Giving Explanation and Delivering Bad News Presented by: Yayi Suryo Prabandari Professional Behavior Team-Communication Skills Team Faculty of Medicine The University Gadjah Mada

Objectives of this session By the end of this session, students will:  Remind the three functions of effective medical interview  Understand empathy  Comprehend on breaking bad news  Understand emotional response of chronic illness

Three Functions of Medical Interview  Building relationship  Assessing the patient’s

problem  Managing the patient’s problem

Building relationship Basic relationships that help build doctor-patient rapport:  Non-verbal skills  Empathy  Partnership  Support  Respect

Empathy  Cognitive capacity to understand patient’s need  An affective sensitivity to patient’s feelings

 A behavioral ability to convey empathy to patient

Level of empathy  0 = denial of patient perspective  1 = perfunctory recognition of patient perspective  2 = implicit recognition of patient perspective  3 = acknowledgement  4 = confirmation

 5 = statement of shared feeling or experience

Level 3 – 5 = explicit recognition of patient perspective

Level of empathy  5 Sharing experiences and feelings  “Yes, I understand that this thing makes both of you scared. Some patients have ever experienced spontaneous abortion, and in the next pregnancy they were very, very, scared”

Level of empathy  4 Confirmation  “You sound like you are very busy. I can see why it would be tough for you to find time to do exercises”

Level of empathy  3 Appreciation  “You said that you’ve been feeling sad? Do you want to tell me more about that?”

Level of empathy  2 Implicit recognition of patient perspective  Patient : “the headache makes it difficult for me to work”  Physician : “Yes….? How is the insurance business lately?”

Level of empathy  1 Perfunctory recognition of patient perspective  Physician : “A-ha”, while the physician doing something else, often with the physician having his/her body oriented away from the patient

Level of empathy  0 Denial of patient perspective  The physician either ignores

the patient’s empathic opportunity or makes a disconfirming statement, like  “if you are under stress, why do you come to this place?”, or “Yes, it’s better be operated now”

Empathy  Reflection

 You look a bit sad right now  I can see this is upsetting to you  This hard to talk about

 Legitimation

 I can certainly understand why you’d be upset under

   

the circumstances Anyone would find this very difficult Your reactions are perfectly normal This would be anxiety provoking for anyone I can understand why you’re so angry

Wrong example: What not say after a miscarriage or pregnancy loss  You can always have another  The don’t want another baby, they want this baby

 Now you have an angel looking after you  The don’t want an angel, they want their baby back

 It’s for the best  The best for whom?

Things to say  I’m sorry  What can I do to help?  I’m here for you

Partnership  Patients are more satisfied with physicians and are more likely adhere to treatment recommendation when they feel a sense of partnership with their physician  Example of statement:  “Let’s work together in developing a treatment

plan once I have reviewed some of the options with you”  “After we’ve talked some more about your problems, perhaps together we can work out some solutions that may help”

Personal support  Statement of personal support can

enhance rapport  The physician should make explicit efforts to let the patient know that he or she is there, personally  Example of statement:  “I want to help in any way I can”

 “Let me know what I can do to help”

Respect  The physician’s respect for patients and their

problems is implied by attentive listening, nonverbal signals, eye contact and genuine concern  Respectful comments also help build rapport, improve the relationship, and help the patient cope with difficult situation  Example of statement:  “I’m impressed by how well you’re coping”  “You’re doing a good job handling the uncertainty  “Despite your feeling so bad, you’re still able to carry on at home and at work. This is quite an accomplishment”

MANAGING PATIENT PROBLEM: DELIVERING BAD NEWS

Skills to deliver bad news  Relationship building

 Giving a warning shot first and then pausing to     

let the information sink in Knowing when to stop because the patient doest not wish to or cannot hear more (shut-down) Interviewing more than one person at a time Co-partnership and advocacy Giving hope tempered with realism Knowing when learners are not coping appropriately with their own distress

Steps to break bad news  Preparing to break bad news

 Choosing the setting  Attribution and expectation

 Breaking the bad news  Emotional support  Giving information  Closing the bad news interview

Preparing bad news Eliciting the patient’sto ideasbreak about etiology  Preparation must include a clear understanding

of the:

 Diagnosis  Possible treatment options  A general idea of prognosis  Specific plans for what will happen next in the way of

consultations, test and return visits

 Preparation should include setting aside

adequate time for the task and assessing the physician’s own feelings about the news

Preparing bad news Eliciting the patient’sto ideasbreak about etiology Example of statement:  Physician: “Mr. Adi, the blood in your stool and your low

blood count really worry me. A lot of thins can cause this. Sometimes it’s hemorrhoids, which are blood vessels in the rectum. Sometimes it’s blood vessels higher up. Sometimes it’s polyps, or little growths on the wall of your intestine. These can bleed, and if they’ve been there a long time, they can even turn into cancer. I think we should do some more test to find out exactly what it is”.  Patient: “Really? What kind of cancer, Doc?”  Physician: “I’m not sure that’s what it is. Like I said, we need some more test. The most important test is to look up inside you and check for anything abnormal. If we see something, we can take out a little piece of it and then tell you what it is. How does that sound to you?”

