Giving Bad News

Delivering bad news is one of the most daunting task faced by health care professionals. During this COVID-19 crisis, this often involves patients they have known for only a few hours. Additionally, they are called upon to deliver the news with little planning or training.

Historically communication skills have not been a priority in medical education. This leaves clinician unprepared for the communication complexity and emotional intensity of breaking bad news. The fear clinicians have about delivering bad news include being blamed, evoking a reaction, expressing emotion, not knowing all the answers, fear of the unknown and untaught, and personal fear of illness and death. This can lead to the clinician becoming emotionally disengaged from their patients. Additionally, bad news delivered inadequately or insensitively can impair patients’ and relatives’ long-term adjustment to the consequences of that news.

Some surveys done have shown that 85% of. both residents and attendings felt that they needed additional training to be effective when delivering bad news. Experience does help with skill-building, but learning good communication skills is always valuable, and during COVID 19, those skills are now critically important.

Given the negative consequences of delivering bad news poorly for both patient and clinician, clinician training in delivering bath news is sorely needed. The best training will include the patient’s family. When the clinician involves the patient’s family, the patient perceives the clinician to be emotional, available, expressive of hope and not dominant.

Ideally, the clinician takes into account the cultural, spiritual and religious beliefs and practices of the family. The clinician must check for understanding. This is in contrast to the clinician expressing sadness, which can hinder information exchange.

As a resource, there is a 1992 book by Rob Buckman, entitled “How to Break Bad News: A Guide for Health Care Professionals.” He suggests finding out how much the patient knows, sharing information, and assuring that the message is understood.

Further, the Irish Hospice Foundation has put together a YouTube to help clinicians deliver bad news.

In this, they describe five important steps.

1. Prepare yourself

2. Make a connection

3. Warn, then deliver the news

4. Acknowledge the impact

5. Make a plan

They also remind the clinician that there is body language, tone of voice, and word choice. All of these are important in talking to patients. COVID-19 adds the additional hardship that the clinician is masked and gowned and therefore not “seen.” However, some hospitals are creating name tags for clinicians with their photos to help the patients feel more comfortable. I think this was a wonderfully soulful intervention during this most traumatic time. Further, the PPE makes it more imperative that the clinician focus on tone of voice and word choice when giving bad news.

As with all difficult situations, the clinician must be open to a variety of responses including denial, anger, sadness, and fear for themselves and their other loved ones. The clinician must learn how to name the dominant feeling that they experience after the bad news has been conveyed. For example, the clinician could say to the patient or their family member, “I am sensing this difficult news is bringing up very angry feelings for you, which is understandable. You are likely to go through a lot of different feelings and I, and my staff, are here to help you with those feelings, as we recognize this is a very difficult time for you and for your loved ones.” The goal here is not to get defensive. Although it may seem, for example, that the patient is angry with the staff, it is more likely that they are angry over the helplessness of the situation, and understanding that helpless feelings can sometimes lead to angry feelings, will help the clinician not get defensive, and remain empathic.

Other factors to consider when delivering bad news include the physical and social setting of the message. Although hospitals may be crowded, it is important to provide a space which is quiet, comfortable, and private. It is also important that there will be no interruptions and that the clinician has set aside protected time to discuss the bad news. Even if this protected time is only 10 minutes, that is far superior than being interrupted while giving bad news.

Finally, delivering bad news requires that the clinician do self-care as a way to acknowledge the wear and tear on the clinician in giving bad news. First, the clinician must recognize that each time the clinician gives bad news, there is increased vulnerability in the clinician. This increased vulnerability may require a break from medical practice, be it ten to twenty minutes for deep breathing or meditation. If this break, still leaves the clinician feeling vulnerable, then the clinician should seek the help of a colleague to de-brief on the situation. Finally, if the clinician still feels out of sorts, or internally disrupted, then the clinician should seek out mental health care. As discussed in a previous podcast, this mental health care should be done by a specialist in COVID-19, as treating clinicians during COVID 19 is a specialty and requires extra training.

To recap, delivering bad news is a skill set which is both cognitively and emotionally demanding. Historically, this has not been a major part of health care training. Going forward, there should be training by communication specialists/mental health providers to help clinicians develop this skill set. Being prepared for a variety of affective responses is important in not becoming defensive after giving bad news. Further, after giving bad news, there should be an immediate opportunity for self-care which includes deep breathing, meditation, talking with a colleague and considering mental health intervention.

