1. Breaking Bad News

2. Objectives: Students will:
Recognize essential principles of breaking bad news.
Identify pitfalls in delivering breaking bad news.
Apply skills of breaking bad news in a simulated situation.

3. THE BAD NEWS ABOUT BREAKING BAD
NEWS IS THAT BAD NEWS IS
BAD NEWS

5. DEFINITION OF BAD NEWS

6. Bad News
any news that drastically and negatively alters the patient’s view of their future
Buckman R. BMJ1984

7. Bad News
any news that drastically and negatively alters the patient’s view of their future
Buckman R. BMJ 1984

8. Bad News
any news that drastically and negatively alters the patient’s view of their future
Buckman R. BMJ 1984

9. It alters one’s self-image : “I left my house as one person & came home another.”
Professional cyclist Lance Armstrong’s recollection

11. Examples of Conditions Requiring Breaking of Bad News ???!!!!

12. 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

13. Examples of Conditions Requiring Breaking of Bad News(cont)
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

14. The Good News! about Bad News!!!
Using a plan for determining the patient’s values, their wishes for participation in decision making, and a strategy for addressing their distress when the bad news is disclosed can increase our confidence in the task.

15. The Good News! about Bad News!!!(cont)
It may also encourage patients to participate in difficult treatment decisions
Those who do so have a better quality of life
Clinicians who are comfortable with giving bad news are subject to less stress and burnout.

16. عن أبي يحي صهيب بن سنان رضي الله عنه قال: قال رسول الله صلى الله عليه وسلم:
(( عجبا لأمر المؤمن إن أمره كله له خير وليس ذلك إلا للمؤمن: إن أصابته سراء شكر فكان خيرا له، وإن أصابته ضراء صبر فكان خيرا له)) رواه مسلم

17. Do You Tell??

18. Do You Tell? So the issue is not “do you?” Issue is “how?”
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 )
So the issue is not “do you?”
Issue is “how?”

19. 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

20. Is this Difficult to break the bad news?
WHY?

21. Is this Difficult to break the bad news?
It is referred by some physicians like “dropping the bomb”
Baile W F, oncologist 2000

22. 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

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

24. 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”

25. 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……”

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

27. 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

28. 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

29. 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

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

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

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

33. So How Do We Do This??

34. Never, never, never, ever…
NEVER “assume”

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

36. If you need to know something
If you want to know something
ASK!!

37. THINGS GO WRONG WHEN: * WE TRY TO ESCAPE * WE REACT IN ANGER
* WE DILUTE THE AGENDA

38. THINGS GO WRONG WHEN: WE TRY TO ESCAPE: INAPPROPRIATE DELEGATION
DISTRACTION
FRONTAL ATTACK
INTELLECTUALIZATION
MINIMIZATION
EMPTY REASSURANCE

39. THINGS GO WRONG WHEN: WE REACT IN ANGER: TO DENIAL TO IDEALIZATION
TO REHEARSAL OF THE STORY
TO ‘UNREASONABLE’ DEMANDS
TO ANGER AND BLAME

40. THINGS GO WRONG WHEN: WHEN WE DILUTE THE AGENDA: BILLING
PRACTICAL ARRANGEMENTS
REQUEST FOR POST MORTEM

41. The SPIKES Protocol SETTING UP the interview
Assessing patient’s PERCEPTION
Obtaining the patient’s INVITATION
Giving KNOWLEDGE and information
Addressing the patient’s EMOTIONS
STRATEGY and SUMMARY

42. SPIKES Step 1: S - SETTING UP the interview
Preparation Preparation- Preparation
Always in person, face to face
NEVER on telephone
Plan, arrange for privacy, involve significant others
Sitting down, Non Verbal Behaviour
Manage time constraints and interruptions
Physical Context
body language, eye contact (“not when hot”) and positioning
Listening Skills
silence (pauses etc), repetition, other facilitation techniques, touch

