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
Steps in Sharing Sensitive News
- 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
- 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
- Feeling of failure
- Do not be afraid to show emotion or distress yourself (within reason!)
Offer next steps and plan for future
- Distinguish the fixable from the unfixable, the known from the unknown
- Identify coping strategies and encourage/reinforce them
- Identify and reinforce parental stengths, build on family assets
- Encourage parents in management of their child's care
- Identify other sources of help and provide written contact information
- Offer to link the family to parent-to-parent support and sibling support (a FRC or CSHCN Coordinator can help link the family to these supports; see your community resource list)
- Determine next steps and create a plan with the family
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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.
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.
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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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
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