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 of 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 of 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 Hospital relationship system & with patient environment Cultural Patient’s factors family
Balancing act Balance between hope, sensitivity, emotions, and honesty (Friedrichsen & Milberg, 2006) Patient needs over 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’ N nderstanding ‘I can’t imagine what it must be like for you’ U espect ‘ You are asking all the right questions’ R upport ‘ I will be around to answer any of your questions’ S xplore ‘Tell me more about what you are thinking’ E
The most important part of breaking bad news is how well you are able to respond to the other person’s emotions
Recommend
More recommend
