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6. Breaking-Bad-News public heath primary health care.pdf
- 1.
- 2. After undergoinga routine colonoscopy, the 50-year- old patient learned that his doctor found a tumor. Immediatelyafter delivering the news, the doctor and nurse left the room. Confused by the sudden departure—and the office staff whoavoided his gaze— the patient got the impression that the doctor and staff were angry with him !!!
- 3. What is BadNews? "any information which adverselyand seriouslyaffects an individual'sview of his or her future"
- 4. Why is itImportant? A Frequent but Stressful Task Breaking bad news can be particularly stressful when the doctor is inexperienced, the patient is young, or there are limited prospects for successful treatment
- 5. Patients Wantthe Truth By the late 1970s most physicians were open about telling cancer patients their diagnosis . In 1982 of 1,251 Americans indicated that 96% wished to be told if they had a diagnosis of cancer 85% wished, in cases of a grave prognosis, to be given a realistic estimate of how long they had to live
- 6. ❑The patient-centered decision-makingmodel is the main stay in delivering bad news. ❑Most patients prefer to know their diagnosis.
- 7. ❑younger patients, femalepatients, and patients with higher education levels tend to desire more detailed information. ❑Some ethnic groups favor a family-centered medical decision model , others prefer a model with more individual patient autonomy .
- 8. Ethical andLegal Imperatives Clear ethical and legal obligations to provide patients with as much information as they desire about their illness and its treatment Physicians may not withhold medical information even if they suspect it will have a negative effect on the patient
- 9. Clinical Outcomes How bad news is discussed can affect the patient's comprehension of information, satisfaction with medical care, level of hopefulness, and subsequent psychological adjustment
- 10. Barriers to BreakingBad News
- 11. Cultural barriers ➢ Patientshave unrealistic expectations of health and life, perhaps secondary to overplayed media reports of medical advances or unrealistic television portrayals. ➢ religious diversity makes it increasingly common that the physician and patient will have different views about an afterlife.
- 12. Physician fears ➢Physicians experiencestressrelated to providing bad news , evidence suggests that this stress does not lessen with a physician'syears in practice or experiencewith delivering bad news. ➢In general, physicians fear eliciting an emotional reaction, being blamed for the bad news, and expressing their emotions during the process.
- 13. Physician fears ➢Physicians alsofear that delivering truthful news abouta terminal illness will leave a patient depressed, without hope. ➢In reality, end-of-lifediscussions are associated with less aggressive medical care, earlier hospice referral, and improved quality of life
- 14. ➢ Physicians oftenwithhold information or overestimate survival. ➢ The inability to effectively and truthfully deliver bad news can lead to patient confusion. ➢ Although bad news may initially increase psychological stress, full and accurate disclosure may help the patient and family emotionally and practically, making the time the patient has left as meaningful as possible
- 15. Models for BreakingBad News SPIKES model Robert Buckman Professor of Oncology – Toronto Trained in Cambridge Used world wide KAYES model
- 16. SPIKES Model Six steps S – Setting up the interview P – assessing the patients Perception I – obtaining the patients Invitation K – giving Knowledge E – addressing Emotions S – Strategy and Summary
- 17. S – Settingup the interview ❖Reviewing the patient's history and situation are critical components of the first step. Mental rehearsal may increase physician confidence. ❖A proper setting also assures privacy, limits interruptions, and involves family if the patient desires. ❖Tissues should be available. ❖Sitting at the bedside increases the perceived time spent in discussion , but it is preferred to ask about patient's preference
- 18. What? Makesure youhave checked all the available information and have test results (including getting the right patient!) Decide general terminology to be used * Where? Arrange for some privacy, * Who? Should break the news, should other staff be there or significant others? * Starting off? Introductions and appropriateopening
- 19. PERCEPTION ✓ Determine thepatient's understanding of his or her condition. ✓ The physician should use broad, open-ended questions, such as, “What is your understanding of what has occurred?” ✓ The physician may also identify misunderstanding, denial, and unrealistic expectations.
- 20. * Whathave you made of the illness so far? * What did doctor X tell you when he sent you here? This helps you gauge how close to the medical reality the patient’s understanding is and will tell you about pacing. Also whether the patient is in denial.
- 21. I – Invitation While a majority of patients express a desire for full information about their diagnosis, prognosis, and details of their illness, some patients do not How much information would the patient like to know
- 22. INVITATION o It isimportant to obtain the patient's permission before delivering the bad news. o A phrase such as, “Would it be okay to give you the results of the tests right now?”engages the patient in shared decision making. o If the patient declines the invitation, it is important to determine the reason (e.g., waiting for a spouse, partner, or other family member to provide support).
