NCC Pediatrics Continuity Clinic Curriculum: Breaking Bad News Goals & Objectives: Goal: Increase your knowledge and skill in delivering difficult news and disclosing adverse events to families. Objectives: At the end of this module, the pediatric resident should be able to: Recognize challenges specific to delivering bad news and disclosure of medical error. Describe the elements of the mnemonic “SPIKES” Apply SPIKES to clinical scenarios requiring delivering bad news or disclosure of medical error. Pre-Meeting Preparation: • “Disclosure of Adverse Events in Pediatrics” (AAP Policy Statement, Pediatrics, 2016) • Do's and Dont's, SPIKES strategies for delivery difficult news • Watch the Ted Talk called "Doctors make mistakes. Can we talk about that?" • Complete quiz questions prior to clinic • Recall a situation in which you have had to break bad news and be prepared to discuss. Conference Agenda: • Review the breaking bad news quiz answers (5 minutes) • Discuss your own case when you delivered bad news. What went well? What do you wish you had done differently? • Practice delivering bad news using the scenarios included here. Make sure that you leave time for meaningful feedback.(10 minute scenario and 5 minute feedback each) Extra Credit: • Medical Disclosure Powerpoint Slides from Ms. Barbara Moidel • "SPIKES -- A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer" (The Oncologist, 2000) • “Disclosing Medical Mistakes: A Communication Management Plan for Physicians" (Permanente Journal, 2013) • “Teaching Physicians How to Break Bad News” (Archives of Pediatric and Adolescent Medicine, 1999) • "The Many Faces of Error Disclosure: A Common Set of Elements and a Definition" (Society of General Internal Medicine, 2007) • "Medical Error Dislosure Among Pediatricians" (Archives of Pediatric and Adolescent Medicine, 2008) • Institute for Healthcare Improvement Open School Course PS 105: Responding to Adverse Events • States with Apology Protection Laws Developed by C. Carr, CPT Cory McFadden, CPT Sarah Thompson 2018-2019
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NCC Pediatrics Continuity Clinic Curriculum: …PEDIATRICS Volume 138 , number 6 , December 2016 patients and their families about AEs and MEs. 13, 21, 25, 29 Several barriers can
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NCC Pediatrics Continuity Clinic Curriculum: Breaking Bad News
Goals & Objectives: Goal: Increase your knowledge and skill in delivering difficult news and disclosing adverse events to families.
Objectives: At the end of this module, the pediatric resident should be able to:
Recognize challenges specific to delivering bad news and disclosure of medical error. Describe the elements of the mnemonic “SPIKES” Apply SPIKES to clinical scenarios requiring delivering bad news or disclosure of
medical error.
Pre-Meeting Preparation:
• “Disclosure of Adverse Events in Pediatrics” (AAP Policy Statement, Pediatrics, 2016)• Do's and Dont's, SPIKES strategies for delivery difficult news• Watch the Ted Talk called "Doctors make mistakes. Can we talk about that?"• Complete quiz questions prior to clinic• Recall a situation in which you have had to break bad news and be prepared to discuss.
Conference Agenda:
• Review the breaking bad news quiz answers (5 minutes)• Discuss your own case when you delivered bad news. What went well? What do you
wish you had done differently?• Practice delivering bad news using the scenarios included here. Make sure that you
leave time for meaningful feedback.(10 minute scenario and 5 minute feedback each)
Extra Credit: • Medical Disclosure Powerpoint Slides from Ms. Barbara Moidel• "SPIKES -- A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer" (The Oncologist, 2000)• “Disclosing Medical Mistakes: A Communication Management Plan for Physicians" (Permanente Journal, 2013)• “Teaching Physicians How to Break Bad News” (Archives of Pediatric and Adolescent Medicine, 1999)• "The Many Faces of Error Disclosure: A Common Set of Elements and a Definition" (Society of General Internal Medicine, 2007)• "Medical Error Dislosure Among Pediatricians" (Archives of Pediatric and Adolescent Medicine, 2008)• Institute for Healthcare Improvement Open School Course PS 105: Responding to Adverse Events• States with Apology Protection Laws
Developed by C. Carr, CPT Cory McFadden, CPT Sarah Thompson 2018-2019
FROM THE AMERICAN ACADEMY OF PEDIATRICSPEDIATRICS Volume 138 , number 6 , December 2016 :e 20163215
Disclosure of Adverse Events in PediatricsCOMMITTEE ON MEDICAL LIABILITY AND RISK MANAGEMENT, COUNCIL ON QUALITY IMPROVEMENT AND PATIENT SAFETY
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have fi led confl ict of interest statements with the American Academy of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Policy statements from the American Academy of Pediatrics benefi t from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not refl ect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time.
From "Disclosing Medical Mistakes: A Communication Management Plan for Physicians" (The Permanente Journal/ Spring 2013/ Volume 17 No. 2)
Table 2. Examples of empathic, exploratory, and validating responses
Empathic statements
“I can see how upsetting this is to you.”
Exploratory questions
“How do you mean?”
“I can tell you weren’t expecting to hear this.”
“I know this is not good news for you.”
“I’m sorry to have to tell you this.”
“Tell me more about it.”
“Could you explain what you mean?”
“You said it frightened you?”
“This is very difficult for me also.”
“I was also hoping for a better result.”
