Breaking Bad NewsBreaking Bad News
Ahmer A. KarimuddinAhmer A. Karimuddin
September 5September 5thth, 2003, 2003
IntroductionIntroduction
ConceptsConcepts
Doctor’s DilemmaDoctor’s Dilemma
Medical EducationMedical Education
Leading upLeading up
InterviewInterview
Cultural FactorsCultural Factors
PrognosisPrognosis
Sudden Death Sudden Death DebriefingDebriefing
SupportSupport
Anger & BlameAnger & Blame
Depression, Despair Depression, Despair & Hope& Hope
IntroductionIntroduction
Yet the first bringer of unwelcome Yet the first bringer of unwelcome newsnews
Hath but a losing office, and his tongueHath but a losing office, and his tongue
Sounds ever after as a sullen bellSounds ever after as a sullen bell
Remembered knolling a departing Remembered knolling a departing friendfriend
King Henry IV, Part 2, IiKing Henry IV, Part 2, Ii
IntroductionIntroduction
Physician Patient relationshipPhysician Patient relationship
Breaking bad newsBreaking bad news Common interventionCommon intervention Testing groundTesting ground
Consequences are immenseConsequences are immense
ConceptsConcepts
““Perception of news as good or bad is a Perception of news as good or bad is a belief, value judgment or affective belief, value judgment or affective response from the provider or receiver of response from the provider or receiver of the information, in a given context” the information, in a given context”
(Bor, et al., 1996)(Bor, et al., 1996)
ConceptsConcepts
Patient must make value judgmentPatient must make value judgment
Indirect pressureIndirect pressure
Patient autonomy?Patient autonomy?
Never assume or anticipate a reactionNever assume or anticipate a reaction
Bad news does not equal deathBad news does not equal death Change in quality of lifeChange in quality of life Ending of hopeEnding of hope
Cannot withhold informationCannot withhold information
Doctor’s DilemmaDoctor’s Dilemma
A lack of skills in what to say and how to A lack of skills in what to say and how to say itsay itFear of blameFear of blamePatient emotionPatient emotionPersonal emotionPersonal emotion Fear of death, illness, mortalityFear of death, illness, mortality HelplessnessHelplessness
Premature advice or reassurance is Premature advice or reassurance is implied insensitivity or rejectionimplied insensitivity or rejection
Doctor’s DilemmaDoctor’s Dilemma
Dosanjh et al. (Med. Educ. 2001)Dosanjh et al. (Med. Educ. 2001) Significant barriers exist to breaking bad newsSignificant barriers exist to breaking bad news Lack of emotional supportLack of emotional support Available timeAvailable time Personal fears about the delivery processPersonal fears about the delivery process Lack of communication skillsLack of communication skills Lack of feedback on prior attemptsLack of feedback on prior attempts Personal feelings, after eventPersonal feelings, after event
MethodsMethods
1.1. Directly, bluntly and with insensitivityDirectly, bluntly and with insensitivity
2.2. Kindly, sadly without overt support and Kindly, sadly without overt support and encouragementencouragement
3.3. Positive with understanding, empathy, Positive with understanding, empathy, reassurance and flexibilityreassurance and flexibility
Patients overwhelmingly prefer which Patients overwhelmingly prefer which option?option?Brevin et al. (Lancet, 1999)Brevin et al. (Lancet, 1999)
Medical EducationMedical Education
Dent et al. (BMJ, 1990)Dent et al. (BMJ, 1990) 75% of housestaff never received adequate training75% of housestaff never received adequate training
General lack of evidence in the literatureGeneral lack of evidence in the literature
Campbell et al. (Behav. Med, 1998)Campbell et al. (Behav. Med, 1998) 35% of residents feel competent in breaking bad 35% of residents feel competent in breaking bad
newsnews
Girgis et al. (NZJS, 1999)Girgis et al. (NZJS, 1999) 80% of surgeons feel breaking bad news well is as 80% of surgeons feel breaking bad news well is as
important as technical surgical skillsimportant as technical surgical skills
Medical EducationMedical Education
Multiple studies demonstrate education Multiple studies demonstrate education works now and later:works now and later: Undergraduate trainingUndergraduate training Video & Audio tapingVideo & Audio taping FeedbackFeedback
Gordon et al. (AGIM, 1993)Gordon et al. (AGIM, 1993) Communication and detection skills Communication and detection skills
deteriorate during internshipdeteriorate during internship
Medical EducationMedical Education
Observe & practice new behavioursObserve & practice new behaviours
Structured experiencesStructured experiences
Systematic feedbackSystematic feedback
Goal oriented evaluationGoal oriented evaluation
Medical EducationMedical Education
Methods have no impact on long term patient Methods have no impact on long term patient adjustmentadjustmentDisclosure brings:Disclosure brings: GratitudeGratitude Peace of mindPeace of mind Positive attitudePositive attitude Reduced anxietyReduced anxiety AdjustmentAdjustment
Tactics should mainly be employed to ensure Tactics should mainly be employed to ensure physician comfort and ability (Persaud, 1993)physician comfort and ability (Persaud, 1993)
Leading upLeading up
Know the history wellKnow the history wellAcknowledge social circumstancesAcknowledge social circumstancesUnderstand the prognosisUnderstand the prognosisQuality of life issuesQuality of life issuesPrivacyPrivacyComfortable environmentComfortable environmentTimeTimeAvailability of a person of choiceAvailability of a person of choiceBE CERTAINBE CERTAIN
InterviewInterview
Simple clear languageSimple clear language
Minimal to no medical jargonMinimal to no medical jargon
Match verbal and emotional cuesMatch verbal and emotional cues
Team approachTeam approach
InterviewInterview
““I am sorry, I have some bad news to tell I am sorry, I have some bad news to tell you”you”
Discuss reason for being hereDiscuss reason for being here
Tell patient firstTell patient first
Small dosesSmall doses
Ask if patient understands frequentlyAsk if patient understands frequently
Repeat and summarizeRepeat and summarize
InterviewInterview
Alllow time to assimilateAlllow time to assimilate
““How do you feel?”How do you feel?”