References

1. Orlander JD, Fincke BG, Hermanns D, Johnson GA. Medical residents’ first clearly remembered experiences of giving bad news. J Gen Intern Med. 2002;17(11):825–831. [PMC free article] [PubMed] [Google Scholar]

2. Buckman R. Breaking bad news: why is it still so difficult? Br Med J (Clin Res Ed) 1984;288(6430):1597–1599. [PMC free article] [PubMed] [Google Scholar]

3. VandeKieft GK. Breaking bad news. Am Fam Physician. 2001;64(12):1975–1978. [PubMed] [Google Scholar]

4. Fallowfield L. Giving sad and bad news. Lancet. 1993;341(8843):476–478. [PubMed] [Google Scholar]

5. Fine RL. Keeping the patient at the center of patient- and family-centered care. J Pain Symptom Manage. 2010;40(4):621–625. [PubMed] [Google Scholar]

6. Schmid Mast M, Kindlimann A, Langewitz W. Recipients’ perspective on breaking bad news: how you put it really makes a difference. Patient Educ Couns. 2005;58(3):244–251. [PubMed] [Google Scholar]

7. Fine RL. Personal choices—communication among physicians and patients when confronting critical illness. Tex Med. 1991;87(9):76–82. [PubMed] [Google Scholar]

8. Cunningham CC, Morgan PA, McGucken RB. Down’s syndrome: is dissatisfaction with disclosure of diagnosis inevitable? Dev Med Child Neurol. 1984;26(1):33–39. [PubMed] [Google Scholar]

9. Buckman R. Communication skills in palliative care: a practical guide. Neurol Clin. 2001;19(4):989–1004. [PubMed] [Google Scholar]

10. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302–311. [PubMed] [Google Scholar]

11. Buckman R. How to Break Bad News: A Guide for Health Care Professionals. Baltimore: Johns Hopkins University Press; 1992. [Google Scholar]

12. Rabow MW, McPhee SJ. Beyond breaking bad news: how to help patients who suffer. West J Med. 1999;171(4):260–263. [PMC free article] [PubMed] [Google Scholar]

13. Ptacek JT, Fries EA, Eberhardt TL, Ptacek JJ. Breaking bad news to patients: physicians’ perceptions of the process. Support Care Cancer. 1999;7(3):113–120. [PubMed] [Google Scholar]

14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4677873/#

15. Buckman, Robert, “How to Break Bad News: A Guide for Health Care Professionals. JHU Press, 1992

16. https://www.youtube.com/watch?v=5I924nWldCI

Vollmer, Shirah | Pri-Med

Vollmer, Shirah | Pri-Med
— Read on www.pri-med.com/globals/faculty/v/vollmer-shirah

Suicide Prevention in Healthcare Workers

Every year an estimated 400 US physicians take their lives (Andrew and Brenner 2015). Global studies indicate that approximately 1 in 3 physicians is experiencing burnout at any given time (Shanafelt et al 2009). This was true before the pandemic. Now, it is too soon to know the statistics, but we have all heard about Dr. Lona Breen who was the medical director of the emergency department at New York Presbyterian Allen Hospital who succumbed to self-inflicted injuries. Although we will never know the details of her mental health journey throughout her years, it seems clear that seeing the devastation of COVID-19 was a contributing factor to her suicide.

Many students, trainees, doctors and health care organizations fail to recognize, report, discuss or pursue treatment for mental distress. Healthcare workers may have too much shame to report mental distress and this is reinforced by health care organizations which demand so much from workers without acknowledging the mental toll.

The stigma of self-reporting depression seems to be magnified amongst medical professionals. Further, their greater knowledge and better access to lethal means, causes health care professionals to have a higher suicide completion rate than the general population. The most common psychiatric diagnoses among medical professionals who complete suicide are affective disorders, alcoholism and substance abuse. The most common means of suicide by health care professionals are lethal medication overdoses and firearms.

When medical professionals feel depressed and they feel less than adequate, the find it even more difficult-and when they can bring themselves to ask, the sometimes find that the help they need is remarkably difficult to obtain. Access to mental health care is a struggle for everyone, including health care professionals. It is hard to find care which meets their economic requirements, their time requirements and care that feels like a good clinician/patient match.

At the same time, some of the reluctance to receive care is self-imposed. Some health care professionals feel an obligation to appear health, perhaps as evidence of their ability to heal others. The myth of invulnerability is hard to penetrate and so it is a deep challenge to question the health care professional when they continue to state that they are “fine” even though they may not appear to be “fine”.

Unconsciously defending against this painful vulnerability, partners or significant others may also fail to notice significant depression or withdrawal, attributing behavioral changes instead to stress or overwork.

Health care professionals as a group like to be in control so situations that decrease the ability to control the environment, the workplace or employment conditions predictably play a higher role in suicide than in populations which are not used to being in control. Before COVID-19, the massive changes that have taken place in medicine in the past several decades leading to increased workloads and regulatory requirements coupled with decreased ability to control income and patient safety and liability concerns also predictably lead to higher levels of stress, job dissatisfaction, burnout and depression in physicians.

There can be fear of treatment from another professional includes fear of loss of privacy, so using insurance to pay for treatment, can feel like an insurmountable barrier as there is fear that insurance companies can be hacked. This is especially likely when the health care professional believes that the consequences of seeking treatment may subject them to stigma, shame or job-loss. As a result, health care professionals can and do prescribe to themselves and this is a huge mistake. Failure to obtain consultation and treatment for depression needlessly and significantly increases the risk of physician suicide.

