Communicating bad news
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COMMUNICATING BAD NEWS. Michael Marschke, MD Medical Director of Horizon Hospice in Chicago. BAD NEWS. Most Americans want to know If done right: Improves doctor-patient relationship Helps patient and family to cope Fosters a collaborative relation. 6 STEP APPROACH. Prepare

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COMMUNICATING BAD NEWS

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Communicating bad news

COMMUNICATING BAD NEWS

Michael Marschke, MD

Medical Director of Horizon Hospice in Chicago


Bad news

BAD NEWS

  • Most Americans want to know

  • If done right:

    • Improves doctor-patient relationship

    • Helps patient and family to cope

    • Fosters a collaborative relation


6 step approach

6 STEP APPROACH

  • Prepare

  • Find out what the patient knows

  • Find out what the patient wants to know

  • Share the information

  • Respond to emotions

  • Plan follow-up

    * from “How to Break Bad News: A Guide for Health Care Professionals,” by Robert Buckman


1 prepare

1. PREPARE

  • Confirm facts yourself; gather necessary data

  • Get the setting right – privacy, pull up the chairs, tissues…

  • Allow adequate time; prevent interruptions

  • Who else needs to be there?


2 how much do they know

2. HOW MUCH DO THEY KNOW?

  • “What do you think is going on?”

  • Establish if they are able to comprehend

  • If unprepared or appears to need support, reschedule (soon!)

  • Can be done in advanced during the initial assessment


3 how much do they want to know

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 not, establish who is to be told


When family says don t tell them anything

When family says “Don’t tell them anything.”

  • You are legally and ethically obligated to get this request from the patient

  • Ask them why, what are they afraid of

  • Discuss this directly with the patient with the family present


4 share information

4. SHARE INFORMATION

Communication skills:

  • Eye level, eye contact

  • Comfortable

  • Interested body language

  • Use language patient understands

  • Promote dialogue, open-ended questions, check for understanding

  • Empathy

  • Silence


4 share information1

4. SHARE INFORMATION

  • Deliver news in a sensitive but straight-forward way

  • Avoid vagueness; well-intentioned efforts to soften the blow may lead to misunderstanding

  • Pause frequently

  • “I’m sorry” may confer aloofness or your responsibility


5 respond to emotions

5. RESPOND TO EMOTIONS

  • Tears, anger, anxiety are normal reactions

  • Cognitively, patients may express denial, blame, guilt, fear, shame.

  • Rarely, one may experience a panic attack

  • Let the emotion express itself, acknowledge it, be attentive

  • Silence, touch, comfort

  • Assess safety, need for support


6 follow up

6. FOLLOW-UP

  • Establish what the next steps are; treat symptoms right away

  • If detailed, may want to do on a second visit soon

  • Remember, they may only retain 10-25% of what you said

  • Re-visit soon; re-address facts/understanding/emotions


Other issues

OTHER ISSUES

LANGUAGE BARRIERS:

  • Need skilled translator, not family

  • Speak directly to patient

  • Verify understanding

    GOALS/ADVANCED DIRECTIVES

    SHARE INFO WITH PRIMARY CAREGIVERS


Communicating prognosis

COMMUNICATING PROGNOSIS

  • Ask why they want to know/what are they expecting

  • Avoid precise answers/give ranges

  • Hope for the best BUT plan for the worst – be prepared/get affairs in order – offer help with this


Final hours

FINAL HOURS

  • In many cases can be recognized

  • Compassionate honesty

  • Re-focus on patient goals

  • Emphasize little things for comfort – oral swabs, open communication, light touching, gentle positioning

  • Empathetic support

  • Evaluate family need for support


Death notification

DEATH NOTIFICATION

  • Try to do in person

  • Be honest

  • 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.

  • Watch for abnormal grief reactions

  • Elicit support system

  • Be sensitive about asking about funeral/autopsy

  • Set up follow-up


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