BREAKING THE BAD NEWS

Dr. Liza Manalo, MSc. Palliative Care, Cancer Center The Medical City, Ortigas, Pasig City Philippines

Breaking Bad News: S-P-I-K-E-S Strategy

Community Oncology, March/April 2005

Robert A. Buckman, MD, PhD University of Toronto, Canada

S-Setting
Privacy Involve significant others Sit down Look attentive and calm Listening mode: silence & repetition Availability
Community Oncology, March/April 2005

P-Patients perception
Find out how much the patient or surrogate decision-maker knows.
What did you think was going on? What have you been told about all this so far? Are you worried that this might be something serious?

I-Invitation
Find out how much the patient or surrogate decision-maker wants to know.
Are you the kind of person who prefers to know all
the details about what is going on? How much information would you like me to give you about diagnosis and treatment? Would you like me to give you details of what is going on or would you prefer that I just tell you about treatments I am proposing?

K-Knowledge
Share the information
Warning shot : Unfortunately, Ive got some bad news to tell you, Mrs.
Dela Cruz. Mrs. Dela Cruz, Im so sorry to have to tell you.

Pause : Wait for them to take a deep breath and get ready to hear the bad news Use short, simple, clear sentences Avoid jargon or technical scientific language Tailor the rate at which you provide information to the patient/surrogate decision-maker

E-Empathy
Step 1: Listen for and identify the emotion (or mixture of emotions).
How does that make you feel? What do you make of what Ive just told you?

Step 2: Identify the cause or source of the emotion

E-Empathy
Step 3: Show your patient/surrogate decisionmaker that you have identified the emotion and its origin
Hearing the results of the tests is clearly a major shock to you. Obviously, this piece of news is very upsetting. Clearly, this is very distressing.

Empathetic silence: Wait for them to take a deep breath

and process the bad news Answer questions patiently Be sensitive and compassionate Respond to the patients or surrogate decision-makers thoughts and feelings Identify the emotionally critical misperception (ECM)

E-Empathy
Validation normalize the patients or surrogate decision-makers feelings
I can understand how you can feel that way. Let the patient or surrogate decision-maker

know that showing emotion is perfectly normal, to minimize feelings of embarrassment and isolation Assure non-abandonment: Inform the patient or surrogate decision-maker that you will be coaching them through the next steps

S-Strategy/Summary
Educate, summarize, and concretize plan of action
Ensure that the patient or surrogate decisionmaker understands the information so that you and they are both on the same page. Summarize the information in your discussion and give the patient or surrogate decision-maker an opportunity to voice any major concerns or questions. Outline a step-by-step plan, explain it to the patient or surrogate decision-maker, and contract about the next step.

Common Communication Error: Information overload and "medspeak" Emergency Room:

Mrs. Dela Cruz: Doctor, how is my husband doing? Dr. Reyes: He had a stroke. Mrs. Dela Cruz: Stroke? But he is only 51. How big is it? Dr. Reyes: Pretty big according to the CT scan. It revealed hemorrhage or a bleed on the right parieto-temporal lobe, with subarachnoid and intraventricular extension. Problem is that he is comatose and hypertensive right now. Also, the pupils are equally dilated and non- reactive and the brainstem reflexes are absent. Anyway., the Neuro folks are coming. They will explain things more. Meantime, dont worry! Mrs. Dela Cruz: (thinking can-you-talk-to-me-in-English or Tagalog?): Doc will he make it? I am so worried.

Breaking the Bad News Emergency Room: BETTER VERSION

Mrs. Dela Cruz: Doctor, how is my husband doing? Dr. Reyes: Mrs. Dela Cruz, let us find a place to sit down. Dr. Reyes: I am afraid that I have some bad news for you. Pause for a few seconds (you may want to count till ten) allowing wife to prepare herself for the news. Dr. Reyes: Your husband has had a stroke. Pause and allow Mrs. Dela Cruz to digest the information. Mrs. Dela Cruz: He had a stroke? Dr. Reyes: Yes. I am afraid so. Pause and allow Mrs. Dela Cruz to digest the information. Mrs. Dela Cruz: Stroke? But he is only 51. How big is it?

Breaking the Bad News Emergency Room: BETTER VERSION

Dr. Reyes: I ran some initial tests on him. Looks like it is a rather big bleed. You did great by bringing him in so quickly. Mrs. Dela Cruz: Doc will he make it? I am so worried. Dr. Reyes: Mrs. Dela Cruz, we already know that your husband has a stroke and I have started him treatment to remove the pressure on the brain. I have talked to the neurology specialists. They will be here momentarily to take over. Im afraid however that even if we do everything we can, the damage to his brain is such that I feel we will not be able to pull him through, Im sorry. Pause and allow Mrs. Dela Cruz to digest the information. Dr. Reyes: How are you doing? What is going through your head? Pause and allow Mrs. Dela Cruz to digest the information and formulate her questions.

