 ISBN: 0-8018-4491-6