Choosing a setting  Patients report that they prefer to receive bad news

   

from a physician, preferable one who knows them and their medical conditions. It should not be delegated to other health care tem members Sitting down and making eye contact is an effective way to communicate attention and concern Occasionally bad news must be broken at a distance Death notification by telephone is sometimes necessary when families ask directly if death has occurred or if they are unable to come to the hospital

Attributions and Expectations  Nearly all patients have assumptions about what

might be wrong (attribution) and what needs to be done to help them (expectations).  Attributions and expectations are based on experiences with self, family, friends, informal health advisors, the media and other sources  Attribution and expectation are important for gaining:  The meaning of the illness to the patient  The level of information the patient desires  The patient’s emotional reaction to bad news

Breaking the bad news  First step in breaking bad news is assessing what

the patient is ready to hear:

 Reviewing the clinical data  Checking the patient’s understanding and concern about the data  Indicating that new information is available Example of statement: Physician: “Pak Ari, you know that we saw a lump on the wall of your intestine and took a biopsy of it. What have you already learned about the result?” Patient: “Well, is it cancer?” or “Could you wait till my wife gets here?” Physician: “Whatever I tell you in a moment, I want you to remember the situation is serious, but there’s plenty we can do. We’ll have to work closely together over the next several months”

Breaking the bad news  Most patients favor a direct statement of the news,

followed by a pause while the message sinks in  Message should clear and unambiguously

Example of statement: Physician: “I’m afraid that the biopsy showed cancer of the colon” Patient: “Oh my God, doctor. Not cancer (weep, wrings hands). Oh my God, what am I going to do now?” Physician: “I know this comes as a shock. This wasn’t what you were expecting at all. But I want you to know that we’ll take it one step at a time and work on it together. The next big step is to find out if it has spread outside the colon. To start that we’ll do a CT scan of your belly. That will help us decide on the best treatment”

Emotional support  Patients who receive bad news usually remember the

physician’s attitude and manner more vividly than technical details of the news.  Be honest and caring even in the face of strong and varied emotions  The real secret is not what you tell your patients, but what you let your patients tell you

Emotional support Example of statement:

Physician: “I can see that you’re feeling overwhelmed right now. I can imagine you’re quite stunned by this news and that it is hard to even think about. Have I got it right?” Patient: “Yes. I can’t believe this is happening. I’m going to wake up in a minute and this will all be a bad dream” Physician: “I wish it were so. Is there anyone that I can call for you? Anyone at home that you can be with?” Patient: “ Yes, my husband should be home by now” Physician: “You two probably have some questions or concern that you’d like to talk about with me. If you’d like, I can call him for you now and explain what has happened. Then I’d like the two of you to come see me tomorrow afternoon, so we can talk about what to do next”

Empathetic communication  Signposting, or forecasting  “Let me make sure I understand”  Reflection  “You put in your time on months of painful treatments and beat this breast cancer. Now, two years later you find it is back. And you’re really feeling cheated, because you did all the right things to beat it. Have I got it right?”  Legitimation  “I think anyone would feel the same way”  Respect  “I think you’re doing the right thing by taking it on again”  Support  “I’d like to healp you through this”  Partnership  “We’ll need to work together. Just as hand as last time”

Giving information  Patients given the news of a serious cancer often want to

know absolutely that:  The diagnosis is correct  How much the disease has spread  How it can be treated or cured  What to expect with the various treatment options  Some patients wants lots of information and involvement in decision making  Technique to give information:  Simple and clear words instead of medical jargon  Giving small amounts of information at a time  Summarize periodically

Giving information  Example of conversation:  Patient:”Am I going to die?.....How long do I have?”  Physician: “I think what you’re asking is whether you will

die because of this cancer. There are statistics on how long people with this kind of cancer live, with and without treatment, but they are just averages. Some patients live much longer and some shorter than average. I can tell you the averages for your condition, but I can’t predict how long you have. I want to tell you again that I am here to help and support you through this”

Closing the bad news interview  Before closing, the physician should think about the dual

tasks of managing the relationship and exchanging information  The easiest and most effective way to close the bad news interview is to outline specific further steps:  Asking who else needs to know the news  How the patient plans on telling those individuals and if patient wants help telling them  And involves gathering more information through consultants and diagnostics test Example of statement:  “We’ve talked about a lot of information today. I’m also wondering how you’re feeling about all this. After all, that’s another important part of you and your medical care”

Emotional response to chronic illness  Denial  Anxiety  Depression

Thanking you for the attention Reference:  Cole, SA., & Bird, J. 2000. The Medical Interview. London: Mosby  Kurtz, S., Silverman, J., & Draper, J. 2005 Teaching and Learning

Communication Skills in Medicine. Oxford: Radcliffe Publishing  Prabandari, YS., Claramita, M., et al. 2007 Communication Skills Manual Book. Yogyakarta: Faculty of Medicine, the Gadjah Mada University  Taylor, SE. 2006. Health Psychology. Singapore: McGraw-Hill International