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Example of statement:
– Physician: “Mr. Adi, the blood in your stool and your
low blood count really worry me. A lot of thins can
cause this. Sometimes it’s hemorrhoids, which are
blood vessels in the rectum. Sometimes it’s blood
vessels higher up. Sometimes it’s polyps, or little
growths on the wall of your intestine. These can bleed,
and if they’ve been there a long time, they can even
turn into cancer. I think we should do some more test
to find out exactly what it is”.
– Patient: “Really? What kind of cancer, Doc?”
– Physician: “I’m not sure that’s what it is. Like I said,
we need some more test. The most important test is to
look up inside you and check for anything abnormal. If
Choosing a setting
– Patients report that they prefer to receive bad news from
a physician, preferable one who knows them and their
medical conditions.
– It should not be delegated to other health care tem
members
– Sitting down and making eye contact is an effective way
to communicate attention and concern
– Occasionally bad news must be broken at a distance
– Death notification by telephone is sometimes necessary
when families ask directly if death has occurred or if
they are unable to come to the hospital
Attributions and
Expectations
– Nearly all patients have assumptions about what
might be wrong (attribution) and what needs to
be done to help them (expectations).
– Attributions and expectations are based on
experiences with self, family, friends, informal
health advisors, the media and other sources
– Attribution and expectation are important for
gaining:
• The meaning of the illness to the patient
• The level of information the patient desires
• The patient’s emotional reaction to bad news
Breaking the bad news
– First step in breaking bad news is assessing
what the patient is ready to hear:
• Reviewing the clinical data
• Checking the patient’s understanding and concern
about the data
• Indicating that new information is available
Example of statement:
Physician: “Pak Ari, you know that we saw a lump on the wall of your
intestine and took a biopsy of it. What have you already learned about the
result?”
Patient: “Well, is it cancer?” or “Could you wait till my wife gets here?”
Physician: “Whatever I tell you in a moment, I want you to remember the
situation is serious, but there’s plenty we can do. We’ll have to work
closely together over the next several months”
Breaking the bad news
– Most patients favor a direct statement of the news,
followed by a pause while the message sinks in
– Message should clear and unambiguously
Example of statement:
Physician: “I’m afraid that the biopsy showed cancer of the colon”
Patient: “Oh my God, doctor. Not cancer (weep, wrings hands). Oh my
God, what am I going to do now?”
Physician: “I know this comes as a shock. This wasn’t what you were
expecting at all. But I want you to know that we’ll take it one step at a time
and work on it together. The next big step is to find out if it has spread
outside the colon. To start that we’ll do a CT scan of your belly. That will
help us decide on the best treatment”
Emotional support
– Patients who receive bad news usually remember
the physician’s attitude and manner more vividly
than technical details of the news.
– Be honest and caring even in the face of strong and
varied emotions
– The real secret is not what you tell your patients,
but what you let your patients tell you
Emotional support
Example of statement:
Physician: “I can see that you’re feeling overwhelmed right now. I can
imagine you’re quite stunned by this news and that it is hard to even
think about. Have I got it right?”
Patient: “Yes. I can’t believe this is happening. I’m going to wake up in a
minute and this will all be a bad dream”
Physician: “I wish it were so. Is there anyone that I can call for you?
Anyone at home that you can be with?”
Patient: “ Yes, my husband should be home by now”
Physician: “You two probably have some questions or concern that you’d
like to talk about with me. If you’d like, I can call him for you now and
explain what has happened. Then I’d like the two of you to come see me
tomorrow afternoon, so we can talk about what to do next”
Empathetic communication
– Signposting, or forecasting
• “Let me make sure I understand”
– Reflection
• “You put in your time on months of painful treatments and beat this
breast cancer. Now, two years later you find it is back. And you’re
really feeling cheated, because you did all the right things to beat it.
Have I got it right?”
– Legitimation
• “I think anyone would feel the same way”
– Respect
• “I think you’re doing the right thing by taking it on again”
– Support
• “I’d like to healp you through this”
– Partnership
• “We’ll need to work together. Just as hand as last time”
Giving information
• Patients given the news of a serious cancer often want
to know absolutely that:
– The diagnosis is correct
– How much the disease has spread
– How it can be treated or cured
– What to expect with the various treatment options
• Some patients wants lots of information and
involvement in decision making
• Technique to give information:
– Simple and clear words instead of medical jargon
– Giving small amounts of information at a time
– Summarize periodically
Giving information
• Example of conversation:
– Patient:”Am I going to die?.....How long do I have?”
– Physician: “I think what you’re asking is whether you
will die because of this cancer. There are statistics on
how long people with this kind of cancer live, with
and without treatment, but they are just averages.
Some patients live much longer and some shorter
than average. I can tell you the averages for your
condition, but I can’t predict how long you have. I
want to tell you again that I am here to help and
support you through this”
Closing the bad
news interview
• Before closing, the physician should think about the dual tasks of
managing the relationship and exchanging information
• The easiest and most effective way to close the bad news
interview is to outline specific further steps:
– Asking who else needs to know the news
– How the patient plans on telling those individuals and if patient
wants help telling them
– And involves gathering more information through consultants
and diagnostics test
Example of statement:
– “We’ve talked about a lot of information today. I’m also
wondering how you’re feeling about all this. After all, that’s
another important part of you and your medical care”
Emotional
response to
chronic illness
• Denial
• Anxiety
• Depression
Thanking you for the attention
Reference:
• Cole, SA., & Bird, J. 2000. The Medical Interview.
London: Mosby
• Kurtz, S., Silverman, J., & Draper, J. 2005 Teaching
and Learning Communication Skills in Medicine.
Oxford: Radcliffe Publishing
• Prabandari, YS., Claramita, M., et al. 2007
Communication Skills Manual Book. Yogyakarta:
Faculty of Medicine, the Gadjah Mada University
• Taylor, SE. 2006. Health Psychology. Singapore:
McGraw-Hill International