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New Video: How Should Providers Deliver Bad News?

  • Delivering bad news is always a challenging task for providers. But certain communication techniques can make the experience less difficult for the patient and family. In a new video, Duke Professor Dr. Michael Haglund demonstrates how providers should and shouldn’t deliver bad news, based on the work of Dr. Neil S. Prose. Filmed with actors playing the role of the parents of a young child, two versions of the same scene sharply demonstrate the impact of a provider’s communication skills. Start a conversation in your class or Chapter with this video. (On a mobile device? Click here to watch on YouTube.) More information about the video, questions to consider and links to the transcript.
  • Published October 19, 2015 by the Institute for Healthcare Improvement

Sharing Sensitive News

By Katherine TeKolste, MD, FAAP, MHPP Co-Director
(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

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
    • 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.

Resources

  • Video: How Should Providers Deliver Bad News?
    • Delivering bad news is always a challenging task for providers. But certain communication techniques can make the experience less difficult for the patient and family. In a new video, Duke Professor Dr. Michael Haglund demonstrates how providers should and shouldn’t deliver bad news, based on the work of Dr. Neil S. Prose. Filmed with actors playing the role of the parents of a young child, two versions of the same scene sharply demonstrate the impact of a provider’s communication skills. Start a conversation in your class or Chapter with this video. (On a mobile device? Click here to watch on YouTube.) More information about the video, questions to consider and links to the transcript.
    • Published October 19, 2015 by the Institute for Healthcare Improvement