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Breaking Bad News


Breaking Bad News

Breaking bad news is a regrettable but important duty that must be done conscientiously, however it seems to receive scant attention in medical training. It isn’t something that most medical students are looking forward to do.

Patients will judge the physicians on their performance. Studies suggest that several aspects are able to affect a doctor’s ability to break bad news sensitively such as personal difficulties, burnout and fatigue, behavioral beliefs, subjective attitudes and prior clinical experience. Stories abound about how unskilled physicians blundered their way through an important conversation, occasionally causing serious harm to the patient. It seems to be a similar case of informing the patient that he has cancer but there are many other diagnoses that fall into the category. It may be about a child who has brain damage or a serious congenital condition. One study found that 50% of parents were dissatisfied with the way they were told about their child's congenital deafness. Even if those who have been diagnosed with a disease are only able to recall parts of the conversation that followed the bad news, but they report that physician competence in such situations is critical to establishing trust.

 

Studies of physician education demonstrates that communication skills can be learned, and have effects that remain long after the training is terminated. Certain physicians believe that breaking bad news is an innate skill such as perfect pitch that cannot be acquired otherwise, but they are wrong for those who are good at discussing bad news with their patients often indicate how hard it was for them to be able to reach this point.

 

Robert Buckman's Six Step Protocol for Breaking Bad News:

Robert Buckman, in an excellent short manual, has outlined a six step protocol for breaking bad news. The steps are:

 

  • Getting started: Both you and patient should be comfortably seated in privacy where you ask the patient who else is supposed to be present. Then, you should try to find out how the patient is feeling at the moment so that he/she will know that this conversation is going to be a two-way affair.
  • Finding out how much the patient knows: In order to see how much the patient is aware of their condition and what have they been led to expect, you may ask what they have been told, how much of what they have been told do they understand, the patient’s level of technical sophistication and the patient’s emotional state. The patient may answer that they have lung cancer and surgery is required, or that the patient has been told they had a spot on the chest x-ray, or that they have a T2N0 adenocarcinoma. You would want to know about the patient’s emotional state for instance when the patient may say they’ve been unable to sleep because they were worried sick about having cancer.
  • Finding out how much the patient wants to know: Since not all patients are the same, you may sense that the patient is not ready to receive all the details of their situation from a question you’ve ask the patient giving the choice whether they want to know all the medical details or just a general knowledge of it all. This also gives the patient the chance to change his choice in the coming conversation. One meta-analysis found that women, young patients and more highly educated patients wanted to receive as much information as possible. Asian patients were shown to prefer that relatives be present when receiving bad news more than Westerners and prefer discussing their life expectancy less than Westerners.
  • Sharing the information: You should come prepared to the patient with all the data needed, in order to be ready to answer all questions. For instance diagnosis, treatment, prognosis and support or coping should be covered as topics in planning an agenda. Yet, an appropriate agenda will often focus on one or two topics. For a patient on a medicine service whose biopsy just showed lung cancer, the agenda might be:
  1. Disclose diagnosis of lung cancer
  2. Discussing the process of workup and formulation of treatment options using language that the patient will understand giving plenty of opportunity to interrupt in case they want something elucidated, indicating that specialized doctors will be seeing the patient on the afternoon to find out whether other tests would be helpful to outline the treatment options. Trying to give the information in small chunks, waiting for the information to sink in, making sure that the patient is following up attentively, and stopping a while to give time for the patient to ask questions. Translating medical terms into English and avoiding long lectures could be helpful for they overwhelm and confuse the patient. Don’t try to teach pathophysiology!
  • Responding to the patient’s feelings: In order to be a good caring physician, you should understand the patient’s reaction by reading subtle signs. Learning to identify and acknowledge a patient’s reaction is something that surely gets better with experience in case you are attentive, but you can also ask outright if the patient can tell you how they’re feeling.
  • Planning and follow-through: Synthesizing the patient’s concerns and the medical issues into a concrete plan that can be carried out in the patient’s system of health care is necessary. You may outline a step-by-step plan, explaining it to the patient, and contracting about the next step. To make clear exactly when you will be able to see the patient again you should tell them for instance that you’ll meet up after 2 weeks in the clinic. Or if you won’t be able to see the patient because you’ll be rotating off service, you should tell the patient that he/she is due to see Dr. Back instead in their clinic. The patient should be given a phone number in case anything comes up before the next meeting.

 

CASE 1:

The first case is of a 62 year old man named Jim who just had a needle biopsy of the pancreas showing adenocarcinoma. The physician bumps into the patient’s brother who pleads for the physician not to talk to Jim about their situation for that may kill him even faster. The physician later that afternoon would already be meeting up with the family for a conference to discuss the prognosis. Although family members would surely want to protect their loved ones from bad news, still this may not be what the patient themselves are asking for. The physician may honestly speak to the brother in this case explaining that in order to avoid being dishonest to the patient and to enable the patient have a say about their situation, the physician should explain the patient’s medical condition to them.  Asking the patient in front of their family about how they’d prefer handling the information about their condition may allow some family discussion time. Due to certain cultures not taking prognosis and naming the illness (e.g. the Navajo) well, the physician may take help from someone who knows how to handle the issue in a culturally sensitive way rather than assuming that refraining from providing medical information would be a simple way out. Because many invasive medical interventions that need a patient to critically weigh burdens and benefits, a patient will need to have some direct knowledge of their disease in Western terms in order to consider treatment options.

 

CASE 2:

Another case reveals a 25 year old female medical student doing a rotation in an HIV clinic. Sara, who is a 30 year old woman with advanced HIV, dropped out of college after finding out that she contracted HIV from her husband, who has hemophilia. The female medical student later talks to Sara about what they have in common, whether that is about where they both came from or how they both have young children and like to cook; suddenly, Sara gets mad when the medical student suggests some blood tests to be done. This case shows that there may be times when the physician provokes a reaction from a patient due to either getting reminded of a dear person’s case or their condition in this case. The best is to get help from another perspective (perhaps from someone in clinic who has known Sara) and avoid taking the reaction too personally.

 

Imparting bad news is an emotional experience for the doctor as well as for the patient, which is why you may take a minute to recognize it and calm down before moving on the next consultation.
 

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Prepared By: Dr. Mehyar Al-khashroum
Edited By: Miss Araz Kahvedjian




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