Breaking Bad News

Attending Version

Breaking Bad News Module

; created by Dr. Jessica Bigney

additional questions created by Dr. Yvonne Dalton-Etheridge

Objectives:

1) Learn more effective techniques for discussing bad news with patients. 2) Learn possible pitfalls about discussing bad news, and ways to avoid them.

References:

1) The University of Wisconsin has a great web site that includes FAST FACTS. www.eperc.mcw.edu Fast Facts contains information on end of life topics ranging from opiate dosing to communication skills. Outline for discussion:

Health care professionals often find themselves in the position of having to communicate bad news to patients and families. Whatever the experience level of the health care provider conversations about death almost always cause some element of discomfort and awkwardness. It is important to recognize that this response is universal. It has been recommended that a six-step protocol be used when discussing “bad news” with patients. This allows for some preplanning which can facilitate communication with the patient and their families.

1. Setting:

If at all possible a private room with adequate space for everyone involved to be seated is optimal. Many floors will have a family meeting room or conference room that can be used.

2. Establish what the patient knows:

It is important to illicit from the patient what they understand about the seriousness of their illness. Try to establish what the patient knows about the impact of the illness on his or her future. It is less important that they understand the minute details of Pathophysiology. Ways to elicit information: “What have the other doctors told you about your illness? “(Patients may tell you that the other physicians on the case have told them nothing about their illness. This may or may not be true, but is an accurate portrayal of what the patient has been able to take in and absorb. The goal at this point is to understand what the patient understands about their illness.) “How has the illness changed your daily life?” “How has your illness impacted your family?” “What have you been worried about? “

3. Finding out how much the patient wants to know:

“Are you the kind of person who likes to know exactly what is going on?” “Are you the kind of person who likes the full details of what is wrong -- or would you prefer to just hear about the treatment plan?” “Are there other family (support persons) who you would like to include in the conversation?”

If a patient indicates that they do not want to know the full details of their disease at the time of the conversation it is important to convey that the information will be available to them should they want it in the future. Revisit this and allow the opportunity for the patient to ask questions when they are ready to hear the answers. 4. Share medical information:

Do this in clear and concise manner. Do not use medical jargon. Give the information in small increments. Check in with the patient that they understand what you are saying. Repeat the information several times if need be. Elicit the patients concerns. They may not be what you would expect.

5. Respond to the patient’s feelings:

Anticipate that the patient may have strong emotions. Have a plan for how to deal with anger, sadness, or grief.

6. Planning and follow through:

It is very important for the patient to feel that there is a plan. Patients should never be left with the feeling that “nothing can be done”. Even if curative therapies are not available they need to feel that things that are reasonable to treat will be treated (depending on the patient’s wishes). Make it clear to the patient that despite our ability to cure we will be providing INTENSIVE CARING …, which does not need to be delivered in an ICU. The patient needs to understand that ongoing care will be provided directed at physical/ emotional and spiritual symptoms.

7) AVOID:

We are going with withdrawal care. There is nothing further we can do. You are in God’s hands now.

Statements like this infer abandonment

We will make sure you don’t suffer

This can sound like you are going to euthanize the patient. Better to directly address the symptoms that you are going to direct TX to: “we will work with you with medication and other therapies to control your pain.”

Delivery of bad news in a public location: hallway.

Interruptions: consider giving your pager to someone else for the duration of the conference with pt and family.

False reassurance: It can be very important to maintain hope, but false hope does not benefit the pt. Hoping for the best but planning for the worst is a good approach to take. Questions:

1. You are caring for an elderly gentleman who has multiple medical problems. You have recently diagnosed widely metastatic cancer of unknown primary. The heme/onc consultants do not feel that aggressive therapy would be of any benefit. You have conveyed this information to the patient’s daughter who has been very involved in the patient’s care. The daughter begs you not to tell her father about the diagnosis and prognosis, stating, “He will just give up and die.”

a. Agree with the daughter and do not tell the patient. b. Just tell the patient c. Get someone else to tell the patient d. Ask the daughter more about what kind of hope she wants her father to have.

