COMMUNICATING BAD NEWS

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COMMUNICATING BAD NEWS

• Michael Marschke, MD
• Medical Director of Horizon Hospice in Chicago

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BAD NEWS

• Most Americans want to know
• If done right
• Improves doctor-patient relationship
• Helps patient and family to cope
• Fosters a collaborative relation

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6 STEP APPROACH

• Prepare
• Find out what the patient knows
• Find out what the patient wants to know
• Share the information
• Respond to emotions
• Plan follow-up
• from How to Break Bad News A Guide for
  Health Care Professionals, by Robert Buckman

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1. PREPARE

• Confirm facts yourself gather necessary data
• Get the setting right privacy, pull up the
  chairs, tissues
• Allow adequate time prevent interruptions
• Who else needs to be there?

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2. HOW MUCH DO THEY KNOW?

• What do you think is going on?
• Establish if they are able to comprehend
• If unprepared or appears to need support,
  reschedule (soon!)
• Can be done in advanced during the initial
  assessment

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3. HOW MUCH DO THEY WANT TO KNOW?

• If this condition turns out to be something
  serious, do you want to know? How much do you
  want to know?
• If not, establish who is to be told

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When family says Dont tell them anything.

• You are legally and ethically obligated to get
  this request from the patient
• Ask them why, what are they afraid of
• Discuss this directly with the patient with the
  family present

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4. SHARE INFORMATION

• Communication skills
• Eye level, eye contact
• Comfortable
• Interested body language
• Use language patient understands
• Promote dialogue, open-ended questions, check for
  understanding
• Empathy
• Silence

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4. SHARE INFORMATION

• Deliver news in a sensitive but straight-forward
  way
• Avoid vagueness well-intentioned efforts to
  soften the blow may lead to misunderstanding
• Pause frequently
• Im sorry may confer aloofness or your
  responsibility

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5. RESPOND TO EMOTIONS

• Tears, anger, anxiety are normal reactions
• Cognitively, patients may express denial, blame,
  guilt, fear, shame.
• Rarely, one may experience a panic attack
• Let the emotion express itself, acknowledge it,
  be attentive
• Silence, touch, comfort
• Assess safety, need for support

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6. FOLLOW-UP

• Establish what the next steps are treat symptoms
  right away
• If detailed, may want to do on a second visit
  soon
• Remember, they may only retain 10-25 of what you
  said
• Re-visit soon re-address facts/understanding/emot
  ions

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OTHER ISSUES

• LANGUAGE BARRIERS
• Need skilled translator, not family
• Speak directly to patient
• Verify understanding
• GOALS/ADVANCED DIRECTIVES
• SHARE INFO WITH PRIMARY CAREGIVERS

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COMMUNICATING PROGNOSIS

• Ask why they want to know/what are they expecting
• Avoid precise answers/give ranges
• Hope for the best BUT plan for the worst be
  prepared/get affairs in order offer help with
  this

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FINAL HOURS

• In many cases can be recognized
• Compassionate honesty
• Re-focus on patient goals
• Emphasize little things for comfort oral swabs,
  open communication, light touching, gentle
  positioning
• Empathetic support
• Evaluate family need for support

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DEATH NOTIFICATION

• Try to do in person
• Be honest
• Be there silence support
• Ask about viewing/body care/bathing,
  cultural/religious rituals, others that need to
  be informed. Take as much time as needed.
• Watch for abnormal grief reactions
• Elicit support system
• Be sensitive about asking about funeral/autopsy
• Set up follow-up