Delivering Serious News Definitions of Serious News Includes - - PowerPoint PPT Presentation

Delivering Serious News

Definitions of Serious News

 Includes communication regarding

• Life-threatening illness
• Imminence of death
• Death of a loved one

 Definition of serious news

• Any information likely to alter drastically a patient’s view
• f his or her future (Buckman, 1984)
• Bor et al (1993):

feeling of no hope a threat to a person’s mental or physical well-being, a risk of upsetting an established lifestyle fewer choices in his or her life

Types of discussion

 Illness/Treatment stage

• Diagnosis: early vs advanced disease
• Progression
• Recurrence
• No further active treatment
• Terminal care

 Factors to consider:

• Your relationship with the patient: new versus existing
• Age of the patient: older versus younger
• Identification within your personal life
• Past experiences & attitudes to delivering “bad news”

Exercise

Personal Reflection:

• Rate your average level of discomfort between 0-10

when delivering serious news

• Name 3 thoughts or feelings in relation to the idea
• f delivering serious news
• Think about a situation that didn’t go well and why?
• Think about a situation that did go well and why?

Impact on Clinicians

 Findings from clinician surveys (Ptacek et al, 2001,

Shaw et al, 2013)

• Stressful
• Difficulties with handling own emotions:

 Guilt  Sorrow  Identification  Feeling like a failure

 Stress can last hours, days  Little evidence that these difficulties ease

with experience

 Can contribute to burnout

Doctor’s Discomfort when Delivering Bad News

Where does it come from?

• Feeling responsible for patient’s misfortune
• Perceptions of failure
• Unresolved feelings about death and dying
• Concerns about patient’s response to the

news

• Clinician’s concerns about their own

emotional response to the circumstance

Impact of Delivery on Patients

 How bad news is delivered can have a

significant impact on:

• Patient’s understanding of their illness
• Treatment decisions
• Patient’s long-term relationship with clinicians

(Rosenbaum et al., 2004)

• Patient’s satisfaction with care
• Hope and subsequent psychological

adjustment

Impact of Delivery on Patients

 Patients are quite critical of how clinicians

deliver serious news

 German study: (Seifart et al, 2014)

• Only 46% of patients were satisfied with their

clinician’s communication

• Inadequate in the areas of:

 Addressing emotions  Providing clear explanation of diagnosis  Explaining the course of the disease

But what do patients want?

 Individual differences & preferences in

WHAT they want to know

• 95% of patients want to be informed of their

diagnosis (Cox et al, 2006)

• But large variation in specific details (Cox et al.,

2006; Rutten et al., 2005; Fujimori et al., 2009)

 Chances of cure  Effectiveness of cancer treatments  Specific prognosis

• Cross-cultural differences

How do we know what patients want?

 Difficult to predict individual preferences  therefore best to ask how much and what

type of information they want

What else do patients want?

 HOW the news is delivered is critical

 Doctor’s caring attitude was more important

than the information provided during the clinical encounter (Siminoff et al., 1989)

 Sydney Study: 100 women, early breast cancer (Lobb et

al, 2001)

• 91% wanted to know their prognosis, but 63% wanted the

clinician to check with them first

• Majority wanted:

 Clinician to check their understanding  Opportunity to ask questions  Explain medical terms  Emotional support (79%)  Their fears & concerns listened to (97%)

What’s Important to Patients

 Randell & Wearn (2005): – The manner of the doctor – Doctor’s level of expertise – Information needs beyond the diagnosis – Support  Two important factors (Back, 2002) – Willingness to talk about dying – Disclosing bad news sensitively

Impact on Patient

• How a patient will respond will differ
• The way news is conveyed can substantially

influence the impact of receiving this news

• Schofield et al (2003):

 Discussions of serious news  When doctors were willing to address patients’ feelings, patients had significantly fewer anxiety symptoms at 4 & 13 month f/up

• Maguire (1999):

 Greater satisfaction, less anxiety, and more treatment compliance when doctors asked about:  Patient perceptions of their problems  Patient reactions to their problems  How illness impacted their daily lives

Balancing act

 Bousquet et al (2015): Metasynthesis

 Review of 40 studies, >600 oncologists, 12 countries  Communication needs to be constantly adaptive & individualised  Differs significantly from stereotypical communication training  Describes breaking bad news as a “balancing act”:

Individual relationship with patient Hospital system & environment Cultural factors Patient’s family

Balancing act

 Balance between hope, sensitivity, emotions, and honesty

(Friedrichsen & Milberg, 2006)

Patient needs

• ver time

Patient preferences

Effective Communication

 7 important themes (Burtow et al., 2002)

