Part B: Section B.2 WHAT TO DO WITH “BAD NEWS” 1 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Learning Objectives 2.1 Use skill in sharing bad news, including disclosure of a life altering diagnosis, death of a patient, and occurrence of a medical error; specifically: a. Answer the question “Am I going to die?” posed by a 4, 8 and 15 year old b. Respond when a parent starts to cry in the middle of a conversation c. Respond effectively when a parent exhibits anger d. Be able to state, in under a minute, that a patient received a drug in error 2 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Learning Objectives continued 2.2. Skillfully lead a discussion of end of life issues and goals of care (e.g., do not resuscitate measures) with a family whose child is severely or terminally ill. 2.3. Listen generously to the grief of patients and families. 2.4. Counsel parents about how to identify a child/teen who is experiencing complicated grief. 3 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
What is bad news? Any information likely to drastically and negatively alter the patient’s view of his or her future. - Robert Buckman 4 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
What bad news have you delivered? 5 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Examples of bad news in pediatrics o Infant born with a deformity not known prenatally o Child given an incorrect medication dose o Child with clinical findings concerning for cancer o Injured child brought to the ED who dies o Teen who is unintentionally pregnant o A delayed discharge or surgery 6 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
What is the scariest part of delivering bad news? 7 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
What makes bad news so bad? o Fear of emotional response o Sadness o Helplessness o Fear of blame o Fear of death o Lack of training o Wanting to protect the child and family 8 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Why learn to do it well? o You will do it, more often than you realize. o Powerful impact on how patients and families cope. o It is rewarding when done well (and stressful when it is not). o It is satisfying when done well (and satisfaction can minimize burnout). 9 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Activity Reflect on the essay “Critical Moments – Doctors and Patients” NEJM 2011; 365:1270-1. 10 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Do it well — not perfectly o Expertise in sharing bad news is not defined as doing it perfectly… rather it is getting it “right” most of the time o Requires: o Communication skills o Being comfortable managing emotions 11 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
The role of self-awareness and mindful practice in sharing bad news o Self-awareness can assist practitioners in becoming more attentive to the presence of stress o Increased mindfulness is correlated with reduced burnout and total mood disturbance in physicians o Patient-centered qualities are correlated with increased mindfulness (Krasner, 2009) 12 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Communication “Words are, in my not -so-humble opinion, our most inexhaustible source of magic; capable of both inflicting injury, and remedying it.” - Albus Dumbledore Harry Potter and the Deathly Hallows , Part B 13 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Basics o How to share bad news: o SPIKES o Ask – Tell – Ask o Handling emotions: o NURSE 14 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Spikes o Set up (staging) o Perception o Invitation (“warning shot”) o Knowledge o Empathy o Summary and strategy “Communication Skills in Clinical Practice Part 4” http://www.youtube.com/watch?v=ftgNapAfV6Q Back et al. CA Cancer J Clin. 2005; 55:164-177 15 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Set up and Staging o Arrange for privacy o Manage interruptions (e.g. pager, phone) o Review the chart; clarify medical facts (for yourself) o Involve others (e.g. other family members, nursing staff) o Sit down (choose seats wisely) o Introduce everyone 16 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Which feels better? Impact of Body Language 17 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Perception o Always get information before you give information: o “What have the doctors told you…” o “What is your understanding of…” 18 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Invitation o Ask how the patient / family likes to receive information (i.e. the “big picture” or details) o Ask if anyone else should be present o Give a warning shot: o "Unfortunately the news is not what we had hoped for..." or o "I am sorry but I have some information which may be hard to hear..." 19 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Knowledge o AVOID JARGON! o “Doctors sometimes use words that not everyone understands. Please stop me if I’m doing this.” o Avoid euphemisms o Give information in small pieces o Check understanding frequently 20 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Empathy and Emotion o Let them know you have connected with their emotions o Stop talking o Observe the emotion o Identify the emotion o Explore the reason for the emotion o (Use the NURSE mnemonic coming up) 21 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Summary and Strategy o Check overall understanding o Recap goals o Discuss the plan o Probe for questions o Document the discussion 22 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Basics o How to share bad news: o SPIKES o Ask – Tell – Ask o Handling emotions: o NURSE 23 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Ask – Tell – Ask o Ask the patient / parent to describe their current understanding of the issue o Tell the patient / parent in straightforward language what the “bad news” is about o Ask the patient / parent to describe the information back to you o Ask what question they have, points they need clarified o Ask what it means to them o Ask how they may share this news with others Back et al. CA Cancer J Clin. 2005; 55:164-177 24 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Sources of conflict o Past experience of both you and the patient / parent o Balance of truth-telling while maintaining hope o Physician wants to be candid, but wants to avoid hurting the patient / parent o Patient / Parent wants to hear the truth yet may be resistant to the content o Cultural differences may mean differences in expected communication patterns 25 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Anticipate reactions o Be prepared for parental reactions, as well as your own o Anticipate expressions of anger, sadness, guilt, relief o Utilize NURSE mnemonic o Never judge a reaction, nor assume you know why they are reacting a certain way 26 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
NURSE Mnemonic N Name I wonder if you are feeling angry. I see that you are frustrated. It seems like you are down today. Understan It is hard to imagine what you are going U d through. This is a lot to be dealing with. I see how strongly you’ve been advocating for Respect R her. You are good, loving parents. S Support I want you to know that I am here for you. We are available for you as questions come up. E Explore Tell me more about what you are thinking. How are you doing today? Back et al. CA Cancer J Clin. 2005; 55:164-177 27 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Tears o Tears are common when hearing bad news o Have tissues available o Demonstrates you know this is emotional o Gives the person ‘permission’ to cry 28 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
Anger o Look for the source of anger o A majority of anger stems from fear o Other sources: genuine insult; personality o Recognize the direction of the anger o Is this internal anger or guilt? o Is it external – toward staff, the hospital, God o Engage, but avoid enmeshment with the emotion Wang-Cheng. EPERC Fast Fact #59 29 PART B. Communicating with Families about Severe and Terminal Illness in Their Children
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