“Could you tell me what you’re “worried about?”
“Now, you said you were concerned about “your children. Tell me more.”
Validating responses
“I can understand how you felt that way.”
“I guess anyone might have that same reaction.”
“You were perfectly correct to think that way.”
“Yes, your understanding of the reason for the “tests is very good.”
“It appears that you’ve thought things through“very well.”
“Many other patients have had a similar“experience.”
From "SPIKES--A Six-Step Protocol to Delivering Bad News: Application to the Patient with Cancer" (The Oncologist, 2000)
DO'S AND DONT'S
Delivering Bad News Set up the interview
Perception of patient/p
Invitation to informati
Knowledge delivered
Emotional response
Summary and strategy
Adapted from “SPIKES-A Six-Step
Put Another Way
Disclosure of Med
Establish a rapport and
Disclose that a medica
Apologize for the erro
Answer all parental qu
Use at least one empat
Explain in plain langu
Arrange for privacy, involve significant others, sit down, establish rapport with good eye contact, and manage time constraints and interruptions
arent
on
forward
Protocol for Delivering Bad News: Application to the Patient with Cancer” (The Oncologist, 2000)
...
ical Error
create an appropriate environment for difficult discussion.
l error occurred.
r.
estions.
hetic statement.
age what has happened and the plan for addressing the situation.
Ask open ended questions to determine what the parent understands about the situation so far, may also allow you to assess medical literacyObtain agreement from family regarding when, how, and what detail of information they want to know.
Explain what has happened (e.g. if there was a medical error what the error was) and its impact on the patient.
Respond to parent's emotional response with empathy. If the bad news involves a medical error, make sure you include an apology.
Provide information regarding next steps. In case of ME, what corrective actions are being taken both for the patient and at the systems level to prevent recurrence. If not ME, focus should be on continued care and support for patient and family.
Breaking Bad Quiz
1. According to the Institute of Medicine, ________________is one of the 6 domainsof health care quality, and _________________ are attributable to 44,000 to 98,000inpatient deaths annually in the United States.
2. What is the difference between an adverse event and a medical error?
4. True or False, Physicians have an ethical obligation to disclose AE’s and ME’s.
5. Which of the following are obstacles to disclosure?
a. Perceived legal risksb. Concern that disclosure will harm patient/familyc. Fear of embarrassmentd. Lack of skill in disclosing bad newse. Language and cultural differencesf. All of the above, although legal concerns may be the most significant barrier.
6. Does Maryland have a protective apology law? DC? Virginia?
Click Here
7. What are the 6 steps of SPIKES? Spikes was developed for breaking bad news in regards to diagnosis and prognosis. Can it be applied to AE’s and ME’s?
____________
_____________
__________________________3.Complete the labelsfor the chart:
“Breaking bad news education for emergency medicine residents: A novel training module using simulation with the SPIKES protocol” From Journal of Emergencies, Trauma and Shock (2010)
Use this tool as you observe the following scenarios.
Her
Highlight
Breaking Bad Case
1. Please share any personal cases you have experienced in disclosing medical errors/adverse events as well as in breaking bad news. What was difficult? What went well? How would you do things differently next time?
2. Please read through the following cases. Take turns in the roles of the provider and the parent. Improvise the discussion around the provided events. If you prefer, you may use one or more of the group’s real-life cases to practice disclosing bad news or medical error instead. Please ensure that you leave time after the parent/provider discussion for a debrief on what went well, what challenges you faced, and strategies that would improve the disclosure.
1. Forsythia Lee is a 3 day old full term AGA female you are seeing in clinic for routinenewborn follow-up. Her prenatal course was unremarkable, but nursery course wasremarkable for DAT+, A neg/O pos incompatability. Forsythia was discharged at 48 hoursof life with a serum bili of 13. The nursery team recommended Forsythia stay an extra dayto receive phototherapy, but her parents declined in favor of close outpatient follow-up. Onarrival to the clinic, Forsythia is visibly jaundiced to at least her abdomen. Transcutaneousbili is 16. You discuss the need for a serum bilirubin obtained via heelstick. The parents areextremely reluctant, mentioning that the first heel stick in the hospital caused Forsythiaterrible pain. They eventually agree. The family lives close by and has returned home. Youhave had a very busy clinic day and now as the clinic is closing, you look up the result andfind that it is “QNS.” You are on the phone with Mr. or Ms. Lee to provide them anupdate.
If you are observing, use the tool on the previous page to structure your feedback.
2. Forsythia Lee is now 7 days old. She eventually had her bilirubin repeated, although herfamily failed to understand the urgency of the situation, was overwhelmed with otherobligations, and returned for repeat labs at 90 hours of life. On repeat presentation,Forsythia’s serum bili was 30. She was admitted to the NICU and is s/p exchangetransfusion. She has been noted to have poor feeding and hypotonia and over the past 24hours has developed extensor muscle hypertonia with opisthotonos. Forsythia’s parentsnote that she seems different today. They are unsure of how to interpret the change theynotice and have asked you for an update. You have just finished rounds during which itwas discussed that Forsythia most likely has bilirubin encephalopathy which you know tobe associated with poor long term developmental outcomes. You are feeling guilty aboutthe initial delayed lab result and your role in this outcome and have continued to havechallenging interactions with the Lee family.