Communicating Bad News PAFP 6 2011 v1

8/2/2019 Communicating Bad News PAFP 6 2011 v1

1/39

Resources: The Philippine Palliative Care Education Program: Educational Programfor Primary Care (PCEP-PC). PCEP. Manila. 2007; Medina. Manual of Palliative

Medicine 2nd edition. Manila. 2007; The Pallium Project. Edmonton, Alberta, Canada;The EPEC Project. Chicago, IL, USA.


2/39

Objectives

Know what is communication of badnews and why it is important

Understand the basic (palliative care)

protocols for communicating bad news &

know what to do at each step


3/39

What is a Bad News?

Bad news may be defined asany information which adversely andseriously affects an individual's view of hisor her future

Bad news is always, however, in the eyeof the beholder

the impact of the bad news is also

determined by the recipient's expectations

The Oncologist. August 2000 vol. 5 no. 4302-311


4/39

Why is it important tocommunicate bad news?

Most people want to know Most Americans & Europeans; many Asians &

Filipinos, probably

Strengthens physician-patientrelationship & fosters collaboration

Shared problem, understanding &

collaboration Permits patients, families to plan, cope


5/39

In North America, ethical principles ofinformed consent, patient autonomy, right toself determination and law

have created clear ethical and legalobligations

to provide patients with as much informationas they desire about their illness and its

treatment In the Philippines


Why is it important tocommunicate bad news?


6/39

Why is it difficult andproblematic to communicate

bad news?Not understanding and realizing whatbad news is; and not understanding thewhat the impact of communicating it is

Fear of how the patient will react

A sense of failure or guilt

View of doctor as scientist & technician,less premium on helping skills

art is nice, but science is much more

important


7/39


8/39

Fear of causing harm

Autonomy vs Non-malficence Surveys conducted from 1950 to 1970, when

treatment prospects for cancer were bleak,revealed that most physicians considered it

inhumane and damaging to the patient todisclose the bad news about the diagnosis

1980s and 1990srise of Autonomy inwestern ethics and law

In the Philippines



9/39

Patient Preferences When PhysiciansCommunicate Bad News

Information about diagnosiswhich provides a name for their condition

Information about prognosis andhow the illness is likely to affect their life(including quality of life)

Practical information about what to do andhow to obtain additional information

(Johnston et al, 1996)


10/39

Patient Preferences When PhysiciansCommunicate Bad News

Clear & Direct

Empathy

Inclusion of a family member or trustedfriend in the discussion

Encouragement to ask questions

Information that is neither overly optimisticnor overly pessimistic

(Johnston et al, 1996)


11/39

Protocols attempt to achieve 4goals Get information from the patient; to

determine the patient's knowledge andexpectations and readiness.

Provide understandable information inaccordance with the patient's needs &preferences.

Support the patient, to reduce the emotional

impact.

Develop a treatment plan or strategy withthe patient.


12/39

6-step protocol . . .

1.Getting started (start)2. What does the patient know?

3. How much does the patient wantto know?

4.Sharing the bad news

5. Responding to the emotionalreaction

6.Planning and follow-up (end)


13/39


1. Getting started2.What does the patient know?

3.How much does the patientwant to know?


5. Responding to the emotionalreaction

6. Planning and follow-up


14/39


1. Getting started2. What does the patient know?

3. How much does the patient wantto know?


5.Responding to the emotionalreaction

6. Planning and follow-up


15/39


16/39

Establishing the

Goals of CareCommunicating

Bad NewsWithdrawing or

Withholding

Treatment

1 Use the right setting. Plan what to say. Determine participants. Allowadequate time.

2 Determine what thepatient knows. Clarify

the situation and

context.

Determine what the

patient knows. Clarify

what he/she can

comprehend.

Determine and review

the goals of care.

3 Determine what the

patient wants toaccomplish. Help

distinguish realistic vs

unrealistic goals.

Determine what the

patient wants to know.Understand, support,

and respect the

patients preferences.

Establish the context of

the case. Discuss thechanges that led to the

discussion about

treatment withdrawal.


17/39

Establishing the Goals

of CareCommunicating

Bad NewsWithdrawing Treatment

4 Help the patient formrealistic goals and

discuss how these can

be achieved. Work out

unrealistic goals.

Share the information. It

should be clear,

accurate, and

understandable.

Discuss the treatment,

and whether it meets the

goals of care. Discuss

alternatives to the

treatment. Discuss what

can happen.

5 Respond to the patients feelings and reactions with empathy. Listen. Allowtime for and encourage the expression and exploration of feelings and

reactions. Be supportive and caring.

6 Summarize. Agree on a

plan of care to meet thegoals. Include plans for

follow-up, review, and

modification of the plan

if needed. Document

well.

Summarize. Plan for the

next steps in the care ofthe patient. Offer

assistance and support.

Discuss other sources

of support. Document

well.

Summarize. Plan for the

withdrawal of treatment ifthis is the patients or

familys decision.

Document the decision

process.


18/39

Step 1: Getting started . ..Plan & prepare what you will say

Confirm the medical facts

Create a conducive environment


19/39

. . . Step 1: Getting started

Have adequate time prevent interruptions; maintain focus

Determine who else the patient

would like to be present

Family

Friend

Priest, Pastor

if child, patients parents


20/39

Prioritize: Prioritize what you

want to accomplish duringthe discussion

Ask yourself: What are two to

four key points that thepatient should retain? Whatdecisions should be madeduring this encounter? What

is reasonable to expect fromthe patient during thisencounter?

