BREAKING BAD NEWS IN OBSTETRICS BY DR SHASHWAT JANI

Dr. Shashwat Jani. M. S. ( Obs – Gyn )

Diploma in Advance Laparoscopy.

Consultant Assistant Professor,

Smt. N.H.L. Municipal Medical College.

Sheth V. S. General Hospital , Ahmedabad.

Mobile : 99099 44160.

E-mail : [email protected]

Bad News

“ Any news that drastically and negatively alters the patient’s view of their future. “

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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Bad news can mean different things to different people.

Can be defined as any information that

Adversely affects an individuals view of future

Carries a feeling of no hope or a threat to a person's mental or physical well-being

Risks upsetting an established lifestyle

Conveys to an individual fewer choices in his or her life.


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Delivering Bad News

• “It is not an isolated skill but a particular form of communication.”

• Frank A. Eur J of Palliat care 1997

• Rabow & Mcphee (West J. Med 1999) described:

“Clinicians focus often on relieving patients’ bodily pain, less often on their emotional distress & seldom on their suffering.”

24-Dec-17

Dr Shashwat Jani. +91 99099 44160.

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Giving Bad News

• Is an important communication skill

• Is a complex communication task which

includes:-

Responding to patients’ emotional reactions

Involving the patient in decision making

Dealing with the stress created

Involvement of multiple family members

How to give hope when situation is bleak


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In Obstetrics

For most, Pregnancy is a time of excitement, expectation and joy.

However, around 1 in 200 women will experience stillbirth, usually diagnosed in utero.


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Breaking the news of an intrauterine death is one of the saddest, most challenging parts of the job. • It can affect not only the patient but also the

doctor.

• Like anything breaking bad news becomes better with experience - but it is never easy.


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Perinatal loss should be defined as one of the following:

1. Loss of a loved one.

2. Loss of future goals.

3. A departure from normal.

4. Loss of expected outcome.

5. Loss of living qualities.


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It's incredibly important for parents that you have prepared for this moment.

Of course, you can't change the outcome.

However, there are steps you can take to ensure that this traumatic event is handled without causing confusion or unnecessary distress.


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So, Before BBN…

1. Prepare yourself 2. Prepare the patient 3. Perform the scan 4. Give the news 5. Plan for next steps 6. Review and reflect


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Advance Preparation

Familiarize yourself with the relevant clinical information (investigations, hospital report)

Arrange for adequate time in private, comfortable environment

Instruct staff not to interrupt

Be prepared to provide at least basic information about prognosis and treatment options (so do read it up)


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Advance Preparation

Mentally rehearse how you will deliver the news. You may wish to practice out loud

Script specific words & phrases to use or to avoid

Be prepared emotionally


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Build a therapeutic Environment / Relationship

Introduce yourself to everyone present

Summarise where things have got to date, check with patient/relative

Discover what has happened since last seen

Judge how the patient is feeling/thinking

Determine the patient’s preferences for what and how much he/she wants to know.


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Build a therapeutic Environment / Relationship (contd)

• Warning shot “ I’m afraid it looks more serious than we had hoped ”

• Use touch where appropriate

• Pay attention to verbal & non verbal cues

Avoid inappropriate humour

• Assure patient that you will be available


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Communicate Well

Speak frankly but compassionately

Avoid medical jargon

Allow silence & tears; proceed at patient’s pace

Have the patient describe her understanding of the information given

Encourage questions

Write things down & provide written information

Conclude each visit with a summary & follow up plan


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Deal with patient &

Family reactions

Assess & respond to emotional reactions

Be aware of cognitive coping (denial, blame, guilt, disbelief, acceptance, intellectualization)

Allow for “shut down”, when patient turns off & stops listening

Be empathetic; it is appropriate to say “I’m sorry or I don’t know. “ Crying may be appropriate

“Don’t argue or criticize colleagues” 24-Dec-17


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Encourage and

validate emotions

• Offer realistic hope

• Give adequate information to facilitate decision making

• Explore what the news means to the patient & inquire about spiritual needs

• Inquire about the support systems in place


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What not to do ?

Do not start giving information until it is required.

Do not hit and run

Do not leave the dirty job for someone else (your patient, your responsibility), unless necessary.

