COMMUNICATING BAD NEWS

1. COMMUNICATING BAD NEWS Michael Marschke, MD Medical Director of Horizon Hospice in Chicago

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

3. 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

4. 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?

5. 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

6. 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

7. When family says “Don’t 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

8. 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

9. 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 • “I’m sorry” may confer aloofness or your responsibility

10. 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

11. 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/emotions

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

13. 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

14. 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

15. 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