David Rothenberg MD, University of Minnesota Department of Surgery states that he relives painful moments over his long career being a physician. “I suddenly am recalling a time in February of my internship year when I was so tired, so down, so discouraged that I thought I could not possibly go on. I thought I would have to give up my dream to be a doctor.” He continues “I have lived in denial of the dark side of the medical profession and its unwritten code-the code that says medical students should keep their mouths shut; that residents can be blamed since that is how they will learn; that repeatedly being pushed to the brink of exhaustion is a necessary part of being a caring physician; and that if a few drop out along the way, it is because they were weak and somehow deficient. “He then asks “do we have the courage and will to break through the culture of silence, end institutional cover-up and commit to finding effective ways for the healing profession to care for ourselves as well as our patients?”

Angela Mathew RN, MBA, wife of a physician also speaks openly about the stresses and strains of healthcare. “I wonder about the physicians I work with and who they have to speak with after a challenging case, how they are working through the stressors of the health care culture and environment every day, and whether they bring their souls to work with them each day.

These testimonial were done before COVID-19. Now, we have testimonials from people like Dr. Lawrence Melniker, the vice chair for quality care at the the New York Presbyterian Brooklyn Methodist Hospital who said that the “corona virus presents unusual mental health challenges.” Further, he says “ doctors are accustomed to responding to all sorts of grisly tragedies, but rarely do they have to worry about getting sick themselves, or about infecting their colleagues, friends and family members. And rarely do they have to treat their own co-workers.

At the same time, other health care workers are having different kinds of struggles. They are having to lay staff off. They are worried about making payroll to their remaining staff, paying their rent, and keeping the lights on. To their physician colleagues on the front lines, it may seem trivial to worry about the economics of running a practice, but as with the virus, the downstream effects can be both severe health consequences and severe economic consequences. It is hard to be sensitive to both groups at the same time, but both groups do need compassion and understanding.

What are the action items? How can we translate our understanding of healthcare worker stress to helpful ways in which we can support our colleagues, friends and family? We call them heroes. I think that helps a little, but that also creates greater difficulty for them to admit that they need psychological assistance. The word heroes idealizes them such that the word could impede their ability to ask for help. Perhaps we need to change our language. Perhaps we need to say that healthcare workers should have limited hours, like trainees, and pilots, as a way of understanding that too many hours may be too hard on their mental well being. Perhaps we should give them hazard pay, as a way of saying we understand this is hard, and by paying them more, we are giving them permission to work less, and take more time to themselves.

We can train mental health professionals how to support healthcare workers. I think that to ask for mental health workers to volunteer to help health care professionals misses the point. We need to have mental health professionals train other mental health professionals to help health care professionals during this time. For example, we need to train therapists about how to talk about the complexity of fear going on now. The fear of one’s health, the health of their loved ones, the health of their co-workers, the health of their patients, and the fear of the economic demands stemming from this crisis. We need to train mental health professionals about how to listen to a healthcare professional without becoming more anxious. The mental health care professional needs to learn how to listen and manage their own anxiety at the same time. This skill of listening without becoming overly anxious needs to be trained through discussions, readings and role-playing. In other words, treating this population, the healthcare workers, is a specialty, and as such, special training is mandatory.

The third action item is helping the loved ones of medical professionals. Their stress is also overwhelming. To support a medical professional may mean assuming all domestic responsibilities including home schooling the children, and taking care of geriatric relatives. In addition, offering support to the medical professional is challenging since the support person also needs a lot of support, which the medical professional may not have enough bandwidth to supply. Once again, mental health professionals should receive special training to help the loved ones of medical professionals and once again, this special training should include our old-school tools of readings, case discussions and role-playing.

Finally, there are resources available that we should have handy. There is the National Suicide Prevention Lifeline at 1-800-273-8255. There is SpeakingOfSuicide.com/resources for a list of additional resources.

References

1. Andrew, L. B., and B. E. Brenner. 2015. Physician suicide. http://emedicine.medscape.com/article/806779 (accessed May 4, 2016).
2. Council on Scientific Affairs. 1987. Results and implications of the AMA-APA physician mortality project: Stage ii. Journal of the American Medical Association 257(21):2949–2953.
3. Shanafelt, T. D., C. M. Balch, G. J. Bechamps, T. Russell, L. Dyrbye, D. Satele, P. Collicott, P. J. Novotny, J. Sloan, and J. A. Freischlag. 2009. Burnout and career satisfaction among American surgeons. Annals of Surgery 250(3):463–471.
4. Wible, P. 2016. Physician suicide letters—Answered. Eugene, OR: Pamela Wible, M.D., Publishing.
5. https://doi.org/10.31478/201606a