Download Breaking Bad News

Resident 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.
b.
c.
d.
Agree with the daughter and do not tell the patient.
Just tell the patient
Get someone else to tell the patient
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.
b.
c.
d.
Establish a comfortable private environment
Establish what the patient knows
Establish what the patient wants to know
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.
b.
c.
d.
leave
ask them to stop immediately
reassure pt that it will be ok
be silent
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?
a) Follow the daughter’s wishes as she is the medical POA. You
intubate the patient and transfer her to the medical ICU.
b) You contact the hospital chief of staff to have his/her input on
the case.
c) Tell the daughter that intubation was against her mother’s wishes
and quickly walk out of the room.
d) 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.
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
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 colleague's 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.
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
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