- 23. K – Knowledge Warning shot: “Well, the situation does appearto be more serious than that” Avoid jargon Small chunks Useof silence Allow time for emotions Repeat Important Points – patients who are upsetor shocked don’t hear or rememberwell. Usediagrams, written messagesas an aide memoir, audiotapesor leaflets. Check your level – try to simplify without being patronising ❑The SPIKES method advocates delivering a warning statement before the bad news (e.g., “I'm afraid the test results were worse than we initially hoped. ”) confirmation of understanding. The four crucial headings are: Diagnosis, Treatment Plan, Prognosis and Support Listen to Patient’s Agenda: - what are their concerns e.g. Patients may be more worried about hair loss from chemotherapy than potential risk of the disease. - listen to the buried questions & invite questions
- 24. KNOWLEDGE ❑Physicians should usesimple, nontechnical words and avoid medical jargon when delivering bad news. ❑They should provide empathy by avoiding being blunt and by allowing time for patients to express emotions. ❑Information should be provided in small amounts, followed by a confirmation of understanding. ❑The SPIKES method advocates delivering a warning statement before the bad news (e.g., “I'm afraid the test results were worse than we initially hoped.”)
- 25. The fourcrucial headings are: Diagnosis, Treatment Plan, Prognosis and Support Listen to Patient’s Agenda: - what are their concerns e.g. Patients may be more worried about hair loss from chemotherapy than potential risk of the disease. - listen to the buried questions & invite questions
- 26. E – Emotions Recognise Listen for and identify the emotion Identify the cause of the emotion Show the patient you have identified both the emotion and its origin
- 27. EMOTIONS o Beforeprovidingadditional informationoreven immediate reassurance,the physician shouldacknowledgeand accept the patient's response. o Empathic statementsare usefulduringexpressionsof sadness and anger. o Validatingresponseshelps patients realizetheir feelingsare important. o Supportivestatementsguardagainstthe feelingof abandonment o exploratoryquestions o A physiciancan accept a patient's response(e.g., the desireto be cured of cancer), withoutagreeingwith it (e.g., cure is not likely).
- 28. S – Strategyand Summary Understanding reduces fear Summarise the discussion Strategy for future care Schedule next meeting Allow time for questions Leaflets
- 29. STRATEGY AND SUMMARY ✓Physicians should provide a summary, explore options, and determine patient-specific goals. ✓ Even with the worst prognosis, most patients prefer to know what is coming next. ✓ Follow-up should include the patient's next appointment and a way for the patient or family to contact the physician with questions.
- 30. STRATEGY AND SUMMARY ✓A second appointment in the next few days, or it may be delayed, depending on patient preference. ✓ Physicians should avoid the phrase “I'm afraid there is nothing more we can do for you.” This leaves the patient feeling helpless and abandoned. Instead, in the absence of cure, the focus should be on defining and supporting the patient's redefined hopes (e.g., less pain, more time with family). ✓ Patients should be assured that the physician will be with them and support them.
- 31. Kaye’s Model 10steps Logical sequence Not based on rigorous research Can be used for any serious illness Mixes facts with questions about feelings
- 32. 1. Preparation 2. Whatdoes the patient know? 3. Is more information wanted? 4. Give a warning shot 5. Allow denial 6. Explain (if requested) 7. Listen to concerns 8. Encourage ventilation of feelings 9. Summary and plan 10. Offer availability
- 33. 1 - Preparation Know all the facts Ensure privacy Find out who the patient would like present Introduce yourself
- 34. 2 – Whatdoes the patient know? Open ended questions Statements may make the best questions “How did it all start?”
- 35. 3 – Ismore information wanted? Not forced on them “Wouldyou like me to explaina bit more?”
- 36. 4 – WarningShots Not straight out with it! “I’m afraid it looksrather serious”
- 37. 5 – AllowDenial Allow the patient to control the amount of information they receive.
- 38. 6 – Explainif Requested Step by step. Detail will not be remembered but the wayyou explain it will be.
- 39. 7 – Listento concerns “What are your concerns at the moment?” Allow time and space for answers.
- 40. 8 – EncourageFeelings Acknowledgethe feelings. Non-judgmental. Vital step for patient satisfaction.
- 41. 9 – Summarise Concerns. Plans for treatment. Foster hope. Written information.
- 42. 10 – OfferFurther Availability. Information. Future needs will change.
- 43.