communicating bad news/bereavement, death, dying, and loss Flashcards
What is “bad news” to a patient?
- Likely to alter drastically a patient’s view of his or her future
- results in a cognitive, behavioral, or emotional deficit in the person receiving the news that persists for some time after the news is received
-That results in decreased hope for the patient and his or her family’s future quality of life
what is the MUM Effect
reluctance to give bad news to patients/families
How can provider talk too much?
- Assuming all patients want to be cured
- Assuming what the patient does and doesn’t know about the condition
- Not allowing patients time to process or speak during the conversation
- Ignoring our own feelings
- Talking in a public place
- Delivering news via phone, e-mail, text, letter, etc.
what are additional stressors in giving bad news?
- being honest with the patient and not destroying hope (MC)
- dealing with patient emotions
- finding the right amount of time to discuss
- other (training, feeling unprepared, etc)
SPIKES 6-step protocal
S - Setup
P - Perception
I - Invitation
K - Knowledge
E - Empathize
S - Summarize and Strategize
What is part of the setup for SPIKES
- Comfortable Environment
- Minimize distractions
- Private setting
- Tissues handy - Who else would the pt want to be there?
- Family members
- Significant others
- Support staff - Time Management
- Allot an appropriate amount of time
- Notify staff in advance to reduce interruptions
what is part of the perception for SPIKES
- What does the patient/family already know?
- opportunity to correct misunderstandings
- gauging pt’s lvl of readiness to discuss diagnosis
what is part of the invitation for SPIKES
- how much does the pt know
- is there anyone the pt would like to know, or to use as a liaison
- if he/she feels that “ignorance is bliss”
what is part of the knowledge for SPIKES
- impart knowledge about condition
- do not minimize severity of situation
- share positive news if present
- avoid saying “i’m sorry”
what is part of the empathize for SPIKES
- acknowledge pt/family emotions
- sample remarks to show empathy
what is part of the summarize/strategize part for SPIKES
- summarize info
- strategize next steps
what are the emotions that pt might experience?
- fear - “anxiety” - of death, of further tests/treatments, of leaving loved ones, of what the future will hold
- anger - “frustration” - at self, at family, at health care providers, at God/nature/the world
- sadness - “disappointment” - sense of loss for themselves or others, changes in relationships, loss of future plans
- shame - “guilt” - for not caring for themselves better, for not seeking treatment sooner
- relief - if already suffering, if diagnosis already suspected
how to deal with emotions when communicating bad news
- active listening
- allow pts to talk about their emotions
- offer culturally sensitive care
cessation of vital functions
death
- Irreversible cessation of circulatory and respiratory functions, OR
- Irreversible cessation of all functions of the entire brain, including the brainstem
process of losing vital functions
dying
Occurs over a span of minutes, to hours, to days depending on the underlying pathology
dying
signs of impending death
- Decreased bodily functions
- Hearing, vision, oral intake, urine output, consciousness - Bedbound and/or profound weakness
- Emotional distance, decreased conversation
- Cool/mottled extremities, “death rattle”
reaction to the loss of a close relationship
“The state of being deprived of someone by death”
bereavement
the emotional response caused by the loss of a close relationship
Includes pain, distress and physical and emotional suffering
grief
Psychological process by which the bereaved person undoes his or her bonds to the deceased and settles his or her personal grief
mourning
variables of reactions to loss of a loved one
- Context of death
- Timely or untimely?
- Intentional or unintentional? - Psychological meaning
- “Blame” for the death
- Relationship to the deceased
- Age (both of deceased and the bereaved)
- Religious or spiritual beliefs
what are common responses to a loss of a loved one
- Shock
- Anger
- Guilt
- Denial
- Frustration
- Sadness
- Relief
what are the 5 stages of impending Death
- shock and denial
- anger
- bargaining
- depression
- acceptance
Person may appear dazed, refuse to believe diagnosis
Some patients may not get past this stage
shock and denial
defense mechanism during shock and denial stage
normal reaction to rationalize overwhelming emotions
how to deal with shock and denial?
- Communicate respectfully and directly basic info about the illness, prognosis, and options for treatment
- Allow for patient’s emotional responses
- Reassure them that they will not be abandoned
Denial wears off, but patient isn’t ready to accept reality
Patient becomes frustrated, irritable, and angry
Displacement of ___ may occur
Anger
how to deal with anger when delivering bad news?
- Understand this attitude is normal - DON’T take it personally!
- Use an empathetic, non-defensive attitude with patients
Patients may attempt to negotiate with physicians, friends, and even God
bargaining
how to deal with bargaining when delivering bad news
- Make it clear that you will take care of the patient to the
best of your ability - Encourage patients to participate as partners in their treatment by being honest and straightforward
Clinical signs of depression manifest
May include suicidal ideation
depression stage
2 stages of depression of impending death
- practical - sadness, regret over implications of death
- preparation - mentally accepting the upcoming separation from a loved one
how to deal with depression when delivering bad news?
- Support and empathy are key to help patients through this phase
- Distinguish between normal sadness and major depressive disorder!
