5 - Breaking Bad News and Communication

Question 1

What is always important to explore in the history of a cancer patient?

Answer 1

MENTAL HEALTH and IMPACT ON LIFE

Question 2

What framework do we use to break bad news?

https://oscestop.education/communication/difficult-encounters/breaking-bad-news/

Answer 2

SPIKES

Question 3

What can you do in ‘S’ of spikes?

Answer 3

Setting

• Get rid of beep and phone on silent
• Tissues
• Remove desk or any barriers between the two
• Introduce self and say you are here to discuss recent investigations
• Ask patient if they want someone to be with them (‘The reason I ask is because I have a lot of information to share with you and some of it might be difficult to process’)

Question 4

What can you do in P of SPIKES?

Answer 4

Perception

• Get patient to explain sequence of events leading up to this e.g biopsies, scans
• Ask patient if they know what the tests were looking for
• Ask patient what they think it could be and ICE. ‘Symptoms like the ones you’ve been describing can sometimes be as a result of an infection, but sometimes they can be as a result of more serious underlying conditions”.

Question 5

What can you do in I of SPIKES?

Answer 5

Invitation

I have the results with me today, would it be ok for me to discuss them with you?

Question 6

What can you do in the K of SPIKES?

Answer 6

Knowledge

Warning shot then sizeable chunks and check understanding

Question 7

What can you do in the E of SPIKES?

Answer 7

Emotion/Empathy

I can see this is a huge shock for you

I can see there are a lot of thoughts running through your head at the moment. Would you like to share any of your worries with me?

Question 8

What can you do in the S of SPIKES?

Answer 8

Strategy/Summary

Make a plan together to meet the patient again and inform them of what the next steps are

Reassure the patient that they are going to be referred to the appropriate team of specialists.

Check the patients understanding, summarise and answer any questions

Question 9

What are important words to use when breaking bad news?

Answer 9

Use the word cancer and the word death/died.

No medical jargon or euphemisms.

Question 10

If you ask a patient if they want to talk about what they feel after bad news and they say ‘what’s the point i am dying anyway’, how can you respond?

Answer 10

Question 11

What should you do before you explain the treatment plan to patients when you have broken a cancer diagnosis?

Answer 11

Let the patient guide the way to the management plan

Question 12

What is the most important part of breaking bad news?

Answer 12

SILENCE!!! LONG SILENCES ARE KEY

Question 13

What is a common misconception you need to address when explaining to patients they have metastases?

Answer 13

Bone metastases are spread of primary cancer they are not new cancers

Question 14

What are some phrases you can use to show emotion?

Answer 14

‘I can see this is really difficult for you’

‘I can’t imagine what this must be like for you’

Question 15

If someone is angry and you need to have a conversation with them and they are stood up what can you do?

Answer 15

‘I can see that you look angry’

‘Can we sit down so that I can listen to what you have to say’

‘I am sorry about the distress this has caused’

Question 16

If a patient asks you if they made the wrong choose choosing one treatment over the other what can you say?

Answer 16

‘I think you made the right descision for you at the time’

Question 17

If someone comes in with abdominal pain and it turns out to be due to liver mets, how can you use this as a warning shot?

Answer 17

‘We have found something on our scans that might explain your pain”

Question 18

What antiemetic is good for gastric stasis?

Answer 18

Metoclopramide

Question 19

What is good for liver capsule pain from liver mets?

Answer 19

Dexamethasone

• If inummerable mets chemo
• If one or to then liver resection surgery

Question 20

When someone has developed brain mets what do you need to inform them of?

Answer 20

No longer allowed to drive

Question 21

What is the cancer OSCE station?

Answer 21

1. Assessment: Hx, Exam, Ix
2. Few Q’s
3. Share information

Won’t be new cancer diagnosis

Could have oncological emergency in A to E station

Question 22

Should you prescribe Dalteparin in end of life care?

Answer 22

No as not expecting them to improve, more burden than benefit

Question 23

What medication do you need to be careful of stopping in end of life care?

Answer 23

• Steroids due to risk of adrenal crisis from suppression of cortisol
• Insulin, can stop metformin and gliclazide
• AEDs especially for brain mets, can give midazolam to cover for phenytoin as IV phenytoin needs cardiac monitoring. Keppra can be used SC through syringe driver

Question 24

How is SVCO diagnosed and managed?

Answer 24

Headache, blurred vision, venous distension (clinical Dx)

Ix: Chest X-ray, CT Thorax with IV Contrast

Mx: Dexamethasone, Stenting, Supplemental Oxygen

Question 25

When doing an A to E what do you need to do with oxygen?

Answer 25

15L non rebreathe mask in emergency then titrate with venturi

Question 26

What investigations are important to order in B of A to E?

Answer 26

• ABG
• CXR

Question 27

When trying to find the cause of neutropenic sepsis where do you need to look on the patient?

Answer 27

• Rashes
• Cellulitis
• Infected lines
• Mucositis

ASK IF RECENT CHEMOTHERAPY

Question 28

What do you need to be wary of when prescribing for neutropenic sepsis?

(important card for finals)

Answer 28

RENAL FUNCTION

Altered doses of antibiotics, check BNF renal impairment section

Question 29

How should you manage suspected MSCC before their MRI spine?

Answer 29

• Bed rest until know spine is stable
• High dose steroid with PPI protection
• Monitor blood glucose levels with steroid

Question 30

What are the blood parameters in DIC?

Answer 30

• Raised PT and APTT
• Raised D-Dimers
• Low fibrinogen

Question 31

What is needed in DIC?

Answer 31

• Senior input
• RBC
• Cryoprecipitate and FFP

Question 32

What effect does heparin have on clotting times?

Answer 32

Only raises PT