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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

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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