Practice and prepare:Practice giving bad news;arrange for an environmentconducive to delivering thenews

Rehearse the discussion;arrange for a private locationwithout interruptions; set cellphones and pagers to vibrateor turn them off; ask thepatient if he or she wants to

invite family members

AFP: Recommendations for Patient-Centered Communication WhenDiscussing Bad News

Am Fam Physician. 2008 Jan

15;77(2):167-174.


21/39

Step 2: What does the patientknow?

Establish what the patient knows

If child what the parents know

Assess ability to comprehend newbad news

Reschedule if emotionally

unprepared to receive bad news


22/39

Step 3: How much does thepatient want to know? . . .

Recognize, respect & supportvarious patient preferences

decline voluntarily to receiveinformation

designate someone tocommunicate on his or herbehalf

decline to know the details


23/39

. . . Step 3: How much doesthe patient want to know?

Know that people handle informationdifferently

According to race, ethnicity,culture, religion, socioeconomicstatus

If child, according to age anddevelopmental level


24/39

When family says "don't tell

Ask the family: Why not tell?

What are you afraid I will say?

What are your previous experiences?

Is there a personal, cultural, or religiouscontext?

Talk to the patient together

Mention that honesty may promote trust Discuss legal obligation to obtain informed

consent from the patient*


25/39

Step 4: Sharing the bad news

Say it, then pause & give themtime

avoid monologue, promote dialogue

avoid jargon, euphemisms

pause frequently

check for understanding

use silence, body language


26/39

. . . Step 4: Sharing theinformationDont minimize severity avoid vagueness, confusion

Implications of Im sorry


27/39

Assess patient understanding:

Start with opening questions, ratherthan medical statements, to determinethe patient's level of understandingabout the situation

Ask the patient: What do you

already know about yourcondition? What does it

mean to you? What do you

think will happen?

Determine patient preferences: Askwhat and how much information thepatient wants to know

Assess how the patient wants

the information presented; askthe patient, Some of mypatients prefer hearing onlythe big picture, whereasothers want a lot of details.Which do you prefer?

Present information: Deliverinformation to the patient usinglanguage that is easy to understand (donot use medical jargon); provide a smallamount of information at a time; check

periodically for patient comprehension

Provide a few pieces ofinformation, and then ask thepatient to repeat it back to you

Recommendations for Patient-Centered Communication WhenDiscussing Bad News

Am Fam Physician. 2008 Jan

15;77(2):167-174.


28/39

Step 5: Responding to feelings . ..Be prepared foroutburst of strong emotion

broad range of reactions

tears, anger, sadness, love,anxiety, relief, other

denial, blame, guilt, disbelief, fear,loss, shame, intellectualization

Give time to react


29/39

. . . Step 5: Responding to feelings

Listen quietly, attentively

Encourage descriptions offeelings

Use nonverbal communication


30/39

Provide emotionalsupport:Allow the patient toexpress his or her

emotions; respond withempathy

Assess the patient's emotionalstate directly and often (ask thepatient: How are you doing? Is

this hard for you? You look

frustrated/disappointed/angryisthat true? Let me know when weshould continue); use nonverbal

cues such as eye contact; listen towhat the patient says and validate

his or her reactions with empathicstatements such as I understand

that this is very difficult news.


Am Fam Physician. 2008 Jan 15;77(2):167-174.


31/39

ABC of palliative care:

Communication with patients,

families, and other

professionals

BMJ 1998;316:130

S 6 Pl i f ll


32/39

Step 6: Planning, follow-up . ..Plan for the next steps additional information, tests

treat symptoms, referrals as needed

Discuss potential sources ofsupport


33/39

. . . Step 6: Planning, follow-up

Give contact information, set next

appointment

Before leaving, assess: safety of the patient

supports at home

Repeat information at future visits


34/39

Discuss options for the

future:Devise a plan forsubsequent visits and care

Help the patient understand the expected

disease course and how the disease mayor may not respond to treatment; schedulefollow-up visits (ask the patient: Can wemeet next week to discuss treatmentoptions and any questions you mayhave?)

Offer additional support:Provide information aboutsupport services

Bring handouts and pamphlets to the visit;refer the patient to support groups,psychologists, social workers, or chaplains

Consider individual

preferencesAssess patient preferences,and tailor the discussionappropriately

Consider the patient's sex, age, health

literacy, health status, previous health careexperiences, social status, culture, andrace/ethnicity; avoid assumptions aboutwhat the patient is likely to want; ask thepatient directly about values and

preferences


Am Fam Physician. 2008 Jan15;77(2):167-174.


35/39

Communicating prognosis .. . Inquire about reasons for asking

What are you expecting to happen?

How specific do you want me to be? What experiences have you had with:

others with same illness?

others who have died?

C i i i


36/39

Communicating prognosis .. .Patients vary

planners want more details

those seeking reassurance wantless

Avoid precise answers

hours to days months to years average

C i i


37/39

. . . CommunicatingprognosisLimits of prediction hope for the best, plan for the worst

well get a bettersense over time

cant predict surprises, get affairs in

order

Reassure availability, whateverhappens


38/39

Resources: The Philippine Palliative Care Education Program: EducationalProgram for Primary Care (PCEP-PC). PCEP. Manila. 2007; Ferris F and Von

Gunten C. The EPEC Project. Chicago, IL, USA.


39/39

COMMUNICATING BAD NEWSin CANCER CARE and

SUPPORTIVE, HOSPICE & PALLIATIVE CARE

Resources: The Philippine Palliative Care Education Program: Educational Programfor Primary Care (PCEP-PC). PCEP. Manila. 2007; Medina. Manual of Palliative

Medicine 2nd edition. Manila. 2007; The Pallium Project. Edmonton, Alberta, Canada;The EPEC Project. Chicago, IL, USA.

Documents

Communicating Bad News PAFP 6 2011 v1