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Resources: The Philippine Palliative Care Education Program: Educational Programfor Primary Care (PCEP-PC). PCEP. Manila. 2007; Medina. Manual of Palliative
Medicine 2nd edition. Manila. 2007; The Pallium Project. Edmonton, Alberta, Canada;The EPEC Project. Chicago, IL, USA.
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Objectives
Know what is communication of badnews and why it is important
Understand the basic (palliative care)
protocols for communicating bad news &
know what to do at each step
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What is a Bad News?
Bad news may be defined asany information which adversely andseriously affects an individual's view of hisor her future
Bad news is always, however, in the eyeof the beholder
the impact of the bad news is also
determined by the recipient's expectations
The Oncologist. August 2000 vol. 5 no. 4302-311
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Why is it important tocommunicate bad news?
Most people want to know Most Americans & Europeans; many Asians &
Filipinos, probably
Strengthens physician-patientrelationship & fosters collaboration
Shared problem, understanding &
collaboration Permits patients, families to plan, cope
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In North America, ethical principles ofinformed consent, patient autonomy, right toself determination and law
have created clear ethical and legalobligations
to provide patients with as much informationas they desire about their illness and its
treatment In the Philippines
The Oncologist. August 2000 vol. 5 no. 4302-311
Why is it important tocommunicate bad news?
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Why is it difficult andproblematic to communicate
bad news?Not understanding and realizing whatbad news is; and not understanding thewhat the impact of communicating it is
Fear of how the patient will react
A sense of failure or guilt
View of doctor as scientist & technician,less premium on helping skills
art is nice, but science is much more
important
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Fear of causing harm
Autonomy vs Non-malficence Surveys conducted from 1950 to 1970, when
treatment prospects for cancer were bleak,revealed that most physicians considered it
inhumane and damaging to the patient todisclose the bad news about the diagnosis
1980s and 1990srise of Autonomy inwestern ethics and law
In the Philippines
The Oncologist. August 2000 vol. 5 no. 4302-311
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Patient Preferences When PhysiciansCommunicate Bad News
Information about diagnosiswhich provides a name for their condition
Information about prognosis andhow the illness is likely to affect their life(including quality of life)
Practical information about what to do andhow to obtain additional information
(Johnston et al, 1996)
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Patient Preferences When PhysiciansCommunicate Bad News
Clear & Direct
Empathy
Inclusion of a family member or trustedfriend in the discussion
Encouragement to ask questions
Information that is neither overly optimisticnor overly pessimistic
(Johnston et al, 1996)
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Protocols attempt to achieve 4goals Get information from the patient; to
determine the patient's knowledge andexpectations and readiness.
Provide understandable information inaccordance with the patient's needs &preferences.
Support the patient, to reduce the emotional
impact.
Develop a treatment plan or strategy withthe patient.
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6-step protocol . . .
1.Getting started (start)2. What does the patient know?
3. How much does the patient wantto know?
4.Sharing the bad news
5. Responding to the emotionalreaction
6.Planning and follow-up (end)
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6-step protocol . . .
1. Getting started2.What does the patient know?
3.How much does the patientwant to know?
4.Sharing the bad news
5. Responding to the emotionalreaction
6. Planning and follow-up
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6-step protocol . . .
1. Getting started2. What does the patient know?
3. How much does the patient wantto know?
4.Sharing the bad news
5.Responding to the emotionalreaction
6. Planning and follow-up
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Establishing the
Goals of CareCommunicating
Bad NewsWithdrawing or
Withholding
Treatment
1 Use the right setting. Plan what to say. Determine participants. Allowadequate time.
2 Determine what thepatient knows. Clarify
the situation and
context.
Determine what the
patient knows. Clarify
what he/she can
comprehend.
Determine and review
the goals of care.
3 Determine what the
patient wants toaccomplish. Help
distinguish realistic vs
unrealistic goals.
Determine what the
patient wants to know.Understand, support,
and respect the
patients preferences.
Establish the context of
the case. Discuss thechanges that led to the
discussion about
treatment withdrawal.
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Establishing the Goals
of CareCommunicating
Bad NewsWithdrawing Treatment
4 Help the patient formrealistic goals and
discuss how these can
be achieved. Work out
unrealistic goals.
Share the information. It
should be clear,
accurate, and
understandable.
Discuss the treatment,
and whether it meets the
goals of care. Discuss
alternatives to the
treatment. Discuss what
can happen.
5 Respond to the patients feelings and reactions with empathy. Listen. Allowtime for and encourage the expression and exploration of feelings and
reactions. Be supportive and caring.
6 Summarize. Agree on a
plan of care to meet thegoals. Include plans for
follow-up, review, and
modification of the plan
if needed. Document
well.
Summarize. Plan for the
next steps in the care ofthe patient. Offer
assistance and support.
Discuss other sources
of support. Document
well.
Summarize. Plan for the
withdrawal of treatment ifthis is the patients or
familys decision.
Document the decision
process.
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Step 1: Getting started . ..Plan & prepare what you will say
Confirm the medical facts
Create a conducive environment
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. . . Step 1: Getting started
Have adequate time prevent interruptions; maintain focus
Determine who else the patient
would like to be present
Family
Friend
Priest, Pastor
if child, patients parents
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Prioritize: Prioritize what you
want to accomplish duringthe discussion
Ask yourself: What are two to
four key points that thepatient should retain? Whatdecisions should be madeduring this encounter? What
is reasonable to expect fromthe patient during thisencounter?
