Communication Skills in Medicine Communication Skills in Medicine - Delivering Bad News- Delivering Bad News

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Pavel Kurfürst, ÚCJ LF UPPavel Kurfürst, ÚCJ LF UP

BAD NEWSBAD NEWS

• any news that drastically and negatively alters the patient’s view of his or her future(Vandekieft)

• it results in a cognitive, behavioral, or emotional deficit in the personreceiving the news that persists for some time after the news is received(Back – Curtis)

BAD NEWSBAD NEWS

• many health care professionals tendto define 'bad news' as worst case scenarios (eg. telling a patient they have cancer or that their loved one has died)

• but a knee cartilage problem requiring rest for a waitress may mean no pay(RFC handbook)

SITUATIONSSITUATIONS

• terminal diagnosis • death in an out-of-

hospital setting • communicating

sensitive subjects to parents and children

• fetal death verifiedby an ultrasound

• multiple sclerosis confirmed by MRI

• onset of diabetesin an adolescent

THE PAST AND THE PRESENTTHE PAST AND THE PRESENT

• Hippocrates advised concealing most things from the patient

• older physicians, who trained duringthe 1950s and 60s, were taughtto "protect" patients from disheartening news(Easton)

• in the past decades traditional paternalistic models of patient care have given wayto an emphasis on patient autonomy

FACTSFACTS

• 50-90% of patients desire full disclosureof a terminal diagnosis (Vandekieft)

• 95% of cancer patients want the physician to be fully honest with them aboutthe outcome of their illness (Thomas)

FACTSFACTS

• over the course of a 40-year career,an oncologist may conduct up to 200,000 interviews with patients, caregiversand/or families;if as few as 10% of those interviews involve the disclosure of bad news, that is still 20,000 interviews in whichyou have to be the bearer of bad news (Buckman)

EDUCATIONEDUCATION

• clinicians are responsible for delivering bad news, this skill is rarely taught in medical schools, clinicians are generally poor at it(Rabow – McPhee)

• breaking bad news is one of a physician’s most difficult duties

• medical education typically offers little formal preparation for this task(Vandekieft)

EDUCATIONEDUCATION

• 1997-1998 AMA survey: only 4 of 126 US medical schools required a separate course on caring for the dying(Acevedo)

• many medical graduates have persisting interpersonal difficulties when confronted with terminally ill patients, death and dying (Barrington – Murrie)

EDUCATIONEDUCATION

• historically, the emphasis on the biomedical model in medical training places more value on technical proficiency thanon communication skills

• in ancient times, the bearer of the news that a battle had been lost was often killed;in a similar fashion, reacting to bad news, some patients blame their clinicians(Rabow – McPhee)

• death represents a failure of the medical system, our failure as physicians,and even our failure as human beings (West)

• clinicians focus often on relieving patients' bodily pain, less often on their emotional distress, seldom on their suffering

• they may view suffering as beyond their professional responsibilities

• if clinicians feel unable to, or simply do not want to, address the powerful issue of patient suffering, it is appropriate to refer the patientto another professional on the healthcare team who is more comfortable in this arena(Rabow – McPhee)

• breaking bad news is not as mucha delivery as it is a dialogue betweentwo people (Rabow – McPhee)

• the patients needs to given an opportunity to express his emotions and to articulate his fears(Thomas)

• the physician’s caring attitude is more important than the information provided during the clinical encounter(Back – Curtis)

• clinicians can deliver bad news well and manage its consequences(Rabow – McPhee)

COMMUNICATE AS A TEAMCOMMUNICATE AS A TEAM

• patient• family• physician• other health care

providers

• psychologist• chaplain• nurse• social worker• translator

GUIDELINESGUIDELINES

• several professional groups have published consensus guidelines onhow to discuss bad news

• few of those guidelines are evidence-based

• the clinical efficacy of many standard recommendations has not been empirically demonstrated(Vandekieft)

S-P-I-K-E-SS-P-I-K-E-S

• a six-step approach by R. Buckman

• proposed by the Project to Educate Physicians on End-of-life Care (EPEC)- supported by the American Medical Association and the Robert WoodJohnson Foundation

S-P-I-K-E-SS-P-I-K-E-S

• setting

• perception

• invitation

• knowledge

• empathy

• strategy and Summary

(Buckman; Maicki; Acevedo; Payne; EPEC materials; Michigan PG)

ABCDEABCDE

• advance preparation

• build a therapeutic environment/relationship

• communicate well

• deal with patient and family reactions

• encourage and validate emotions(reflect back emotions)

(Rabow – McPhee; Vandekieft; Dyer)

OTHER GUIDELINESOTHER GUIDELINES

• preparation

• place

• people

• position

• pronouncement

• post-event follow up

(Rodgers)

OTHER GUIDELINESOTHER GUIDELINES

• preparation

• introduction

• achieving understanding

• pacing and shared control

(Rodgers)

• respondingto emotions

• honesty

• support

• closure

OTHER GUIDELINESOTHER GUIDELINES

• preparation

• setting

• delivery

• emotional Support

• information

• closure

(Gordon)

OTHER GUIDELINESOTHER GUIDELINES

• prepare for the encounter• assess the patient’s understanding• discuss the news• respond to the patient’s emotions• offer to discuss implications of the news• summarize the discussion• arrange a follow-up time for patient and family

questions and concerns• document the discussion in the medical record

(Back – Curtis)

OTHER GUIDELINESOTHER GUIDELINES

• the World Health Organisation (WHO) Guidelines on Communicating Bad News

• WHO/MNH/PSF/93.2.B

(WHO Guidelines on Communicating Bad News - adapted abstract)

REMEMBERREMEMBER

people handle information differentlydepending on their• educational level• ethnicity and culture• religion, beliefs• socioeconomic status• age(Michigan Physician Guide)

REMEMBERREMEMBER

• technical language usually misunderstoodby the patient(73% of women with breast cancerdo not understand the term MEDIANwhen told about prognosis and survival) (Back - Curtis)

• avoid euphemisms• do not minimize the severity of the situation

(Michigan Physician Guide)

REMEMBERREMEMBER

never give bad news on a Friday!

(RFC handbook)

KEY WORDSKEY WORDS

• communicating / delivering / breaking / giving bad news

• communication skills / communication issues / doctor-patient communication

• end-of-life care / palliative care / palliative medicine

• end-of-life communication

RESOURCESRESOURCES

see a separate list of resources

click here (*.rtf file)

CONTACTCONTACT

kurfurst@seznam.cz

www.ucjlf.upol.cz/svoc