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 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 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’

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

other 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

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