Bad News DPR (Dr Mohr) Flashcards
A major goal of information delivery is _______.
to get the patient to cooperate with the recommended treatment; compliance
Physicians generally fail to communicate information effectively due to: (3)
- Poor listening skills
- Understanding what patients already know
- Conceptualizing the situation with the patient
Most of the information delivered to patients tends to ______.
be difficult or even bad news
Why is delivering bad news difficult? (4)
- Fundamentally unpleasant
- Lack of training/role models - not addressed during residency
- Fear of emotional reaction
- Concern over admitting guild or responsibility;
Saying “I am sorry” does not equal?
claiming responsibility
Delivering bad news well….(4)
- Strengthens the physician-patient relationship
- Fosters collaboration
- Permits patients, families to cope
- Minimizes litigation if done well
ABCDE Mnemonic
A: Advanced Preparation B: Build a Therapeutic relationship C: Communicate Well D: Deal with patient and family reactions E: Encourage and Validate emotions
Advance Preparation:
Familiarize yourself with ___.
relevant clinical information
Advance Preparation:
Arrange for ____.
adequate time in private setting, turn pager/phone off
Advance Preparation:
Consider the environment ____.
seating, tissues available
Advance Preparation:
Mentally (or verbally) ____ and _____.
rehearse how you will deliver the news and Prepare emotionally (breathe)
How to build a Therapeutic Relationship? (3)
- Have a support person present
- Introduce yourself to everyone present
- Determine the patients’ preference for what and how much information they want
What if the family says “don’t tell the patient”? - the family (3)
- Acknowledge the families fears;
- Ask: why not tell them?
- Talk to the patient together
What if the family says “don’t tell the patient”? - Legally (2)
- Legal obligation to obtain informed consent from patient;
2. Law states that clinicians must provide as much information as the patient desires;
Build a Therapeutic Relationship: Delivering the news (4)
- When appropriate, foreshadow the bad news - don’t just drop the bomb
- Use touch when appropriate
- Avoid inappropriate humor and flip comments
- assure your pt you will be available; schedule a follow up
Patients will have difficulty remembering what is said _____.
after the initial statement
Communicate well: (6)
- Ask the pt what they know/understand
- Speak frankly but compassionately
- Encourage questions.
- Have pt repeat what you have told them to check for understanding
- Write/draw things out
- Repeat key information, summarize and make follow up plans
Communicate well: Things to avoid (4)
- Jargon
- Monologue (you should be promoting dialogue)
- Vagueness
- Confusion
______ is paramount in dealing with patient and family reactions
Nonverbal Communication
It is important to assess and respond to _____ and _____.
emotional reactions and be aware of patients’coping strategies
Patient Responses: Affective/Emotional (7)
- Quiet
- Tears, sadness
- Hopelessness
- Anger, aggression
- Fear
- Anxiety
- Relief
Patient Responses: Cognitive (6)
- Denial
- Blame
- Guilt
- Disbelief
- Shame
- Intellectualization
Patient Response: Physiologic (2)
- Fight or Flight
2. Physically agitated
What happens to a patient in fight or flight (high anxiety/panic) mode? (3)
- Heart rate increase
- Breathing increase/shallow
- Thinking becomes unclear and/or simple
Physician Responses to patients emotions: (7)
- Be prepared for strong reactions of your own - self awareness and monitoring
- Give pt time to react - wait and watch non-verbals
- Give permission by naming the feeling (i can see that you are feeling….)
- Acknowledge own feelings; be empathetic; it is ok to say “I’m sorry” or “I don’t know”
- Don’t argue or criticize colleagues; avoid defending self or others
- Monitor Pt’s ability to understand information
- Insert information as appropriate
How to deal with the patient’s emotional reactions: (3)
- Mirror or reflect their emotional reactions (I would be angry too)
- Encourage them to describe their emotions
- Listen quietly and attentively
- Tune into the pt’s nonverbal messages
Encourage and Validate Emotions: (5)
- Offer realistic hope; discuss treatment options
- Explore what the news means to the pt
- Determine what support systems the pt has in place
- Use interdisciplinary services to enhance patient care – but not to disengage from relationship
- Attend to your own needs (self reflect/projection/ self monitoring)
Barriers when Communicating Bad News (5)
- Denying Defeat
- Confusion instead of clarity
- Fear of destroying hope.
- Keeping your distance
- disappearing
Denying Defeat
- Postponing discussions until ‘absolutely sure’
- Continuing to run tests
Denying Defeat - Results
This does not allow patient to make appropriate decisions
Confusion instead of Clarity
Using jargon and talking around the actual subject
Confusion instead of Clarity - Results
Patients/families are often left confused
Fear of destroying hope
The notion that telling the truth will destroy hope and therefore a will to live
Fear of destroying hope - Results
- the Pt will believe that you think they cannot handle the situation
- Instead convey confidence that patient can and will handle the situation
Keeping your distance
Being professional is being detached
Results of keeping your distance
pt feels abandoned
Disappearing
Since physician can’t change the outcome, the physician has nothing to offer