List of questionsList of questions
InformationInformation
HopeHope Positive approachPositive approach Sincere, controlled optimismSincere, controlled optimism Hope leads to a will to live, does it increase longevity?Hope leads to a will to live, does it increase longevity?
Probabilities & AbsolutesProbabilities & Absolutes
ReactionReaction
Most distressing aspect for physicianMost distressing aspect for physician
Outpouring of emotionOutpouring of emotion
SilenceSilence
Inappropriate responseInappropriate response
Do not break the silenceDo not break the silence
ReactionReaction
QuestioningQuestioningDenialDenial Inability to copeInability to cope RepeatRepeat Ask to explainAsk to explain
AngerAnger DefensivenessDefensiveness
AcceptanceAcceptance ““I notice you are taking the news calmly, many people I notice you are taking the news calmly, many people
react differently”react differently”
ReactionReaction
LonelinessLonelinessBurdenBurden To familyTo family To systemTo system
Manner of dyingManner of dying Suffocation, choking, bleedingSuffocation, choking, bleeding Loneliness, poveryLoneliness, povery
AbandonmentAbandonmentConfirmation of suspicionConfirmation of suspicion 88% of patients suspect bad news before they are 88% of patients suspect bad news before they are
toldtold
Cultural FactorsCultural Factors
English speaking countriesEnglish speaking countries Full disclosureFull disclosure
Asian and Hispanic communitiesAsian and Hispanic communities Family centered model of decision makingFamily centered model of decision making
Patients should be asked if they wish to Patients should be asked if they wish to delegate treatment decisions to families or delegate treatment decisions to families or be informed of full storybe informed of full story
““How long do I have?”How long do I have?”
Productive quality of lifeProductive quality of life
Expected survival – Admission of failureExpected survival – Admission of failure
Gloomy prognosis may lead patient elsewhereGloomy prognosis may lead patient elsewhere
Process of dyingProcess of dying Avoid detailsAvoid details
Ensure patient wants to know expected survivalEnsure patient wants to know expected survival
Be honest, not overly optimistic or pessimisticBe honest, not overly optimistic or pessimistic
Sudden DeathSudden Death
Death = ShockDeath = Shock
Over the telephone?Over the telephone? 64% NO64% NO 26% YES26% YES
Privacy with other staff membersPrivacy with other staff members
Medical trauma to Family traumaMedical trauma to Family trauma
Feelings of failure, inadequacy, guiltFeelings of failure, inadequacy, guilt
Contradict self recriminationContradict self recrimination
Allow silence and emotionAllow silence and emotion
Sudden DeathSudden Death
ReviewReview
PrivacyPrivacy
ViewingViewing Avoid disturbing imagesAvoid disturbing images
Autopsy?Autopsy? SensitivitySensitivity TimeTime
Broken Heart SyndromeBroken Heart Syndrome
DebriefingDebriefing
Caregiver reactionsCaregiver reactions Sadness, anger, guilt, self reproachSadness, anger, guilt, self reproach AvoidanceAvoidance OveractivityOveractivity
Grief of rescuersGrief of rescuersCritical Incident debriefingCritical Incident debriefing Critical responsibilityCritical responsibility Health educationHealth education
Should occur after every CPR attemptShould occur after every CPR attempt
Support for Patient & FamiliesSupport for Patient & Families
SupportSupport Time spent listening and acknowledging Time spent listening and acknowledging
emotionsemotions Frame their fearsFrame their fears Answer their questionsAnswer their questions Acceptance vs. denialAcceptance vs. denial
Denial of diagnosisDenial of diagnosis
Denial of implicationsDenial of implications
Denial of deathDenial of death
Anger & BlameAnger & Blame
Overt vs. subtleOvert vs. subtleAgainst health care professionalsAgainst health care professionals OverwhelmingOverwhelming Negative responseNegative response
Against disease, loss of control, God, self, Against disease, loss of control, God, self, friends, familyfriends, familyIdentify the cause of the angerIdentify the cause of the anger Fear?Fear?
Guilt = problemGuilt = problem
Depression, Despair & HopeDepression, Despair & Hope
DepressionDepression IdentifyIdentify DiagnoseDiagnose TreatTreat
SuicidalitySuicidality
Hope vs. despairHope vs. despair Undeliverable promisesUndeliverable promises AbandonmentAbandonment
ConclusionsConclusions
Difficult taskDifficult task
Part of patient carePart of patient care
Patients are dissatisfied with the quality of Patients are dissatisfied with the quality of informationinformation
Clinicians are uncomfortable with Clinicians are uncomfortable with providing informationproviding information
Lack of empirical dataLack of empirical data
Medical educationMedical education