43. Assessing The PATIENT’S PERCEPTION
SPIKES
Step 2: P –
Assessing The PATIENT’S PERCEPTION
Gather before you Give
Patient’s knowledge, expectations and hopes
What do they understand about the situation? Unrealistic expectations?
What is their state of mind? Hopes?
Opportunity to correct misinformation and tailor your information

44. SPIKES Step 3: I – Obtaining the patient’s INVITATION
Gather before you give
How much does the patient want to know?
Coping strategy?
Answer questions, offer to speak to another
Majority of patients express a desire for full information
Discuss information disclosure while ordering tests
“How would you like me to give the information about the test results?”
If patient does not want to know details involve a relative or friend.

45. SPIKES Step 4: K – Giving KNOWLEDGE and information to the patient
Warning shot
Use simple language, no jargon,
Vocabulary and comprehension of patient
Small chunks, avoid detail unless requested
Pause, allow information to sink in
Wait for response before continuing
Check understanding
Check impact
Give a warning shot
E.g. “Unfortunately, I have some bad news to tell you……” or “I’m sorry to tell you….”
Start at level of comprehension of the patient
Use nontechnical words “spread” instead of “metastasized”
Avoid being blunt as it may make the patient isolated and angry “You have such a bad cancer that you will not survive without treatment…”

46. SPIKES
Step 5: E – Addressing the patient’s EMOTIONS with empathic responses
Shock, isolation, grief
Silence, disbelief, crying, denial, anger
Observe patient’s responses and identify emotions
Offer empathic responses

47. Emotions of the patient
Respond to patients’ emotions with empathy
Often shock, isolation, disbelief, grief or anger
Observe for emotion on patient’s part
Identify the emotion.
Identify the reason for the emotion
Connect with the patient

48. Emotions of the patient
Exploratory questions
How do you mean?
Tell me more about it
You said it frightens you
You said you were concerned about your children, tell me more
Could you tell me what you are worried about?

49. Emotions of the patient
Validating responses
I can understand how you felt that way
I guess anyone might have the same reaction
You are perfectly correct to think that way
Your understanding of the reason for the tests is very good
Many other patients have had a similar experience

50. Emotions of the patient
Doctor: “I’m sorry to say that the X-ray shows that the chemotherapy is not working [pause]. Unfortunately, the tumor has grown somewhat”
Patient: “I’ve been afraid of this!” [Cries]
Doctor: [Moves his chair closer, offers the patient a tissue and pauses,] “I know that this isn’t what you wanted to hear. I wish the news were better”

51. What is Empathy?
The capacity to recognise emotions that are being felt by another person.

52. Empathic Responses
An indication to the patient that you recognise what they are feeling (and why)
Verbal and Non verbal
Often associated with the impact of the news rather than the understanding.
Wait for response
Clarify

53. Emotions of the patient
Empathic statements
I can see how upsetting this is to you
I can tell you were not expecting to hear this
I know this is not good news for you
I’m sorry to have to tell you this
This is very difficult for me also
I was also hoping for a better result

54. SPIKES Step 6: S – STRATEGY and SUMMARY Clarify patient’s goals
Are they ready?
Involve the patient in the decision making
Check understanding
Clarify patient’s goals
Summarise
Contract for future

55. REVISION OF THE 6 STEPS

56. 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

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

58. 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

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

60. 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

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

62. 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

63. 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

64. 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

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

66. 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

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

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

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

70. 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

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

72. How to Break Bad News: A Guide for Health Care Professionals
Robert Buckman, M.D.
Johns Hopkins University Press, 1992
ISBN:

74. Scenario 1 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.

75. Scenario 2
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)

76. SAQs
(1) One of the famous strategy for breaking bad news is the SPIKES Model: Explain briefly any 3 of the 6 areas mentioned in this model? (2) What is a warning shot? What you say and what skills you use after and before breaking bad news? (3) Breaking bad news is difficult: Give 3 reasons for that?