Breaking Bad News

1. Breaking Bad News A Critical Clinical Skill

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

4. 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

5. What is Bad News? Any news that seriously and negatively alters the patient’s view of his or her future. Buckman

6. The Goal • Help the patient and family understand the condition • Support the patient and family • Minimize the risk of overwhelming distress or prolonged denial

7. Why is it a critical skill? The Patient’s Perspective • Patients often have vivid memories of receiving bad news • Negative experiences can have lasting effects on anxiety and depression • Can facilitate adaptation to illness and deepen the patient-doctor relationship

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

9. What do patients want? For themselves… • more time to talk • and show feelings From the doctor… • more information, caring, hopefulness, confidence • a familiar face Strauss 1995

10. What Do Patient’s Want? • Studies show that 50-90% of patients with terminal illnesses want full disclosure • Not everyone wants to know

11. HOW TO DO IT??

12. SPIKES Strategy:

13. 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

14. 1. Setting up the interview • Avoid telephone • Private setting, sitting down • Turn off beeper, no interruptions • Ensure adequate time

15. 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

16. Assessing the patient’s 2. Perception • ASK then TELL • Important if the patient is not well known to you OR if visits to consultants have occurred • “Assess the Gap” • “What have you already been told about might be going on? • “What is your understanding of why the CT scan was ordered?”

17. Obtaining the patient’s3. Invitation • Preferably before the visit • Easier if patient is well- known • Listen to patient cues • “Are you the sort of person who likes to know all the details of your condition? • “Would you like me to discuss the results of the CT scan with you?”

18. Giving 4. Knowledge and Information • Align yourself with the patient’s understanding and vocabulary • Start with a warning shot: “I’m afraid that the scan shows that the problem is fairly serious.” Silence…… • Give diagnosis simply, avoid euphemisms or excessive bluntness • Provide information in small chunks • Check frequently for understanding

19. Giving 4. Knowledge and Information • Check for knowledge or experience with condition • Allow for pauses, use repetition • Will usually want basic but clear information re treatment plan and prognosis BUT • Tune into patient readiness to hear more, and know when to stop

20. Balancing Truth and Hope: The Skillful Use of Indirect Language S Healing et al 2006 • “It looks like….” not “You have….” • “there are tumours in the liver…” not “you have tumours in your liver…” • Emphasize on maintaining the relationship as well as communicating the news

21. Respond to 5. Emotions empathically • Observe for and allow emotional reactions • Kleenex handy, use of touch N aming the feeling “I know this is upsetting” U nderstanding “It would be for anyone” R especting “You’re asking all the right questions” S upporting “I’ll do everything I can to help you through this.”

22. Things Go Wrong When: * WE TRY TO ESCAPE * WE REACT IN ANGER * WE DILUTE THE AGENDA

23. 6. Summary and Strategy for follow-up • Summarize discussion • Clear follow-up plan re: referral, tests, next contact (in <48 hrs) • Provide written summary or brochures • Refer to community resources • Invite support person for next visit if not present

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

25. 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

26. Patients’ Views:Research Findings • receiving bad news in a quiet, private place • arranging a follow-up visit soon to review with patient and family • inform patient about support services Girgis, Behavioural Medicine 1999

27. Follow-up • Please take a handout outlining the SPIKES steps in sharing bad news • Try out one or two of the suggestions next time you have bad news to share

28. 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

29. CONCLUSIONS • BAD NEWS CANNOT BE CONVERTED TO GOOD NEWS • KNOWLEDGE OF NORMAL PSYCHOLOGY WILL HELP INFORM THE PROCESS • SPECIFIC SKILLS (LISTEN) CAN BE LEARNED AND APPLIED • SELF AWARENESS IS ESSENTIAL TO GOOD COMMUNICATION

30. Case Scenario • During morning clinic, you receive a phone call from the radiologist at your local hospital. A chest x-ray carried out on Mr. Ahmed shows features highly suggestive of lung cancer. You remember that Mr. Ahmed is a 50 year old in your practice area.

31. What problems confront you and how could they be dealt with?

32. Case scenario • 30-year-old lady delivered a baby with down syndrome 8 hours ago. The pediatrician told you as an intern to tell her husband about the diagnosis. • What points would you like to consider in discussing this request with him?

33. Thank you!