1. Communication within a caring, trusting, long term relationship 2. Open and repeated discussions about patient preferences for information 3. Clear, straightforward presentation of prognosis where desired 4. Strategies to ensure patient understanding 5. Encouragement of hope and a sense of control 6. Consistency of communication within the MDT 7. Communication with other members of the family

Effective Communication

 Fundamental prerequisites

• Information is…

 Adequate  Understood  Believed  Remembered  Acted upon

Key elements in communicating serious news

• 1. Preparation & setting
• 2. Asking patient/family what they

understand or perceive

• 3. Sharing the serious news
• 4. Attending to emotions as they arise
• 5. Planning & discussing next steps

• 1. Preparation & setting

 Time to prepare & gather all medical

information needed (scans, results, consult with other drs)

 Quiet space  Adequate time  No distractions / pagers  Support person present

Emotional support Aids the later recall of information

 Only 25% of the important facts are recalled (Dunn et al., 1993)

 Interpreter

• 2. Asking the patient

 What do they already know?

• Prepares you to fill in the gaps
• Prevents any unnecessary confusion

‘To start, I want to make sure we are on the same page. What is your understanding of your medical situation?’ ‘What have the doctors told you so far?’ ‘You had a CT scan of your stomach yesterday; what did the doctors say about why we did the CT?’

• 3. Sharing the serious news

 Prepare the patient or not???

• ‘I’m sorry that the test did not show what we

hoped for’ or ‘there is no easy way to say this…’

 Find their starting point, be gentle, but come

to the point

 Use simple and direct language with

attention to keeping the news brief

 Use pauses to allow the patient time to

process

Language

 Patient confusion = major contributor to

distress

 Medical terms and phrases scare and

confuse patients; they are also the biggest source of misunderstanding

• E.g. 73% of patients did not understand the term

‘median’ survival (Back, 2002)  Simple language encourages patients to ask

questions

What information to give?

 Key principles (Randell & Wearn, 2005):

• Tailor the information to patient wishes & what they’re

ready to hear

• Allow enough time
• Allow for silences
• Give information in stages
• Repeat information over time
• Avoid withholding information (even if relatives insist)
• Acknowledge distress and explore reasons for it

 Check that the patient would like to continue the discussion

• Be willing to answer questions openly and honestly

What information to give?

 Consider providing information about… – Diagnosis – Prognosis – Treatment options – Life expectancy – Impact of the disease on other aspects of their life (e.g. sexuality, roles) – Fears are reduced when given enough factual information

re: what is wrong + what emotional and physical symptoms to expect in the future

– Providing information about the prognosis and course of

disease decreases anxiety and gives time to prepare for dying (Friedrichsen & Milberg, 2006)

Providing Reassurance and Hope

 Patients fear abandonment – reassure that they will

continue to be followed up and supported

 Reassurance to address fears

E.g. analgesia will be given early and at an appropriate dose

 Reassurance ≠ fixing the problem  Reassurance is found in being seen & heard

• 4. Attending to emotions

 Emotional responses can be an indicator that the

patient has heard what you have said  NURSE model (Smith, 2002)

ame ‘It sounds like you are frustrated’ nderstanding ‘I can’t imagine what it must be like for you’ espect ‘You are asking all the right questions’ upport ‘I will be around to answer any of your questions’ xplore ‘Tell me more about what you are thinking’

N U R S E

The most important part of breaking bad news is how well you are able to respond to the other person’s emotions

Compassion (Kearsley, 2011)

 Actively develop a deep awareness of

another person’s world

 Actively attempt to understand their

suffering

 Actively desire to play our part in the

person’s healing

Sackett: “The most powerful therapeutic tool you’ll ever have is your own personality” (Smith, 2003)

“who you are may affect your patients as deeply as what you know. You will often heal with your understanding and your presence things you cannot cure with your scientific knowledge” (Remen, 2001)

Emotions

 “Am I going to die?” – recommend

hearing the question as an emotion

 Listen for the emotion, and stay with the

emotion

 Being able to sit with distress in the room

• “I understand that you are scared”
• “I see how frightened/worried/_____ you are”

 When emotionally overwhelmed =

cannot process information

 Sitting with silence

• 5. Planning next steps

 Patients consistently want to know what comes

next (Back et al., 2011)

• Why is it important?

