nw pall care bad news

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Slide1: 

Giving Bad News

Learning objectives: 

Learning objectives List the 6 steps in giving bad news Adapt the bad news protocol to your work setting Explain how the manner in which bad news is given can impact patient outcome and patient care Explain how culture impacts patient information needs and decision-making

Consider a case: 

Consider a case 24-year-old F; HIV+ for 3 years; current IVDU Unstable living situation Estranged from family On HAART, but questionable adherence Recent abnormal LFTs You are meeting with her to give her a Hep C diagnosis

Giving bad news: 

Giving bad news Reviewing the evidence Recommendations for clinicians Cultural considerations

Reviewing the evidence : 

Reviewing the evidence How do patients experience bad news? How competent are physicians in giving bad news? How should physicians give bad news? Does how bad news is given make a difference? Do cultural differences matter?

How do patients experience bad news?: 

How do patients experience bad news? Bad news results in a cognitive, behavioral, or emotional deficit in the person receiving the news that persists Clinicians can’t change the news Clinicians can make the news worse, or they can help give realistic hopes

A variety of responses to bad news: 

A variety of responses to bad news 100 patients diagnosed with cancer: Shock 54% Fright 46% Accept 40% Sadness 24% Not worried 15% Lobb, Med J Aust 1999: 290-4

Medical jargon can make bad news worse: 

Medical jargon can make bad news worse Technical language frequently unclear 100 women with breast cancer: 73% misunderstood “median survival” No agreement on what a “good” chance of survival meant numerically Ford, Soc Sci Med 1996: 1511-9

Physicians are inaccurate in detecting distress : 

Physicians are inaccurate in detecting distress 5 oncologists studied intensively None predicted patient distress better than chance One had negative predictive behavior All very satisfied with their performance Little probing about patient emotional state Ford, Br J Cancer 1994: 767-70

Patient and clinician stress related to bad news: 

Patient and clinician stress related to bad news Ptacek, JAMA 1996: 496-502 Stress Time Encounter Patient Clinician

Gaps in what patients want and what they receive: 

Gaps in what patients want and what they receive Most patients are highly ‘satisfied’ yet: 57% wanted to discuss life expectancy, but only 27% actually did 63% wanted to discuss the effects of cancer on other aspects of life, but only 35% actually did Lobb, Med J Aust 1999: 290-4

Pitfalls in giving bad news: 

Pitfalls in giving bad news 79 patients, 68 family said bad news encounter was suboptimal because: Physician was too blunt Place or time was inappropriate Patient got the sense that there was no hope, they wanted physicians to balance sensitivity and honesty Curtis, J Gen Intern Med 2001: 41-9

How should physicians give bad news?: 

How should physicians give bad news? 2,331 patients at UK cancer centers: –98% wanted to know if the illness was cancer –87% patients preferred “as much information as possible” Need to individualize delivery to patient needs Jenkins, Br J Cancer 2001;84:48-51

How bad news is given makes a difference: 

How bad news is given makes a difference 100 patients with breast cancer, adjustment to illness correlated with: Physician behavior during cancer diagnostic interview History of psychiatric issues Premorbid life stressors Patients dissatisfied with how physicians provided information were 2x likely to be depressed or anxious Roberts, Cancer 1994, 74 (1 supp): 336-41

A recommended protocol for giving bad news: 

A recommended protocol for giving bad news 1. Prepare info, location, setting 2. Find out what they already know 3. Ask how much they want to know 4. Share the information 5. Respond to the patient’s emotion 6. Negotiate a concrete follow-up step Buckman, How to Break Bad News, 1992

Bad news protocol: 

Bad news protocol 1. Prepare Find time A quiet space The right people Nonverbal cues: distance, posture, eye level

Bad news protocol: 

Bad news protocol 2. Find out what the patient already knows: “I want to make sure we’re on the same page; what have other doctors told you?”

Bad news protocol: 

Bad news protocol 3. Ask how much the patient wants to know: “Are you the kind of person who wants to know all the details?”

Bad news protocol: 

Bad news protocol 4. Share the information: Use language at the same level as the patient’s: “Did you get that? Did that make sense to you?”

Bad news protocol: Final steps: 

Bad news protocol: Final steps 5. Respond to the patient’s emotions: –Acknowledge, name, empathize “I can see that this wasn’t something you expected to hear.” –You don’t have to agree with the emotion or share it.

Bad news protocol: Final steps: 

Bad news protocol: Final steps 6. Negotiate a concrete follow-up step: “Let’s talk next week after you see the GI specialist.”

Dealing with the fallout: 

Dealing with the fallout Walk through the bad news encounter Use case-specific knowledge Know usual clinician pitfalls: Failure to assess understanding Failure to acknowledge emotion

Survey of 800 patients in LA: Assessing cultural differences: 

Survey of 800 patients in LA: Assessing cultural differences Should a patient: Be told of a Decide diagnosis about of cancer life-support African American 88% 60% European American 87% 65% Mexican American 43% 41% Korean American 35% 28% Blackhall, JAMA, 1995; 274:820

Can discussing death cause harm?: 

Can discussing death cause harm? Studies have shown that people from many different cultures are more likely to believe discussing death can bring death closer: African Americans Some Native Americans Immigrants from China, Korea, Mexico Curtis, Arch Intern Med, 2000; 60:1690 Caralis, J Clin Ethics, 1992; 4:155 Caresse, JAMA, 1995; 274:86

Exploring cultural beliefs: 

Exploring cultural beliefs What do you think might be going on? If we needed to discuss a serious medical issue, how would you and your family want to handle it? Would you want to handle the information and decision-making, or should that be done by someone else in the family? Kagawa-Singer, JAMA 2001; 286:2993

Summary: 

Summary Giving bad news is a fundamental communication skill How bad news is delivered can affect how patients adjust to the illness Exploring cultural beliefs is important in adapting the bad news communication to each patient

Contributors: 

Contributors Anthony Back, MD Director J. Randall Curtis, MD, MPH Co-Director Frances Petracca, PhD Evaluator Liz Stevens, MSW Project Manager Visit our Web site at uwpallcare.org Copyright 2003, Center for Palliative Care Education, University of Washington This project is funded by the Health Resources and Services Administration (HRSA) and the Robert Wood Johnson Foundation (RWJF).