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Communicating Bad News to Cancer Patients. Joel S. Policzer, MD, FACP, FAAHPM Sr. VP – National Medical Director VITAS Innovative Hospice Care Miami, FL. Bad News. any news that drastically and negatively alters the patient’s view of their future. Bad News.

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communicating bad news to cancer patients

Communicating Bad Newsto Cancer Patients

Joel S. Policzer, MD, FACP, FAAHPM

Sr. VP – National Medical Director

VITAS Innovative Hospice Care

Miami, FL

bad news
Bad News
  • any news that drastically and negatively alters the patient’s view of their future
bad news1
Bad News
  • any news that drastically and negatively alters the patient’s view of their future
bad news2
Bad News
  • any news that drastically and negatively alters the patient’s view of their future
do you tell
Do You Tell?
  • 50 – 90% of patients want the truth
  • So the issue is not “do you?”
  • Issue is “how?”
do you tell1
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
time frames
Time Frames
  • Study looked at prognostication of three groups:
  • cancer patients
  • chemo nurses
  • oncologists
  • Looked at accuracy of estimated survival
time frames1
Time Frames
  • Patients were very accurate in when they expected death to occur
  • Chemo nurses closely tracked the patients’ estimates
  • Oncologists were off by months, usually estimating many months of survival in patients that were close to death
time frames2
Time Frames
  • Take home message:
  • if an oncologist tells you that you have months to live, you’ll probably be dead in a week
time frames3
Time Frames
  • Patients do not expect:
  • “5:34 PM on July 21”
  • People want:
  • “a few months”
  • “a few weeks”
  • “days”
  • “hours”
time frames4
Time Frames
  • As physicians and oncologists, if we’ve taken care of enough patients, we know in our gut, with our clinical instinct, where a patient is in their trajectory
  • People want to know to be able to plan
  • Maybe they want to live the next month in Tuscany or Provence instead of wretching in your chemo room
why is this difficult
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
why is this difficult1
Why is this Difficult?
  • Physician factors
  • Fear of causing pain
  • Uncomfortable in uncomfortable situations
  • Sympathetic pain due to patient’s distress
why is this difficult2
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”
why is this difficult3
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……”
why is this difficult4
Why is this Difficult?
  • Fear of medico-legal system
  • Everyone has “right” to be cured;
  • If no cure happens, someone is to blame
why is this difficult5
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
why is this difficult6
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
why is this difficult7
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
why is this difficult8
Why is this Difficult?
  • Fear of expressing emotions
  • Viewed as unprofessional
  • Suppressing emotions increases distance
  • between ourselves and patients
why is this difficult9
Why is this Difficult?
  • Ambiguity of “I’m sorry”
  • Two meanings
  • “I’m sorry for you”
  • “I’m sorry I did this”
  • Easily misinterpreted
why is this difficult10
Why is this Difficult?
  • Fear of one’s own illness and death
  • Cannot be honest with the dying unless you accept you will die
never never never ever
Never, never, never, ever…
  • NEVER “assume”
  • To assume: to make an ASS
  • of U
  • and ME
slide26
If you need to know something
  • If you want to know something
slide27
If you need to know something
  • If you want to know something
  • ASK!!
six step protocol
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
arrange physical context
Arrange physical context
  • Always in person, face to face
  • NEVER on telephone
  • Assure privacy
  • Verify who is present
  • Verify who should be present
  • ASK
arrange physical context1
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
find out what patient knows
Find out what patient knows
  • Not just knows, but understands
  • Use open questions
  • closed questions excellent for history-taking
  • prevent discussion
find out what patient knows1
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
find out what patient knows2
Find out what patient knows
  • Tolerate silences
  • Listen for “buried question”
  • question asked while you are speaking
find out what patient wants to know
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
share the information
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
share the information1
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
respond to feelings
Respond to feelings
  • Acknowledge emotions
  • strong emotions prevent communication
  • identify and acknowledge them
  • Learn to be comfortable with silence and with emotion
respond to feelings1
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
respond to feelings2
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
respond to feelings3
Respond to feelings
  • Respond with empathic responses
  • “it must be very hard to…”
  • “you sound angry (afraid, depressed)…”
respond to feelings4
Respond to feelings
  • In the face of true conflict: act, don’t react
  • If you cannot change behavior, get help
planning follow through
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
slide43
You have one chance to get this conversation right
  • Patient/family will remember this always
  • How do you want to be remembered?
slide44
How to Break Bad News: A Guide for Health Care Professionals
  • Robert Buckman, M.D.
  • Johns Hopkins University Press, 1992
  • ISBN: 0-8018-4491-6