Breaking
Bad News
Objectives: After completion of this course the student will
be knowledgeable in:
- Robert Buckman's Six Step Protocol for
Breaking Bad News
- What if the patient starts to cry while I
am talking?
- I had a long talk with the patient
yesterday, and today the nurse took me aside to say that the
patient doesn't understand what's going on! What's the
problem?
- I just saw another caregiver tell something
to my patient in a really insensitive way. What should I do?
Breaking bad news is not something
that most Health Care Professionals are eager to try. Dilbert's advisor
Dogbert says: "Never break bad news...it will only get you in
trouble." And stories abound about how unskilled physicians
blundered their way through an important conversation, sometimes
resulting in serious harm to the patient. Many patients with
cancer, for example, can recall in detail how their diagnosis was
disclosed, even if they remember little of the conversation that
followed, and they report that physician competence in these
situations is critical to establishing trust.
Some people contend that breaking bad news is an innate
skill, like perfect pitch, that cannot be acquired otherwise. This
is incorrect. Professionals who are good at discussing bad news with
their patients usually report that breaking bad news is a skill
that they have worked hard to learn. Furthermore, studies of
education demonstrate that communication skills can be
learned, and have effects that persist long after the training is
finished.
Robert Buckman's Six Step Protocol for Breaking Bad News
Robert Buckman, in an excellent short manual, has outlined a six
step protocol for breaking bad news. The steps are:
- Getting started.
The physical setting ought to be private, with both physician
and patient comfortably seated. You should ask the patient who
else ought to be present, and let the patient decide--studies
show that different patients have widely varying views on what
they would want. It is helpful to start with a question like,
"How are you feeling right now?" to indicate to the
patient that this conversation will be a two-way affair.
- Finding out how much the patient knows.
By asking a question such as, "What have you already been
told about your illness?" you can begin to understand
what the patient has already been told ("I have lung
cancer, and I need surgery"), or how much the
patient understood about what's been said ("the
doctor said something about a spot on my chest x-ray"),
the patients level of technical sophistication ("I've
got a T2N0 adenocarcinoma"), and the patient's
emotional state ("I've been so worried I might have
cancer that I haven't slept for a week").
- Finding out how much the patient wants to know.
It is useful to ask patients what level of detail you should
cover. For instance, you can say, "Some patients want me
to cover every medical detail, but other patients want only
the big picture--what would you prefer now?" This
establishes that there is no right answer, and that different
patients have different styles. Also this question establishes
that a patient may ask for something different during the next
conversation.
- Sharing the information.
Decide on the agenda before you sit down with the patient, so
that you have the relevant information at hand. The topics to
consider in planning an agenda are: diagnosis, treatment,
prognosis, and support or coping. However, an appropriate
agenda will usually focus on one or two topics. For a patient
on a medicine service whose biopsy just showed lung cancer,
the agenda might be: a) disclose diagnosis of lung cancer; b)
discuss the process of workup and formulation of treatment
options ("We will have the cancer doctors see you
this afternoon to see whether other tests would be helpful to
outline your treatment options"). Give the
information in small chunks, and be sure to stop between each
chunk to ask the patient if he or she understands ("I'm
going to stop for a minute to see if you have questions").
Long lectures are overwhelming and confusing. Remember to
translate medical terms into English, and don't try to teach
pathophysiology.
- Responding to the patients feelings.
If you don't understand the patient's reaction, you will leave
a lot of unfinished business, and you will miss an opportunity
to be caring. Learning to identify and acknowledge
a patient's reaction is something that definitely improves
with experience, if you're attentive, but you can also simply
ask ("Could you tell me a bit about what you are
feeling?").
- Planning and follow-through.
At this point you need to synthesize the patient's concerns
and the medical issues into a concrete plan that can be
carried out in the patient's system of health care. Outline a
step-by-step plan, explain it to the patient, and contract
about the next step. Be explicit about your next contact with
the patient ("I'll see you in clinic in 2 weeks")
or the fact that you won't see the patient ("I'm
going to be rotating off service, so you will see Dr. Back in
clinic"). Give the patient a phone number or a way
to contact the relevant medical caregiver if something arises
before the next planned contact.
What if the patient starts to cry while I am talking?
In general, it is better simply to wait for the person to stop
crying. If it seems appropriate, you can acknowledge it ("Let's
just take a break now until you're ready to start again")
but do not assume you know the reason for the tears (you may want
to explore the reasons now or later). Most patients are somewhat
embarrassed if they begin to cry and will not continue for long.
It is nice to offer kleenex if they are readily available
(something to plan ahead); but try not to act as if tears are an
emergency that must be stopped, and don't run out of the room--you
want to show that you're willing to deal with anything that comes
up.
I had a long talk with the patient yesterday, and today the
nurse took me aside to say that the patient doesn't understand
what's going on! What's the problem?
Sometimes patients ask the same question of different
caregivers, sometimes they just didn't remember it all, and
sometimes they need to go over something more than once because of
their emotional distress, the technical nature of the medical
interventions involved, or their concerns were not recognized and
addressed.
I just saw another caregiver tell something to my patient in a
really insensitive way. What should I do?
First, examine what happened and ask yourself why the
encounter went badly. If you see the patient later, you might
consider acknowledging it to the patient in a way that doesn't
slander the insensitive caregiver ("I thought you looked
upset when we were talking earlier and I just thought I should
follow up on that--was something bothering you?")
Breaking Bad News:
Case 1
|
| Jose is a 62-year-old man who just had a
needle biopsy of the pancreas showing adenocarcinoma. You
run into his brother in the hall, and he begs you not to
tell Jose because the knowledge would kill him even faster.
A family conference to discuss the prognosis is already
scheduled for later that afternoon.
How should you handle this?
Breaking Bad News:
Case 1 Discussion
It is common for family members to want to protect their
loved ones from bad news, but this is not always what the
patient himself would want. It would be reasonable to tell
Jose's brother that withholding information can be very bad
because it creates a climate of dishonesty between the
patient and family and medical caregivers; also, that the
only way for Jose to have a voice in the decision making is
for him to understand the medical situation. Ask Jose how he
wants to handle the information in front of the rest of the
family, and allow for some family discussion time for this
matter.
In some cultures it is considered dangerous to talk about
prognoses and to name illnesses (e.g., the Navajo). If you
suspect a cultural issue it is better to find someone who
knows how to handle the issue in a culturally sensitive way
than to assume that you should simply refrain from providing
medical information. For many invasive medical interventions
which require a patient to critically weigh burdens and
benefits, a patient will need to have some direct knowledge
of their disease in Western terms in order to consider
treatment options.
Breaking Bad News:
Case 2
|
| You are a 25-year-old female medical
student doing a rotation in an HIV clinic. Sara is a
30-year-old woman with advanced HIV who dropped out of
college after she found that she contracted HIV from
her husband, who has hemophilia. In talking to Sara,
it turns out you share a number of things--you are
from the same part of Montana originally, also have
young children, and like to cook. Later in the visit,
when you suggest that she will need some blood tests,
she gets very angry and says, "What would you
know about this?"
What happened?
Breaking Bad News:
Case 2 Discussion
Although the protocol for breaking bad news is
helpful, it doesn't cover everything. There are
instances when you may provoke a reaction from a
patient because you remind them of someone else--or,
as in this case, themselves. In these instances it can
be helpful to step back, get another perspective
(perhaps from someone in clinic who has known Sara),
and try not to take this reaction too personally--even
though it is likely that Sara will know how to really
bother you.
MEDCEU
Continuing Education Courses CEU for Nurses and
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