Breaking Bad News. Mary Ellen Foti, MD Revised August 11, 2003. Hercules fights the angel of death. Objectives. Know why “good” communication of “bad” news is important Understand the 6-step protocol for delivering bad news: know what to do at each step know how to facilitate the process
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Mary Ellen Foti, MD
August 11, 2003
Hercules fights the angel of death
Know why “good” communication of “bad” news is important
Understand the 6-step protocol for delivering bad news:
patient relationship and
Creating the right atmosphere
Adapted from Robert Buckman, MD
Adapted from Robert Buckman, M.D.
“No, I didn’t tell her! After all, I’m not a psychiatrist!”
(the radiologist’s last email).
Nancy’s NP took a deep breath and mentally reviewed the case. Nancy was a 48 year old woman who had colon ca 4 years ago. She did well after an intensive array of interventions – radiation, surgery, chemotherapy. She had good follow-up, too. But lately she just was not herself. Staff thought it was an exacerbation of her psychosis.
(Nancy also suffered from schizophrenia.)
The last set of studies were devastating – not only had it returned, it had returned with a vengeance. There were no viable options, and she was to be referred to hospice. Nancy had already returned to her group home (of several years) where she lived with 7 other persons with serious mental illness and program staff. I knew that she had a short time to live.
As I drove to the house in the rain, I struggled with how to share the news with Nancy and her roommates and staff (or better, her “family”).
Making the last turn approaching her home, I shuddered…
- confirm the medical facts first
- don’t delegate, no matter how much you might want to
- prevent interruptions ( forward the phone, put the pager on “silent”, turn off the call phone).
Recognize and support various patient preferences
To do this, you ask a question:
“How much do you want to know?”
People handle information differently
Consider the person’s
age and developmental level
What does the patient know? (step 2)
How does the patient handle information? (step 3)
How to Say It
- avoid vagueness, confusion
- that could be misinterpreted as the Medical staff are responsible for situation or pity.
- be empathic, not guilty
- tears, anger, sadness,
love, anxiety, relief, etc.
- denial, blame, guilt, disbelief, fear, loss, shame, intellectualization
- an outburst of
- broad range of
Expect strong emotion
To cope with this:
- additional information, tests
- treatment for symptoms, especially pain
- referrals as needed
sources of support
- extended family
- include emergency access numbers
- the safety of the patient
- the understanding of the family
- supports at home
- review Emergency Interventions
at the next visit
Use a skilled translator who is
Speak directly to the patient
-this may confuse family members who are unable to translate medical concepts
- family members may modify the news to protect the patient and supplement the translation
Some patients want to plan
Others are seeking reassurance
There are no crystal balls
“What are you expecting to happen?”
“How specific do you want me to be?”
“What experiences have you had with:
Others with the same illness?
Others who have died?”
The 2 extremes are those who
Maintain common chart
or log book for the team
“Do It Your Way!”End-of-Life Care for Persons with Serious Mental IllnessA Robert Wood Johnson Foundation Grantfor more information go towww.promotingexcellence.org/mentalillness
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