Breaking

Let your light shine. Be the source of strenght and courage

Communication Skill Team FKUB

 Foundation :
Patient-Centered Care
Soul

Emotion Patient Mind

• Health professionals do not

deal only with the diseases or Body
laboratory findings ; they deal
with people
 What is Bad News ?
• Any information which adversely and seriously
affects an individual's view of his or her future
• Any news that client does not want to hear
• Any situation fostering sense of hopelessness
 Example of Bad News

• Life threatening illness

- Ex : cancer, HIV
• Chronic illness with systemic impact and long-life treatment
- Ex : SLE
• Degenerative conditions
- Ex : Alzhaeimer
• Multiple congenital anomaly and/or Mental retardation in
children
- Ex : Down syndrome + atresia ani
 General Principle about
Patient’s Right

• The right of information which is accurate and true

• The right to decide how much information they feel
they need and a right not to receive information
• The right to decide who should be present during the
consultation i.e family members/significant others
• The right to decide who should be informed about
their condition and what information that other
person (s) should receive
6-5
Remember about Ethical Principles !

• Requires that in a healthcare context, health

Principle of professional recognize and support the
autonomy unique values, priorities ad preferences of
patients

Principle of • Requires that health professionals ‘do

good’ for the patient, they actively
beneficience concerned for patient well being

Principle of non • Requires that health professionals ‘do no

harm’, they avoid or minimize harm to patient
maleficience
 Ethical Problem of Telling the Truth in
Breaking Bad News

• The capacity and the circumstances of every

patients are unique. Some situation where it is
more important to sensitively communicate with
patient in a way that is meaningful to them.
• When the doctors/caregivers believe that telling the
truth about their illness risk seriously harming
them, they may withhold the information.
Advantages of Breaking Bad News Skill

Improve wellbeing
Improve the
(Emotional &
Quality of Life
Spiritual)

Increase
Promote comfort adherence to
doctor’s advice
 Please...feel sensitive with
your patient’s symptoms
• General Weakness
- Fatique
• Pain
- Common, complex
• Respiratory Symptoms
- Shortness of breath, coughing, wheezing
• Gastrointestinal Symptoms
- Nausea, constipation, pressure ulcer
• Psychological Symptoms
- Depression, delirium, anxiety

From Johnson DC, Kassner CT, Houser J, Kutner JS. Barriers to effective symptom
management in hospice. J Pain Symptom Manage 2005;29:69-79.
 Stages of Grief-DABDA
(Kubler-Ross, 1969)

• Denial
• Anger
• Bargaining
• Depression
• Acceptance
 Explanation of Each Stage

• Denial — The first reaction is denial. In this stage

individuals believe the diagnosis is somehow mistaken
(doctor shoping), and cling to a false, preferable reality.

• Anger — When the individual recognizes that denial cannot

continue, it becomes frustrated, especially at proximate
individuals. Certain psychological responses of a person
undergoing this phase would be: "Why me? It's not fair!";
"How can this happen to me?"; '"Who is to blame?"; "Why
would this happen?".
• Bargaining — The third stage involves the hope that
the individual can avoid a cause of grief. Dialogue
with God, “God, I promise I’ll never use drug again if
you just get me out of trouble.Please give me a
chance”
• Depression — In this state, the individual may
become silent, refuse visitors and spend much of the
time mournful and sullen."I'm so sad, why bother
with anything?"; "I'm going to die soon so what's the
point?";
• Acceptance — In this last stage, individuals
embrace mortality or inevitable future, or that of a
loved one, or other tragic event. "It's going to be
okay."; "I can't fight it, I may as well prepare for it.";
"Nothing is impossible.“
Maslow’s Hierarchy of Patient with Advance Disease
 Nuclear needs of patients

1. Spiritual
2. Dignity
3. Realistic hope
4. Respect
 How to break bad News with “SPIKES”
(Buckman, 1992)

• Setting, Listening Skills

• Patient’s Perception
• Invite patient to share Information
• Knowledge transmission
• Explore Emotion and Emphatize
• Summarize and Strategies
 Setting , Listening Skills

• Arrange for some privacy

• Involve significant others (family members)- with
permission from the patient
• Sit down. Sit down help us relax.
• Make connection with the patient (eye contact, listen
carefully, touch the patients when they feel
comfortable)
• Manage time constraints and interruptions (silent
your gadget please)
 Assesing the Patient’s Perception

• Before discussing the medical findings, the clinician uses

open-ended questions to create a reasonably accurate
picture of how the patient perceives the medical situation
• Example :
• “Apakah sebelumnya ibu sudah pernah mendapatkan informasi
tentang kemungkinan penyebab dari kondisi ibu ?
• “Apakah ibu sudah faham kenapa harus ada pemeriksaan ini?”
• “Apakah ibu sudah pernah membaca informasi mengenai
pemeriksaan ini atau kondisi ibu ini?”
 Invitate patient to share Information

• While a majority of patients express a desire for full

information about their diagnosis, prognosis, and details of
their illness, some patients do not
• Remember stages of Grief from Kubler Ross on previous
slide
• Some patients are still standing at denial until bargaining
phase
• Do not impose your explanation to your patient. Arrange
another appointment (Respect for autonomy)
• Example : “Ibu...jika sekarang saya menjelaskan hasil pemeriksaan
ini, ibu tidak berkeberatan kan ?
 Knowledge Transmission

• Warning the patient that bad news is coming may lessen the shock
that can follow the disclosure of bad news and may facilitate
information processing
• Example of warning shot: “Maaf ibu, saya harus mengatakan bahwa hasil
pemeriksaan darah dan sumsum tulang ibu ini tidak begitu baik (pause-diam
sejenak)....kami menemukan ada sejenis kelainan darah”
• Giving medical facts but try to use too much nontechnical words
(avoid medical jargon) like biopsi, metastase jauh etc.
• When the prognosis is poor, avoid using phrases that indicated
pessimism such as “Kami menyerah....kami sudah tidak bisa berbuat
apa apa lagi”
 Explore Emotions and Emphatize

• F = FEELINGS related to the illness, especially fears

- Saya mengerti berita ini tidak terlalu baik dan mungkin membuat ibu khawatir.
(pause)
• F = FUNCTIONING, the illness’ impact on daily life
- Apakah ibu khawatir penyakit ini mempengaruhi hidup ibu ?
Atau apakah ibu khawatir penyakit ini mempengaruhi orang-orang di sekitar
ibu?
• E = EXPECTATIONS of the doctor & the illness
- Apa harapan ibu terhadap saya dan tim disini ?

Remember about emphatic response in previous Lecture !!!

 Summarize and Strategy

• Patients who have a clear plan for the future are less likely
to feel anxious and uncertain.
• Before discussing a treatment plan, it is important to ask
patients if they are ready at that time for such a discussion.
• Presenting treatment options to patients when they are
available is not only a legal mandate in some cases , but it
will establish the perception that the physician regards their
wishes as important.
 Another Concept of Breaking Bad News

ABCDE
•Advanced Preparation
•Build a therapeutic environment
•Communicate well
•Deal with patient and family reactions
•Encourage and validate emotions