Do not share information (e.g. to relatives), unless appropriate and after consent


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What not to do ?

Do not assume (mis)understanding

Do not lie

Do not give false hopes (science cannot always do miracles)

Do not use terms such as “there is nothing more we can do for you”

Do not abandon patients after session


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Many emotions surface as the patient & her partner experience labor

for a late pregnancy loss. • Labor as a painful experience without reward.

• Appearance of her newborn following delivery.

• Feel guilt.

• Anger, either at herself or as a protective shield against those around her.

• Loneliness and isolation as the sensation of "why me?" Surfaces.

• Interpret this outcome as punishment for activities that they have indulged in during their life.


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Managing Delivery

Of A Stillbirth

• Care provider must be sensitive to the unique nature of this birth.

• Dead baby should be placed in a blanket immediately after delivery.

• Stillborn baby should never be delivered into a bucket or pan or left straddling the delivery table.

• Initial encounter with their dead baby.

• Care providers also must remember during this period that the woman and her family are observing them as they interact with the dead baby.


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The SPIKES Protocol

1. SETTING UP the interview

2. Assessing patient’s PERCEPTION

3. Obtaining the patient’s INVITATION

4. Giving KNOWLEDGE and information

5. Addressing the patient’s EMOTIONS

6. STRATEGY and SUMMARY


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SPIKES

Step 1: S - SETTING UP the interview • Preparation Preparation- Preparation

• Always in person, face to face

NEVER on telephone

• Plan, arrange for privacy, involve significant others

• Sitting down, Non Verbal Behaviour

• Manage time constraints and interruptions

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SPIKES

• Step 2: P –

Assessing The PATIENT’S PERCEPTION

• Gather before you Give • Patient’s knowledge, expectations and hopes • What do they understand about the situation?

Unrealistic expectations? • What is their state of mind? Hopes? • Opportunity to correct misinformation and tailor your

information


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SPIKES

• Step 3: I – Obtaining the patient’s INVITATION

• Gather before you give

• How much does the patient want to know?

Coping strategy?

• Answer questions, offer to speak to another

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SPIKES • Step 4: K – Giving KNOWLEDGE and

information to the patient • Warning shot • Use simple language, no jargon, • Vocabulary and comprehension of patient • Small chunks, avoid detail unless requested • Pause, allow information to sink in • Wait for response before continuing • Check understanding • Check impact

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SPIKES

• Step 5: E – Addressing the patient’s EMOTIONS with empathic responses

• Shock, isolation, grief

• Silence, disbelief, crying, denial, anger

• Observe patient’s responses and identify emotions

• Offer empathic responses

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What is Empathy?

“ The capacity to recognise emotions that are being felt by another person. “


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SPIKES • Step 6: S – STRATEGY and SUMMARY

• Are they ready?

• Involve the patient in the decision making

• Check understanding

• Clarify patient’s goals

• Summarise

• Contract for future

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Response To Reaction


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1. If patient begins

to cry

• Allow sometime to cry.

• Could say, “ I can see you are very upset ”

• Could touch the patient appropriately.

• After a few moments you should continue talking even if patient continue to cry.


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2. If Patient Becomes Angry

• Defensive or irritation with patient are unhelpful.

• Acknowledge patient’s position and avoid talking about it.


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3. If The Patient Refuses To

Accept The Diagnosis

• Explore reasons for patient’s denial.

• Do not be combative.

• Appreciate that there is an information gap and try to educate the patient.

• Check that patient has a clear understanding of the problem.

• Empathize with patient.

• Get family members involved if appropriate.

• Give time to adjust to new information.


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FEARED

Get all the FACTS

Express EMPATHY and EDUCATE

Search for sources of ANGER

Have the patient RECITE back to you her

understanding of your explanation.

Evaluate the EXTENDED family response.

DOCUMENT the conversation 24-Dec-17


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A Difficult But Fundamentally Important Task for All Health Care Professionals.

Focused Training in Communication Skills & Techniques Improves Performance.

Enhances Patients’ Satisfaction & Physicians’ Comfort.

An Essential Skill of Good Medical Practice.


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24-Dec-17 39 Dr Shashwat Jani. +91 99099 44160.

Health & Medicine

BREAKING BAD NEWS IN OBSTETRICS BY DR SHASHWAT JANI