Communicating Bad News Flashcards
- Know Yourself
Physicians communicate their own emotional responses
Be aware of own responses
Process your feelings with others
- Create a Plan
Allot adequate time - Prevent interruptions Determine who else the patient would like to present - If child, patient's parents Plan what you will say - Confirm medical facts - Don't delegate Create a conducive environment
- What Does the Patient Know?
Establish what the patient knows
Assess ability to comprehend new bad news
Reschedule if unprepared
- How Much Does the Patient Want to Know?
Recognize, support various patient preferences
- decline voluntarily to receive information
- designate someone to communicate on his/her behalf
People handle information differently
- race, ethnicity, culture, religion, socioeconomic status
- age and developmental level
- Sharing the Information
Say it, then stop
- avoid monologue, promote dialogue
- avoid jargon, euphemisms
- pause frequently
- check for understanding
- use silence, body language
Don’t minimize severity
- avoid vagueness, confusion
Implications of “I’m sorry”
- Responding to Feelings
Affective response
- tears, anger, sadness, love, anxiety, relief
Cognitive response
- denial, blame, guilt, disbelief, fear, loss, shame, intellectualization
Basic psychophysiologic response
- fight-flight
Be prepared for
- outburst of strong emotion
- broad range of reactions
Give time to react
Listen quietly, attentively
Encourage descriptions of feelings
Use nonverbal communication
- Planning, Follow-Up
Plan for the next steps
- additional information, tests
- treat symptoms, referrals as needed
Discuss potential sources of support
Give contact information, set next appointment
Before leaving assess: safety of patient, supports at home
Repeat news at future visits
Preparing for the Last Hours of Life
Time course unpredictable
Any setting that permits privacy, intimacy
Anticipate needs for medications, equipment, supplies
Regularly review the plan of care
Caregivers
- awareness of patient choices
- knowledgeable, skilled, confident
- rapid response
Likely events, signs, symptoms of the dying process
Physiologic Changes During the Dying Process
Increasing weakness, fatigue Decreasing appetite/fluid intake Decreasing blood perfusion Neurologic dysfunction Loss of ability to close eyes Pain
Weakness/Fatigue
Decreased ability to move Joint position fatigue Increased risk of pressure ulcers Increased need for care - activities of daily living - turning, movement, massage, OMT
Decreasing Appetite/Food Intake
Fear: “giving in”, starvation
Reminders
- food may be nauseating
- anorexia may be protective
- risk of aspiration
- clenched teeth express desires, control
Help family find alternative ways to care
Decreasing Fluid Intake
Oral rehydrating fluids Fears: dehydration, thirst Remind family, caregivers - dehydration does not cause distress - dehydration may be protective Parenteral fluids may be harmful - fluid overload, breathlessness, cough, secretions Mucosa/conjunctiva care
Decreased Blood Perfusion
Tachycardia, hypotension Peripheral cooling, cyanosis Mottling of skin Diminished urine output Parenteral fluids will not reverse
Neurologic Dysfunction
Decreasing level of consciousness
Communication with the unconscious patient
Terminal delirium
Changes in respiration
Loss of ability to swallow, sphincter control
Frequency of Symptoms Last Two Weeks of Life
Pain 51-100% Dyspnea 22-46% Athenians 80% Anorexia 80% Dry mouth 70% Mental confusion 68%
Signs of Active Dying
Retained audible respiratory secretions - death rattle (24-60 hrs)
Respiration with mandibular movement - jaw movement increases with breathing (2-5.8 hrs)
Cyanosis of extremities (1-5 hrs)
No radial pulse (1-3 hrs)
“The usual road to death”
Decreasing level of consciousness
Progression
Eyelash reflex
“The difficult road to death”
Terminal delirium Medical management - benzodiazepines (lorazepam, midazolam) - neuroleptics (haloperidol, chlorpromazine) Seizures
Changes in Respiration
Altered breathing patterns
- dismissed tidal volume
- apnea
- Cheyne-Stokes respiration a
- accessory muscle use
- last reflex breaths
Fears
- suffocation
Management
- family support
- oxygen may prolong dying process
- breathlessness
Loss of Ability to Swallow
Loss of gag reflex Buildup of saliva, secretions - scopolamine or glycopyrrolate to dry secretions - postural drainage - positioning - suctioning
Loss of Sphincter Control
Incontinence of urine, stool
Cleaning, skin care
Urinary catheters
Absorbent pads, surfaces
Pain
Fear of increased pain Assessment of the unconscious patient - persistent vs fleeting expression - grimace or physiologic signs - incident vs rest pain - distinction from terminal delirium Management when no urine output - stop routine dosing, infusion of morphine - breakthrough dosing as needed - least invasive route of administration
Loss of Ability to Close Eyes
Loss of retro-orbital fat pad Insufficient eyelid length Conjunctival exposure - increased risk of dryness, pain - maintain moisture
Medications
Limit to essential medications
Choose less invasive route of administration
- buccal mucosal or oral first, then consider rectal
- subcutaneous occasionally
- intravenous rarely
- intramuscular almost never
As Expected Death Approaches
Discuss - patient/family wishes - status of patient - realistic care goals - role of physician/interdisciplinary team Reinforce signs, events of dying process Personal, cultural, religious, rituals, funeral planning Family support throughout the process
Signs that Death has Occured
Absence of heartbeat, respirations Pupils fixed Color turns to a waxen pallor as blood settles Body temperature drops Muscles, sphincter so relax - release of stool, urine - eyes can remain open - jaw falls open - body fluids may trickle internally
Loss, Grief with Life-Threatening Illness
Highly vulnerable Frequently losses: - function/control/independence - image of self/sense of dignity - relationships - sense of future Confront end of life - high emotions - multiple coping responses
Loss, Grief, Coping
Grief = emotional response to loss
Coping strategies
- conscious, unconscious
- avoidance
- destructive
- suicidal ideation
Normal Grief
Physical
- hollowness in stomach
- tightness in chest
- heart palpitations
Emotional
- numbness
- relief
- sadness
- fear
- anger
- guilt
Cognitive
- disbelief
- confusion
- inability to concentrate
Complicated Grief
Chronic grief
- normal grief reactions over very long periods of time
Delayed grief
- normal grief reactions are suppressed or postponed
Exaggerated grief
- self-destructive behaviors (eg, suicide)
Masked grief
- unaware that behaviors are a result of the loss
7 Step Protocol
- Know yourself
- Create a plan
- What does the patient know?
- How much does the patient want to know?
- Sharing the information
- Responding to patient, family feelings
- Planning and follow-up
