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This page was last modified on : 10/29/2010

Sharing Sensitive News

Communicating Sensitive Subjects to Parents and Children


By Katherine TeKolste, MD, FAAP, MHLN Medical Consultant

(Adapted from St. Benedict’s Hospice, Sunderland, UK; Kaye P. Breaking Bad News.  EPL Publications. 1995; and the readings listed below)

Patients and families rank the following as the most important factors when they receive sensitive news:

  • Physician competence, honesty and attention
  • Time allowed for questions
  • Use of clear language
  • Privacy

 

Steps in Sharing Sensitive News


Prepare

  • Know the facts, what has happened, and what options are available
    Be humble. Recognize room for error in diagnosis and prognosis
  • Set up a time to meet as soon as possible
  • Shed personal baggage

Get started

  • Meet face to face, if possible
  • Include others at the parents’ request; if there is no one else there, consider whether or not someone should be there –
    • Should relatives or friends be invited? 
    • It may be helpful to have another support person there should relatives or friends be unavailable.  This might be a social worker or clergy member, or nurse the family recognizes as a helpful resource.
  • Meet in a private location with a comfortable place to sit
  • Allow plenty of time and avoid interruptions
  • Initiate with normal courtesies, such as ‘How are you today?’  Assess the family's stress level and emotional state.  Ask/decide if this is a reasonable time to proceed.

Find family’s current level of understanding and emotional state

  • Ask questions first!  What is known?  What is wanted?
  • Elicit concerns and encourage expression of feelings

Find out how much the family wants to know

  • The real issue is not, “Do you want to know?” but “In what detail do you want to know?”

Sharing the information

  • Start from the parent’s or child’s starting point.
    • What they currently know and understand
    • What they have been told
  • Summarize things to date
  • Pause frequently to allow patient to absorb the information and to ask questions
  • Reinforce correct understanding, using the family’s words where possible
  • Give information in small chunks; be clear and simple
  • Check understanding frequently and modify when needed (negotiate the agenda)
    • “Is this making sense?”
    • “Have I covered what you want to talk about?”
  • Summarize, repeat important points; ask if the family wants you to go over anything again.
  • Provide hope and optimism whenever possible
  • Use diagrams and written information when possible
  • Avoid medical terminology, or define and check for understanding when must use medical terminology
  • Listen for the family/child responses and desires
    • Most doctors interrupt the patients within 30 seconds of speaking.  Be patient!
  • Reinforce with resources for further information and personal availability to respond to further questions and concerns. Let them know they are not alone in this.
  • Respond to family and child’s feelings – Identify and acknowledge their reactions.  Be prepared for a mix of emotions, such as
    • Sadness
    • Shock
    • Disbelief
    • Anger
    • Denial
    • Feeling of failure
  • Do not be afraid to show emotion or distress yourself (within reason!)

Offer next steps and plan for future

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Additional Thoughts


No one is expected to have all the answers

 
  • If you cannot answer a question, do not evade it.  Indicate that you will make a note of it and attempt to find an answer.
  • Utilize referral sources and specialists.
  • Make the family a partner in finding answers.

Follow-up is important (phone, another appointment, email, other) for THREE REASONS:

  • The initial information is remembered less than the way the information was given.
  • Emotional adjustment takes time.
  • It provides an opportunity to see other family members and support persons.

What to do when the patient/family breaks out in tears?

  • Plan ahead – have tissues in the room and offer them.
  • Do not act as if tears need to be stopped.
  • Often it is best to simply wait for the person to stop crying, while acknowledging the tears and the emotions.
  • If it seems appropriate, you can ask if the person would like to take a brief break and let you know when they would like to continue.

 

References

Delivering Difficult News by Francis Glascoe, PhD, at www.dbpeds.org/articles/detail.cfm?TextID=232

Mueller PS.  Breaking Bad News to Patients: the SPIKES approach can make this difficult task easier.  Postgraduate Med.  112(3):15f.  Sept 2002.

A Framework for Breaking Bad News.
www.skillscascade.com/badnews.htm

Buckman R.  How to Break Bad News: A Guide for Health Care Professionals.  Basingstoke.  Papermac, 1992.

Vandekieft GK.  Breaking Bad News.  Amer Fam Phys.  64(12):1975-1978.  2001.

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Resources


Delivering Difficult News in Sharing Concerns: Physicians to Parents

www.firstsigns.org/concerns/doc_parent.htm - bad_news

Communication Tips for Providers

National Center of Medical Home Initiatives for Children with Special Needs, American Academy of Pediatrics

www.medicalhomeinfo.org/tools/communication.html

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