2. The steps in delivery of bad news include all of the following except:

a. Establish a comfortable private environment b. Establish what the patient knows c. Establish what the patient wants to know d. Leave immediately after you give the patient the bad news so they can process the information.

3. You have just told a patient and his family that the prognosis is poor. They are all in tears. You should:

a. leave b. ask them to stop immediately c. reassure pt that it will be ok d. be silent

Answers to questions:

Physicians may be asked by family members to withhold information from the patient when the news is bad. It is important to explore the family’s reasons for not sharing the information. It is often the concern that the news will result in the patient just “giving up”. Asking about what hopes the family member has for the patient is a good place to start the conversation. Reframing the idea of hope to include aggressive symptom management, the maximization of quality over time may be more realistic for the patient, and does not take away hope. Hoping for the best but preparing for the worst is also a helpful way to frame this discussion. Not telling the patient without ascertaining what he wants to know is not appropriate. If the patient indicates that he does not want the information now it is important that he understands that the discussion can be reopened when he is ready to discuss the information. Just telling the patient without some discussion and negotiation with the family can undermine trust and the therapeutic relationship with both the patient and the family. After talking with the family member the next step would be to have a family meeting which includes the patient so that the patient can express their desires regarding how medical information will be handled.

2. D Setting up a quiet environment, which allows discussion, is important. Ascertaining what the patient and family understand about the current medical condition is critical to help prevent misunderstanding. This is very important especially if there have been multiple consultants participating in the patients care or there are multiple family members. It is also important to ask the patient how they want the information handled: Who gets the information? How much information the patient wants re: diagnosis, therapies, and prognosis. Silence is an important part of the process. Being present but quiet allows the patient and family to take in the information and formulate any questions they might have. It is then important that the patient be reassured that the medical establishment will not abandon them, but the focus of care may shift to symptom control and quality of life. Set up a time to follow up.

3. D This question is directed at the physician’s response to strong emotion. Leaving the room, false reassurance and asking them to stop crying conveys the message that you are not interested in their emotional response. Thinking through how you will respond to strong emotion may be helpful. Silence and presence is often the most important thing you can do. It demonstrates to the patient / family that you are available to them. “Being” instead of “doing” is sometimes the most supportive thing you can do. Expressions of empathy …” I know this hard for you” may be helpful. ETHICS CASES (Reference www.acponline.org/ethics/ethicman.htm)

1) 84 yo female with end stage COPD who had been admitted for pneumonia was found in her bed tachypnic and unresponsive. Her vitals were BP 80/40 P 110 RR 28 O2 sat 60% on NRB. ABG drawn by eager intern shows respiratory acidosis with pCO2 80. The patient had clear living will and did not want life sustaining measures and was DNR/DNI. She has been this status on her multiple recent admissions. You had a conversation with her on this admission and she was clearly DNR/DNI. Her middle daughter who has medical POA and is a RN, walks in and states, “my mother should be in the ICU.” The respiratory therapist is questioning why you are not intubating this patient. Upon hearing this, the daughter asks, “why are you not intubating my mother?” You explain that her mother has clear living will which stated that she is DNR/DNI. The daughter responds that she has medical POA, her mother cannot make decisions for herself currently, and so she wants to reverse this previous order. What is the appropriate course of action to take?

1. Follow the daughter’s wishes as she is the medical POA. You intubate the patient and transfer her to the medical ICU. 2. You contact the hospital chief of staff to have his/her input on the case. 3. Tell the daughter that intubation was against her mother’s wishes and quickly walk out of the room. 4. Explain to the daughter that her mother has a clear living will that states she is DNR/DNI and that furthermore you held a conversation with her this admission where she confirmed this decision. Try to explain to her calmly that you as the doctor have to respect this decision and that you will continue to treat her mother medically up until the point of using life sustaining measures.

