Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for May 12th, 2020

Giving Bad News

Posted by Dr. Vollmer on May 12, 2020

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

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