 Reduces fears about the future  Creates a sense of predictability

 May involve:

• Treatment planning
• Follow-up appointments
• Upcoming tests

Considerations

 Patients benefit from:

• Ongoing care; knowing that they will be seen regularly

and kept informed

• A consistent doctor or for their doctor to be familiar

with their case history (Randell & Wearn, 2005)

Considerations cont’d

 Reasons for patients poor understanding or

recall:

 Primacy and recency phenomena  Emotional distress, nervousness, unrealistic

expectations and the seriousness of the disease

 Patients experience of shock  Disturbances in the consultation or perception of a

hurried / disinterested doctor

 Language

 Cultural differences

SPIKES Protocol (Buckman1992)

Step Description of Task Setting Establish rapport by creating an appropriate setting that provides for privacy, patient comfort, uninterrupted time, setting eye contact and inviting significant others (if desired) Perception Elicit the patient’s perception of his or her problem Invitation Obtain the patient’s invitation to disclose the details of the medical condition Knowledge Provide knowledge and information to the patient. Give information in small chunks, check for understanding, and avoid medical jargon Empathize Empathize and explore emotions expressed by the patient Summary and Strategy Provide a summary of what you said and negotiate a strategy for treatment or follow up.

Alternative Protocols

ABCDE (Rabow, et al,

1999)

• Advance
• Build
• Communicate
• Deal
• Encourage

GUIDE (Back, 2013)

• Get
• Understand
• Inform
• Deepen
• Equip

BREAKS (Narayanan, et al,

2010)

• Background
• Rapport
• Explore
• Announce
• Kindling
• Summarise

For another presentation….

 When conflict is present  Managing angry patients/family members  Varied cultural perspectives & values

SELF MANAGEMENT

Using CBT to manage own anxieties

 Cognitive Behaviour Therapy can be used to influence our

thoughts and behaviour when we have to break bad news

 Personal thoughts of having “failed” or feeling “hopeless

about the future” for the patient may affect our communication and the help we offer

‘The patient is going to get upset or angry and I don’t know how to deal with them’ Helpless Ashamed Worried Guilty Avoid the conversation / procrastinate / try to get in and out really quickly

Unhelpful Thought

‘The patient is going to get upset or angry and I don’t know how to deal with them’ Helpless Ashamed Worried Guilty Avoid the conversation / procrastinate / try to get in and out really quickly ‘I have let them down; I am a bad doctor’ Feelings intensify Avoid or delay further consultations and follow up

Unhelpful Thought

‘The patient is likely to become distressed but this is a normal reaction and it is not a personal attack’ Helpless Worried Sit with the patient during their distress

Helpful Thought

‘The patient is likely to become distressed but this is a normal reaction and it is not a personal attack’ Helpless Worried Sit with the patient during their distress ‘That was difficult and I feel sad for them but I managed to provide support as best I could’ Sadness Loss Less discomfort approaching the family / patient for future consultations

Helpful Thought

Challenging Negative Thoughts

 Is this a helpful thought?

• Not if it leads to unhelpful feelings (guilt, shame

etc) and behaviours (escape / avoidance)

 Is there evidence to support this thought?

Evidence against?

• Weigh up evidence and come up with a more

balanced thought

 Is there another way of looking at it? / What

are some alternative thoughts?

 What would I say to a friend in this situation?

Self Care

 Be aware of transference and manage  Know your own limitations  Know how to access adequate backup and

support for the patient and their family. What

• ther services exist?

 Have support for yourself and opportunities to

debrief when you need to

 Know what strategies you can put in place to

support yourself in your workplace

 EAP

QUESTIONS??

St. Vincent’s Hospital The Kinghorn Cancer Centre & Sacred Heart Rehabilitation Jennifer.Menon@svha.org.au Tara.Stern@svha.org.au

References

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• n January 13, 2015)

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Bor et al.. (1993). The meaning of bad news in HIV disease: counselling about dreaded issues

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Bousquet, G., Orri, M., Winterman, S. et al (2015). Breaking Bad News in Oncology: A

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References

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Lobb, E. A., Kenny, D. T., Butow, P . N., & Tattersall, M. H. (2001). Women’s preferences for discussion of prognosis in early breast cancer. Health Expect, 4, 48 Maguire, P . (1999). Improving communication with cancer patients. Eur J Cancer, 35, 1415. Narayanan, V., Bista, B. & Koshy, C. (2010). ‘BREAKS’ Protocol for Breaking Bad News. Indian J Palliat Care, 16, 61. Ptacek, J. T., Ptacek, J. J. & Ellison, N. M. (2001). “I’m sorry to tell you…” physicians’ reports of breaking bad news. J Behav Med, 24, 205. Rabow, M. W., & McPhee, S. J. (1999). Beyond breaking bad news: how to help patients who

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