- If MDD, treatment is appropriate
- Patient realizes that death is inevitable and accepts the universality of the experience
- Broad range of feelings depending on the individual
– Solemn to euphoric
acceptance
not every patient makes it to this stage of the 5 stages impending death
acceptance
how to deal with acceptance when delivering bad news
- Spend time with your patients and allow them to discuss feelings
- Offer appropriate spiritual support as needed
what age age group has this attitude towards death?
Aware of death only in the sense that it is a separation
similar to sleep
<5yrs
what age group has this attitude towards death?
Developing sense of inevitable human mortality and often fear that their parents will die and that they will be abandoned
5-10 yrs
what age age group has this attitude towards death?
Realize that death can happen to them, and by puberty will recognize death as universal, irreversible, and inevitable
~9-10 yrs
It is essential to have a consistently present, trusted person in order to provide optimal care for this demographic of pts
children
what age group understands that death is inevitable and final
Fears parallel those of all of them
adolescents
1. Fears parallel those of all teenagers
- Loss of control
- Being imperfect
- Being different
broad range of emotions
who often readily accept that their time has come
May talk or joke openly about dying and
sometimes welcome it
elderly
1. The older one gets…the more he/she no longer harbors illusions of indestructibility
2. May either have a sense of integrity or despair
- Reflect on their time and how it was lived
expressions of grief encompasses a wide range of emotions, depending on:
- Cultural norms
- Expectations
- Circumstances of loss
what is the normal grief reaction
- Immediately following death
- Numbness, shock, disbelief
- “Going through the motions” - Weeks following death
- May still see numbness and shock
- Transitioning to intense sadness, yearning for the deceased, anxiety, disorganization, emptiness - “Searching behaviors” - including visual and auditory hallucinations of the deceased, “sense” of the deceased’s presence
- Somatic complaints - sleeplessness, appetite disturbances, agitation, chest tightness, sighing, exhaustion
- Self-reproach is common
- Mental “replays” and rumination about the relationship of the deceased
- Anger at the person for dying, at God, at healthcare providers - May withdraw socially
- Investment in “linkage objects” that belonged to the deceased
- Identification Phenomena - taking on qualities, mannerisms, or characteristics of the deceased person
traditionally, grief lasts ?
6 months to 1 yr
Should see at least some improvement by the 6 month mark
characteristics of survivor guilt
- May occur in those who are relieved that someone other than them has died
- May believe that they should have died if guilt persists
- May have difficulty establishing new intimate relationships from fear of betraying the deceased
Describes the symptoms of grief following the loss of a loved one
May have symptoms characteristic of a major depressive episode
uncomplicated bereavement
Almost 25% of bereaved individuals meet criteria for major depression at ____ and again at ____
2 months
7 months
may continue meet criteria at 13 months
what can be given if prolonged behavioral symptoms or functional impairment when dealing about bad news
antidepressants
Risk factors for poor bereavements outcomes
- those who suffer a loss suddenly or through horrific circumstances
- those who are socially isolated
- those who believe they are responsible
- hx of traumatic losses
- those who have intensely dependent relationship with the person who died
- those who have suffered the death of a child
what is considered prolonged grief disorder
- Death of someone close to the patient, at least 1 yr ago
- Since the death, on most days, the patient has felt one or both:
- Intense yearning or longing for the deceased
- Preoccupation with thoughts of the deceased - The patient must have significant distress or impaired functioning
- The patient’s grief response (duration and intensity) exceeds social, cultural, or religious norms for the patient’s social context
- The symptoms are not due to another psychiatric disorder
Since the death, on most days, the patient has felt at least 3 of the following: (prolonged grief disorder)
- Disruption of identity (feeling like part of themselves has died)
- Disbelief about the death
- Avoiding reminders of the death
- Emotional pain related to the death
- Emotional numbness due to the death
- Feeling that life is meaningless, due to the death
- Loneliness, due to the death
- Problems resuming relationships and activities
what are tx options for prolonged grief disorder
- Psychotherapy - Prolonged grief disorder therapy preferred over other approaches
- Others - CBT, behavioral activation, exposure therapy - Medications - Antidepressants are generally preferred
bereavement - medical sequelae
- Higher rates of mortality (especially in older men)
- Higher rates of morbidity and health care costs
- Special risk for exacerbation of HTN, CHF - Higher rates of alcohol, tobacco, and sedative usage
- Higher rates of impaired immune function
- Complicated grief - increased risk of cancer, HTN, heart disease, change in eating/smoking/drinking habits, hospitalization, disability, reduced quality of life
differences between grief and depression
- mood disturbances
- Depression: typically pervasive and unremitting… fluctuations are relatively minor
- Grief: fluctuations are common (even in intense grief, moments of lightheartedness and happy reminiscence are possible) - Shame and guilt
- Depression: fundamental belief that one is wicked or worthless
- Grief: usually involves not having done enough for the deceased before death - Suicidal ideation
- Depression: threaten suicide more often
- Grief: often claim life is unbearable, but do not truly wish to die
