Sie sind auf Seite 1von 35

Giving Explanation

and Delivering Bad


News
Presented by:
Yayi Suryo Prabandari
Professional Behavior Team-Communication Skills
Team
Faculty of Medicine
The University Gadjah Mada
Objectives of this session

• Understand the three functions of


effective medical interview
• Understand empathy
• Comprehend on breaking bad news
• Understand emotional response of
chronic illness
Three Functions of
Medical Interview
• Building relationship
• Assessing the patient’s
problem
• Managing the patient’s
problem
Building relationship

Basic relationships that help build


doctor-patient rapport:
• Non-verbal skills
• Empathy
• Partnership
• Support
• Respect
Empathy
• Cognitive capacity to understand
patient’s need
• An affective sensitivity to patient’s
feelings
• A behavioral ability to convey
empathy to patient
Level of empathy
• 0 = denial of patient perspective
• 1 = perfunctory recognition of patient perspective
• 2 = implicit recognition of patient perspective
• 3 = acknowledgement
• 4 = confirmation
• 5 = statement of shared feeling or experience

Level 3 – 5 = explicit recognition


of patient perspective
Level of empathy  5
Sharing experiences and feelings
• “Yes, I understand that this thing
makes both of you scared. Some
patients have ever experienced
spontaneous abortion, and in the
next pregnancy they were very, very,
scared”
Level of empathy  4
Confirmation
• “You sound like you are very busy. I
can see why it would be tough for
you to find time to do exercises”
Level of empathy  3
Appreciation
• “You said that you’ve been feeling
sad? Do you want to tell me more
about that?”
Level of empathy  2
Implicit recognition of patient
perspective
• Patient : “the headache makes it
difficult for me to work”
• Physician : “Yes….? How is the
insurance business lately?”
Level of empathy  1
Perfunctory recognition of patient
perspective
• Physician : “A-ha”, while the
physician doing something else,
often with the physician having
his/her body oriented away from the
patient
Level of empathy  0
Denial of patient perspective
• The physician either ignores
the patient’s empathic
opportunity or makes a
disconfirming statement, like
• “if you are under stress, why
do you come to this place?”, or
“Yes, it’s better be operated
now”
Empathy
• Reflection
– You look a bit sad right now
– I can see this is upsetting to you
– This hard to talk about
• Legitimation
– I can certainly understand why you’d be upset under
the circumstances
– Anyone would find this very difficult
– Your reactions are perfectly normal
– This would be anxiety provoking for anyone
– I can understand why you’re so angry
Wrong example:
What not say after a
miscarriage or pregnancy loss

• You can always have another


– The don’t want another baby, they want this baby
• Now you have an angel looking after you
– The don’t want an angel, they want their baby
back
• It’s for the best
– The best for whom?
Things to say
• I’m sorry
• What can I do to help?
• I’m here for you
Partnership
• Patients are more satisfied with physicians and
are more likely adhere to treatment
recommendation when they feel a sense of
partnership with their physician
• Example of statement:
– “Let’s work together in developing a treatment plan
once I have reviewed some of the options with you”
– “After we’ve talked some more about your problems,
perhaps together we can work out some solutions
that may help”
Personal support

• Statement of personal support can


enhance rapport
• The physician should make explicit
efforts to let the patient know that he
or she is there, personally
• Example of statement:
– “I want to help in any way I can”
– “Let me know what I can do to help”
Respect
• The physician’s respect for patients and their problems is
implied by attentive listening, nonverbal signals, eye
contact and genuine concern
• Respectful comments also help build rapport, improve the
relationship, and help the patient cope with difficult
situation
• Example of statement:
– “I’m impressed by how well you’re coping”
– “You’re doing a good job handling the uncertainty
– “Despite your feeling so bad, you’re still able to carry
on at home and at work. This is quite an
accomplishment”
MANAGING PATIENT
PROBLEM:
DELIVERING BAD NEWS
Skills to deliver bad
news
• Relationship building
• Giving a warning shot first and then pausing
to let the information sink in
• Knowing when to stop because the patient
doest not wish to or cannot hear more (shut-
down)
• Interviewing more than one person at a time
• Co-partnership and advocacy
• Giving hope tempered with realism
• Knowing when learners are not coping
appropriately with their own distress
Steps to break bad
news
• Preparing to break bad news
• Choosing the setting
• Attribution and expectation
• Breaking the bad news
• Emotional support
• Giving information
• Closing the bad news interview
Preparing
Eliciting the patient’sto
ideasbreak bad news
about etiology

• Preparation must include a clear


understanding of the:
– Diagnosis
– Possible treatment options
– A general idea of prognosis
– Specific plans for what will happen next in the way
of consultations, test and return visits
• Preparation should include setting aside
adequate time for the task and assessing the
physician’s own feelings about the news
Preparing
Eliciting the patient’sto
ideasbreak bad news
about etiology

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

Das könnte Ihnen auch gefallen