Answer is (d). You have to follow the instructions of the living will. In this situation you have both a verbal and written “contract” between yourself and the patient to uphold the patient’s wishes. It does not matter that the daughter is the medical POA. The family may threaten legal consequences, however, living wills will hold up in court.

2) You are evaluating a 35 yo male in the ER for a seizure. The patient is not very forthcoming with his answers and you suspect that drugs and or alcohol may be playing a part in the etiology for the seizure. There is a young boy (you estimate around 10 years of age) in the examination room who the patient introduces to you as his son. You are unclear how the patient arrived at the hospital, but the patient seems to imply that he drove himself. The patient seems to be a little upset at his waiting time in the ER. When you mention that you would like to draw some lab work and obtain a head CT and that the results may take several more hours, the patient responds, “This is crap, we’re leaving”. Your next course of action should be:

a) Allow the patient to leave as he is a competent adult and able to make decisions about his healthcare for himself b) Ask the patient to sign an “AMA form” which states that he is leaving against medical advice. c) Ask the patient to sign an AMA form as above, and then also notify child protective services so they can investigate into whether the patient’s son is living in a safe environment. d) Place a “medical hold” on this patient and don’t allow him to leave the ER

Answer is (d) which may involve hospital security and the hospital ethics committee. You have not yet determined if this patient is under the influence of alcohol or drugs (may interfere with his competency) and more importantly he could be considered a danger to others (his son who is a minor and the general public if he leaves the hospital and drives a vehicle).

3) You are making rounds on the general medicine floor. You notice your colleague opening the medication cart and taking out some pills. At first, you think this is a bit odd, but then forget about the occurrence as you get tied up with patient care issues. Later, you overhear the charge nurse reprimanded a nurse for not having some of her patients’ opiates accounted for on the medication cart. You confront your colleague with your suspicions that he is stealing opiates. He tells you that he has been taking them for back pain which developed after a recent car accident. He admits to his wrongdoing, but begs you not tell anyone. He states that he never takes the opiates prior to or during his duties at the hospital. Your opinion of your colleague is that he has always provided appropriate medical care to his patients. What is your next course of action?

a) Since the opiate use does not seem to affecting your colleague's medical judgment, you advise your colleague to go to his primary care doctor to obtain his opiate prescription rather than taking them from medication cart.

b) Gather more information from your other colleagues in your medical group on whether they have ever witnessed such behavior and if so, report the incident to your supervisor.

c) Urge your colleague to seek treatment and report your findings to your supervisor and local medical licensing board.

d) Urge your colleague to seek treatment. Your colleagues possible chemical dependence falls under a medical condition and should be treated as a confidential matter. You will be violating HIPPA if you report this matter.

The correct answer is (c). You are obligated to report your findings to your supervisor and local medical licensing board. Although your colleague does not currently seem impaired, he is already demonstrating behavior which can be classified as being an addict (stealing opiates). You should urge your colleague to seek treatment for his chemical dependence. Most licensing boards and medical societies now have confidential treatment programs of impaired physicians. Although you should not discuss this matter with anyone other than your supervisor and the licensing board, you are obligated to tell these entities since your medical colleague may be endangering his patients.

Post Module Evaluation

Please place completed evaluation in an interdepartmental mail envelope and address to Dr. Wendy Gerstein, Department of Medicine, VAMC (111).

1) Topic of module:______

2) On a scale of 1-5, how effective was this module for learning this topic? ______(1= not effective at all, 5 = extremely effective)

3) Were there any obvious errors, confusing data, or omissions? Please list/comment below:

______

4) Was the attending involved in the teaching of this module? Yes/no (please circle).

5) Please provide any further comments/feedback about this module, or the inpatient curriculum in general:

6) Please circle one:

Attending Resident (R2/R3) Intern Medical student