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Communicating Bad News Communicating bad news is an essential skill for physicians. Breaking bad news in a direct and compassionate way can improve the patient's and family's ability to plan and cope, encourage realistic goals and autonomy, support the patient emotionally, strengthen the physician-patient relationship, and foster collaboration among the patient, family, physicians, and other professionals. protocol for communicating bad news The recommended 6-step protocol has been adapted from How to Break Bad News: A Guide for Health Care Professionals by Robert Buckman: Step 1: Getting started Don't delegate the task. The patient needs to hear this news from you. Confirm the medical facts of the case. Ensure that all the needed information is available. Ensure privacy and adequate seating. A box of facial tissues should be handy. Allot adequate time for the discussion. Do not slip this into a short interval between other critical tasks. Prevent interruptions. Arrange to hold telephone calls and pages. Determine who else the patient would like to have present for the discussion. This might include family, significant others, surrogate decision makers, and/or key members of the interdisciplinary team (nurse, social worker, chaplain, etc). Step 2: What does the patient know? Start the discussion by establishing what the patient and family know about the patient's health. With this information, decide if the patient and family will be able to comprehend the bad news. Questions might include:
Occasionally a patient (or a parent if the patient is a child) will fall silent and seem completely unprepared or unable to respond. To encourage discussion, try to clarify what the patient understands about his or her medical history and recent investigations. If this is ineffective and the patient remains silent, or if it appears the patient requires more support, it may be better to reschedule the meeting for another time. Step 3: How much does the patient want to know? Next, establish what and how much each patient, or parent if the patient is a young child, wants to know. People handle information differently, depending on their race, ethnicity and culture, religion, and socioeconomic class. Each person has the right to voluntarily decline to receive any information and may designate someone else to communicate on his or her behalf. Ask the patient and family how they would like to receive information. If the patient prefers not to receive critical information, establish to whom information should be given. Possible questions include the following:
Step 4: Sharing the information Deliver the information in a sensitive but straightforward manner. Say it, then stop. Avoid delivering all of the information in a single, steady monologue. Use simple language that is easy to understand. Check for understanding. Use silence and body language as tools to facilitate the discussion. Do not minimize the severity of the situation. Well-intentioned efforts to "soften the blow" may lead to vagueness and confusion. You might choose to break bad news by using language like:
The phrase "I'm sorry" may be interpreted to imply that the physician is responsible for the situation. If you use the phrase, adjust it to show empathy. For example, "I'm sorry to have to tell you this." Step 5: Responding to feelings Give the patient and family time to react. Be prepared to support them through a broad range of reactions. Listen quietly and attentively. Acknowledge their emotions. Ask them to describe their feelings:
Nonverbal communication may also be very helpful. Consider touching the patient in an appropriate, reassuring manner. Offer a drink of water, a cup of tea, or something else that might be soothing. Allow time for the patient and family to express all of their immediate feelings. Don't rush them. Step 6: Planning and follow-up Establish a plan for the next steps. This may include gathering additional information or performing further tests. Treat current symptoms. It may include helping parents to tell their child about their illness and what treatment will be like for them. Arrange for appropriate referrals. Explain plans for additional treatment. Discuss potential sources of emotional and practical support: family, significant others, friends, social worker, spiritual counselor, peer support group, professional therapist, hospice, home health agency, etc. Discuss sources of support for an ill child's siblings. Reassure the patient and family that they are not being abandoned and that the physician will be actively engaged in an ongoing plan to help. Indicate how the patient and family can reach the physician to answer additional questions. Establish a time for a follow-up appointment. Ensure that the patient will be safe when he or she leaves. Is the patient able to drive home alone? Is the patient distraught, feeling desperate or suicidal? Is there someone at home to provide support?guage is a barrier Communicating with a patient who speaks a different language The assistance of an experienced translator who understands medical terminology and is comfortable translating bad news is required. Brief translators before the interview and reassure them their role is only to translate. Verify that they will be comfortable translating the news you are about to give. If possible, avoid using family members as primary translators. When working with a translator, sit in a triangular arrangement so that you can face and speak directly to the patient, yet still turn to look at the translator. Speak in short segments, then give the translator time to convey the information. Verify the patient's and family's understanding and check for an emotional response.rognosis Patients frequently ask about prognosis. Consider the implications of the prognostic information you provide. Definitive answers, such as "You have 6 months to live," run the risk of producing disappointment if the time proves to be less, and anger or frustration if you have underestimated the patient's lifespan. Consider responding by giving a range of time that encompasses an average life expectancy, such as "hours to days," "days to weeks," "weeks to months," "months to years," etc. Always caution patients and families that unexpected surprises can happen. Suggest that they get their affairs in order so they won't be so vulnerable if something unexpected does occur. Reassure them that you will be available to them to deal with issues and support them throughout their illness, whatever happens. C The sharing of information among caregivers is critical. Maintain a chart or log book close to the patient that can be shared by all who provide care, including physicians. The chart or log book should include goals for care, treatment choices, what to do in an emergency, likes and dislikes, things to do and or not to do, and contact information for family, physicians, and other members of the interdisciplinary team. Ensure that data is recorded accurately and accessible to everyone © EPEC Project, The Robert Wood Johnson Foundation, 1999. The Project to Educate Physicians on End-of-life Care comes from the Institute for Ethics at the American Medical Association. Emanuel LL, von Gunten CF, Ferris FD. The Education for Physicians on End-of-life Care (EPEC) curriculum, 1999. © EPEC Project, 1999 Module 2: Communicating Bad News
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