Practice and prepare:Practice giving bad news;arrange for an environmentconducive to delivering thenews
Rehearse the discussion;arrange for a private locationwithout interruptions; set cellphones and pagers to vibrateor turn them off; ask thepatient if he or she wants to
invite family members
AFP: Recommendations for Patient-Centered Communication WhenDiscussing Bad News
Am Fam Physician. 2008 Jan
15;77(2):167-174.
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Step 2: What does the patientknow?
Establish what the patient knows
If child what the parents know
Assess ability to comprehend newbad news
Reschedule if emotionally
unprepared to receive bad news
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Step 3: How much does thepatient want to know? . . .
Recognize, respect & supportvarious patient preferences
decline voluntarily to receiveinformation
designate someone tocommunicate on his or herbehalf
decline to know the details
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. . . Step 3: How much doesthe patient want to know?
Know that people handle informationdifferently
According to race, ethnicity,culture, religion, socioeconomicstatus
If child, according to age anddevelopmental level
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When family says "don't tell
Ask the family: Why not tell?
What are you afraid I will say?
What are your previous experiences?
Is there a personal, cultural, or religiouscontext?
Talk to the patient together
Mention that honesty may promote trust Discuss legal obligation to obtain informed
consent from the patient*
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Step 4: Sharing the bad news
Say it, then pause & give themtime
avoid monologue, promote dialogue
avoid jargon, euphemisms
pause frequently
check for understanding
use silence, body language
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. . . Step 4: Sharing theinformationDont minimize severity avoid vagueness, confusion
Implications of Im sorry
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Assess patient understanding:
Start with opening questions, ratherthan medical statements, to determinethe patient's level of understandingabout the situation
Ask the patient: What do you
already know about yourcondition? What does it
mean to you? What do you
think will happen?
Determine patient preferences: Askwhat and how much information thepatient wants to know
Assess how the patient wants
the information presented; askthe patient, Some of mypatients prefer hearing onlythe big picture, whereasothers want a lot of details.Which do you prefer?
Present information: Deliverinformation to the patient usinglanguage that is easy to understand (donot use medical jargon); provide a smallamount of information at a time; check
periodically for patient comprehension
Provide a few pieces ofinformation, and then ask thepatient to repeat it back to you
Recommendations for Patient-Centered Communication WhenDiscussing Bad News
Am Fam Physician. 2008 Jan
15;77(2):167-174.
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Step 5: Responding to feelings . ..Be prepared foroutburst of strong emotion
broad range of reactions
tears, anger, sadness, love,anxiety, relief, other
denial, blame, guilt, disbelief, fear,loss, shame, intellectualization
Give time to react
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. . . Step 5: Responding to feelings
Listen quietly, attentively
Encourage descriptions offeelings
Use nonverbal communication
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Provide emotionalsupport:Allow the patient toexpress his or her
emotions; respond withempathy
Assess the patient's emotionalstate directly and often (ask thepatient: How are you doing? Is
this hard for you? You look
frustrated/disappointed/angryisthat true? Let me know when weshould continue); use nonverbal
cues such as eye contact; listen towhat the patient says and validate
his or her reactions with empathicstatements such as I understand
that this is very difficult news.
Recommendations for Patient-Centered Communication WhenDiscussing Bad News
Am Fam Physician. 2008 Jan 15;77(2):167-174.
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ABC of palliative care:
Communication with patients,
families, and other
professionals
BMJ 1998;316:130
S 6 Pl i f ll
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Step 6: Planning, follow-up . ..Plan for the next steps additional information, tests
treat symptoms, referrals as needed
Discuss potential sources ofsupport
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. . . Step 6: Planning, follow-up
Give contact information, set next
appointment
Before leaving, assess: safety of the patient
supports at home
Repeat information at future visits
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Discuss options for the
future:Devise a plan forsubsequent visits and care
Help the patient understand the expected
disease course and how the disease mayor may not respond to treatment; schedulefollow-up visits (ask the patient: Can wemeet next week to discuss treatmentoptions and any questions you mayhave?)
Offer additional support:Provide information aboutsupport services
Bring handouts and pamphlets to the visit;refer the patient to support groups,psychologists, social workers, or chaplains
Consider individual
preferencesAssess patient preferences,and tailor the discussionappropriately
Consider the patient's sex, age, health
literacy, health status, previous health careexperiences, social status, culture, andrace/ethnicity; avoid assumptions aboutwhat the patient is likely to want; ask thepatient directly about values and
preferences
Recommendations for Patient-Centered Communication WhenDiscussing Bad News
Am Fam Physician. 2008 Jan15;77(2):167-174.
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Communicating prognosis .. . Inquire about reasons for asking
What are you expecting to happen?
How specific do you want me to be? What experiences have you had with:
others with same illness?
others who have died?
C i i i
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Communicating prognosis .. .Patients vary
planners want more details
those seeking reassurance wantless
Avoid precise answers
hours to days months to years average
C i i
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. . . CommunicatingprognosisLimits of prediction hope for the best, plan for the worst
well get a bettersense over time
cant predict surprises, get affairs in
order
Reassure availability, whateverhappens
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Resources: The Philippine Palliative Care Education Program: EducationalProgram for Primary Care (PCEP-PC). PCEP. Manila. 2007; Ferris F and Von
Gunten C. The EPEC Project. Chicago, IL, USA.
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COMMUNICATING BAD NEWSin CANCER CARE and
SUPPORTIVE, HOSPICE & PALLIATIVE CARE
Resources: The Philippine Palliative Care Education Program: Educational Programfor Primary Care (PCEP-PC). PCEP. Manila. 2007; Medina. Manual of Palliative
Medicine 2nd edition. Manila. 2007; The Pallium Project. Edmonton, Alberta, Canada;The EPEC Project. Chicago, IL, USA.