Phraseology : Do's and Don'ts

What not to say
"I know exactly how you feel." Sweeping statements that are not grounded in personal or professional experiences are hard to believe.

What to say
"My past experience with many patients in this situation has taught me that you must be in distress right now." "I can imagine how upset you must be."

http://endoflife.stanford.edu/M19_communic/dos_and_donts.html

Phraseology : Do's and Don'ts

What not to say
"Your husband have failed medical decompression therapy." This implies that it is the patient's fault that the therapies are not working.

What to say
"Unfortunately, the __________ therapy does not seem to be working very well."

http://endoflife.stanford.edu/M19_communic/dos_and_donts.html

Phraseology : Do's and Don'ts

What not to say
"There is nothing else we can do."

What to say
"Looks like the ________ is not working very well. However, you can be sure that we will do everything in our power to make sure that you (your husband) won't suffer."

http://endoflife.stanford.edu/M19_communic/dos_and_donts.html

What not to say

"There is nothing more that can be done. I am going to refer you to hospice and palliative care."

What to say
"Doctor: As we have just discussed, it looks like the ________ treatment we tried is not working. So we have to stop the ________medication. Mrs. Dela Cruz: What do we do next, doc? Doctor: At this time, I do not have other viable medications that I can offer to you Mrs. Dela Cruz: ..... Doctor: I would like to refer you to hospice and palliative care. Hospice professionals have a lot of expertise in treating symptoms and increasing comfort and quality of life. They will help your husband by managing your husbands ________________ (dyspnea, agitation/restlessness, respiratory secretions, etc).
http://endoflife.stanford.edu/M19_communic/dos_and_donts.html

DNR Discussions with Surrogate Decision-Maker: Patient With a Life-Limiting Illness

What not to say
Mrs. Dela Cruz, do you want every thing done for your husband?

What the doctor might say instead

Dr. Reyes: Mrs. Dela Cruz, I want to talk to you more about what we call advance directives and Do Not Resuscitate orders for your husband. (Pause and give the decision-maker time to digest the information.) As you know, your husband had a massive stroke and the medical team members agree that his prognosis is grave and his chances for survival and recovery nil. In thinking about decisions regarding resuscitation there is a whole spectrum of choices. In event of an adverse situation, some patients would like to be connected to life support and would like us to do heroic life sustaining treatments. Others do not want such measures. (Pause and give the decision-maker time to digest the information.)
http://endoflife.stanford.edu/M19_communic/dnr_disc_bbn.html

DNR Discussions with Surrogate Decision-Maker: Patient With a Life-Limiting Illness

Mrs. Dela Cruz: But I dont want my husband to die. Dr. Reyes: Mrs. Dela Cruz, of course you want your husband to live, but with good quality of life. I do not want you and him to suffer and as your doctor, I will do what is in my power to help both of you. (Pause and give the decision-maker time to digest the information.) Mrs. Dela Cruz: Yes. I do not want him to suffer. (Pause and give the decision-maker time to digest the information.) Dr. Reyes: Your husband is now in coma. If his heart were to stop, putting him on life support will not prolong life. It would only prolong the dying process. (Pause and give the decision-maker time to digest the information.)

http://endoflife.stanford.edu/M19_communic/dnr_disc_bbn.html

DNR Discussions with Surrogate Decision-Maker: Patient With a Life-Limiting Illness

Mrs. Dela Cruz: (Pause and give the decision-maker time to digest the information.) Dr. Reyes: Things look grim for your husband and the increasing intracranial pressure has compressed the brain that at this point, any life support measures would be ineffective. (Pause and give the decision-maker time to digest the information).

http://endoflife.stanford.edu/M19_communic/dnr_disc_bbn.html

DNR Discussions with Surrogate Decision-Maker: Patient With a Life-Limiting Illness

Mrs. Dela Cruz: Dr. Reyes: In a situation like this, it is my opinion that we should hold back on futile resuscitative measures, but really focus on making your husband comfortable. (Pause and give the decision-maker time to digest the information). Mrs. Dela Cruz: (If decision-maker still seems reluctant) Dr. Reyes: I want you to think a little more about this and we can talk again in a while. I want you to remember that no matter what, I will still be your husbands doctor and I am here to help both of you.

http://endoflife.stanford.edu/M19_communic/dnr_disc_bbn.html

Breaking Bad News: S-P-I-K-E-S Strategy

S Setting P Patients Perception I Invitation K Knowledge E Empathy S Strategy/Summary
Before you tell, ASK!
What is your understanding of your illness?