PRESENTATION OUTLINE
We describe a protocol for disclosing unforable information - "breaking bad news" - to cancer patients about their illness.
The goal - is to enable the clinician to fulfill 4 most important objectives of the interview disclosing bad news:
- gathering information from the patient,
- transmitting the medical information,
- providing support to a patient;
- eliciting the patient's collaboration in developing a strategy or treatment plan for the future.
Oncologist, oncology trainees and medical students who have been taught a protocol reported increased confidence in their ability to disclose unfavorable medical information to their patients.
Bad news can be defined as 'any information which adversely and seriously affects an individual's view on his of her future'
A patient who is told that her back pain is caused by a recurrence of her breast cancer when she was expecting to be told it was muscle strain is likely to feel shocked.
Busy clinicians may disclose unfovourable medical information to patients and families many thousands of times during their practice. So they stop thinking that is completely changing an individual's life from that moment.
Breaking badness to cancer patients is inherently aversive, described as "hitting the patient over the head" or "dropping a bomb". So it's important to follow a protocol to minimize a damage for a patient
So, now a six step strategy for telling bad news to a patients.
Step1 : setting up the interview
Mental rehearsal can be useful way for preparing for stressful tasks. This can be accomplished by reviewing a plan for telling the patient and how one will respond to patient's emotional reaction and difficult questions.
At the beginning, follow a guidelines like
- arranging privacy: interview in room is ideal but if one is not available, draw the curtains around patient's bed. Prepare a tissues in case if patient get upset.
Involve significant others:
Most of patients what to have someone else with them but this should be a patient's choice.
Sit down: sitting down relaxes the patient and is also a sign that you will not rush. When you sit, thy not to have barriers between you and patient. If you have recently examined a patient, give him a time to dress up.
Also, important to make a connection with the patient. Maintaining eye contact may be uncomfortable but it's an important way of establishing rapport. The other way - is to touch or hold patient's arm (is patient is comfortable about it)
Step to is assessing the patient's perception
Implement the axiom "before you yell, ask"
That is, before discussing medical findings, use open-ended question to create a reasonable accurate picture about how the patient perceives the medical situation
For example, "What have you been told about your medical situation so far?" Or "what is your understanding of the reasons we did the MRI?"
While a majority of patients express a desire for full information about their diagnosis and prognosis, some patients don't.
When a clinician hears a patient express explicitly a desire for information, it was lessen the anxiety assisiated with divulging the bad news.
Discussing information disclosure at the time of ordering tests can cue the physician to plan next discussion.
Examples of question would be"how would you like me to give an information about the test resulTs? Would you like me to give you all information out the results and discuss treatment plan?"
If patient don't want to know the details, offer to answer any question they will have in future or to talk to a relative or a friend.
Step for is Giving knowledge and information to the patient.
Warning the patient that. Bad news if coming May lessen the shock that can follow the disclosure of bad news and may facilitate information processing.
Examples of phrases that can be used May include "Unfortunately, I've got some bad new for you..." or "I'm sorry to tell you that..."
Important to avoid medical jargon, so patient could understand words like "spread" should be used instead of "metastasized" and "sample of tissue" instead of biopsy.
Also, excessive bluntness should be avoided "you have a very bad cancer and if we won't start treatment immediately you are going to die" - cause it's likely yo leave patient isolated and angry, with a tendency to blame a messenger of bad news.
Step 5: addressing the patient's emotions with empathic responses
Responding to the patient's emotional reaction is one of the most difficult challenges of breaking bad news. Patient's emotional reaction May wary from silence to disbelief, crying, denial, or anger.
Firstly, observe for any emotion on the part of patient. This may be tearfulness, a look of sadness, silence, shock.
Second, identify the emotion experienced by the patient by naming it to oneself.
Thirdly, identify the reason for the emotion. Usually it's connected to bad news, but if you re not sure, ask.
Fourth, after you have given a patient a brief period to express feelings, let patient know that you have connected the emotion with the reason for the emotion by making a connecting statement.
IN THIS STEP AVOID DESTROYING A HOPE
Last step is strategy and summary.
1. Summaries important points if the consultation.
2. Address any further questions.
3. Before discussing a treatment plan, it's important to ask patient of he is ready for such a discussion.
4. Make firm plans for next contact (within 24h to 2 weeks)
5. Share information given to the patient's general practitioner.
