Delivering Bad News

Question 1

What is bad news?

Answer 1

situations where there is either a feeling of no hope, threat to a person’s mental or physical well-being, a risk of upsetting an established lifestyle, or where a message is given which conveys to an individual fewer choices in his or her life

Question 2

Why is bad news delivery important

Answer 2

1. It is a frequent occurence
   - 74% of providers deliver BN
2. Legal and Ethical oblications (informed consent)

Question 3

What are the effects on clinical outcomes?

Answer 3

1. Patient Satisfaction
2. Treatment Compliance
3. Psychiatric State
4. Lifespan
5. Quality of Life

Question 4

Is there a lack of provider training when giving bad news?

Answer 4

Less than 25% of physician have had training in bad news delivery

Question 5

What are the important factors defined by patients?

Answer 5

1. Personalization
2. Quality
3. simplicity
4. Accessibility
5. Multiplicative effect

Question 6

What are the patients desires?

Answer 6

For the physician to: exhibit empathy, be honest and encourage questions
For the environmental factors to be: sitting face-to-face, promote privacy, set aside time, encourage inviting loved ones, remove distractions

Question 7

What are the factors that influence patient response to bad news?

Answer 7

Expectations
Previous experiences
General personality disposition
Demographics
Types of responses: shock, horror, anger, disbelief, denial, acceptance

Question 8

How are patients different?

Answer 8

Females
Patients with higher education
Elderly

Question 9

How are different doctors characteristics?

Answer 9

1. Inexperienced Messenger
2. Emotionally burdened
3. Rough and Ready
4. Benevolent but tactless
5. Distanced doctor
6. Empathetic !!!!! BEST!

Question 10

What is involved in the provider’s perspective?

Answer 10

Emotional challenges
Competing Impulses
Inferring patient preferences
Lack of training

Question 11

What are the emotional challenges?

Answer 11

Fear of:
being blamed for poor outcomes, patient reactions, and inadequate
Feelings of:
anxiety, guilt, sadness

Question 12

What are the three major tensions?

Answer 12

Autonomy vs. Connection
Openness vs. Closedness
Novelty vs. Predictability

Question 13

What is inferring patient preferences?

Answer 13

Rating and detecting patient distress
Determination of patient viewpoint
Recognizing need for emotional support

Question 14

What occurs with lack of training?

Answer 14

BN delvier often comes early in career
Inadequate guidance and help
Resort to trial and error
Negative experience for physician and patient

Question 15

What are the types of BN delivery?

Answer 15

Non-disclosure
Full disclosure
Individualized disclosure

Question 16

What is non-disclosure?

Answer 16

Assumptions:

Physician decides for patient, patient doesn’t want to know BN, patient need to be protected from BN

Question 17

What are the key characteristics in non-disclosure?

Answer 17

Ambivalence, use of euphemisms, ambiguity

Question 18

What is involved in full disclosure?

Answer 18

Appropriate for patient to make own decisions
Patient has the right to full information
No account for patient’s desire
Key Characteristics
– general bluntness
– lack of concern for patient

Question 19

What is involved in individualized disclosure?

Answer 19

Assumptions:
Different coping mechanisms
Different desires
Key characteristics:
- Tailoring amount and rate of disclosure
- simple strategy --> ask the patient
- most effective
-  better clinical judgement

Question 20

What is SPIKES?

Answer 20

A delivery protocol:
S - setting
P - Perception
I - Invitation
K - Knowledge
E - emotions/ empathy
S - sympathy / summary

Question 21

What is the setting

Answer 21

Setting up the interview

1. arrange for a convenient time
2. manage time restraints
3. arrange for privacy
4. Involve family /sign others

Question 22

What is perceptions?

Answer 22

Assessment of patients perception:
Ask patient what they know (open end)
Correct misinformatin
Tailor bn to patients understanding of condition

Question 23

What is obtaining patient’s invitation

Answer 23

Ask patient if they want to know results

Respect the patient’s decision

Question 24

What is giving knowledge?

Answer 24

Speak at a level of patient comprehsion
give info inchunks
Periodically check for understanding
Provide alternative resources for learning

Question 25

What is addressing emotions with empathy

Answer 25

Acknowledge patient’s emotions
Allow time to express emotions
Make connecting statements

Question 26

What is providing strategy and summary?

Answer 26

Ask permission to switch to treatment discussion
Be honest without destroying hope
Summarize main points of consultation
Refer patient to a support group

Question 27

What is the efficacy of SPIKES?

Answer 27

Practical and easy to remember
90% of physician used SPIKES
Addressing emotions is diffuction

Question 28

What is adapting to cirumstances?

Answer 28

Cancer relapse:
added complications:
- new relationship
- shift from curable to manageable
- patients have heard BN before
- health status typically terminal

Question 29

What are the goals to therapeutic alliance?

Answer 29

Achieve optimal outcomes
Combine organization of care with consideration of patients needs
Humanize care

Question 30

What are the strategies

Answer 30

Emphasize hope
mutual trust and respect
Combine social and medical resources
 --- one page summaries
---- editable calendars

Question 31

Death in the ER?

Answer 31

Added complications:
Circumstances
Relationship
Environment
Time restrictions
Physician emotions

Question 32

What are suggestions in the ER?

Answer 32

Teamwork
Debriefing
Giving information
Role-playing situations