Communicating Bad News in the Health Care Organization

Ask-Tell-Ask Tool [33]
Involves asking what the patient understands (Ask) before telling the news (Tell) and then evaluating what the patient understood (Ask) from the information provided
ABCDE mnemonic [52]
Proposes Advance preparation, Build a therapeutic environment/ relationship, Communicate well, Deal with patient and family reactions, Encourage and validate emotions
SPIKES protocol [53]
Considers “Setting,” “Perception,” “Invitation,” “Knowledge,” “Exploration,” and ‘‘Summary/strategy’’ during delivering bad news to patients
Nondisclosure, Full Disclosure and Individualized Models [54]
Nondisclosure assumes the patient needs to be protected from bad news and physician decides what information to provide. Full disclosure upholding the patient’s right to full information gives too much detail causing negative emotional experiences. Individualized disclosure model believes that people have different coping methods and desires for information and so tailors it to the patient’s needs
Individualize the Bad News:
According to Hippocrates , when communicating, one should “give necessary orders with cheerfulness and serenity, revealing nothing of the patient’s future or present condition” [29]. This norm has shifted historically in the physician-patient interaction to increased effort to open, honest and full disclosure. Some patients may not like full disclosure of their illness, and physicians are challenged with individualizing the bad news delivery based on the patients’ needs and desires [30]. Though more time consuming, the individualized disclosure model is a more effective way of giving clinical information [31].
Hope and Healing In Medical Communication:
Healing is making a patient feel better or helping them peacefully accept their diagnosis and prognosis through the preservation of hope and a positive outlook, no matter the gravity of the news. Healing is the wellness of not just the body, but the mind, attitudes and soul. Hope is the prerogative of every patient and should not be taken away [32]. Good communication is more than being a “warm and caring” physician, but the ability to effectively assess patient’s understanding, elicit care values and preferences, and encourage participation [33]. Patients appreciate honesty, but also positive, supportive and hopeful statements not merely listing worst case scenarios [34]. Doctors by aligning themselves to their patients can learn to respect and respond to the patient’s sense of hope, even though not fully sharing it [23]. “Nothing can be done” statements should be replaced with “everything will be done” attitudes by adopting a cultural shift away from singular, curative biomedicine to seeking resources that help patients embrace living ‘‘as well as you can for as long as you can” [35].
Full Disclosure is Vital in Medical Communication:
Evading medical disclosure and shifting responsibility can foster negative feelings in patients or families. Saying “I’m sorry,” is not an acceptance of guilt or responsibility—it is merely a sharing of empathy and validation of the suffering person’s emotions. Hospitals have now established a risk management task force to investigate medical errors or mistakes, and make full disclosure to the families, which has improved accountability of medical staff, patient satisfaction, and reduced medico-legal liability.

Practical Reflections on Breaking Bad News in a Clinical Setting

Reflection # 1
When breaking bad news to a patient, it is important to strike the right balance between providing information and overwhelming a patient with details, by tailoring information to the individual situation. Physicians sometimes feel an obligation to complete a predetermined script and mentally check off boxes as each piece of information is provided. This can leave patients feeling overwhelmed and confused. It is important to realize that many details may need to be repeated later after the initial shock has worn off. The most important aspects of the initial encounter are to make sure the patient feels supported and that there’s a clear plan and direction about what the immediate next steps will be, whether it is further testing, hospitalization, or other treatments and when the next contact with the provider will be. -Amy L Fothergill, MD, Internal Medicine, Associated Physicians, Madison, WI.
Reflection # 2
Historically, some medical professionals, especially doctors, are seen as aloof, abrupt and lacking empathy. Below are simple ways one can break bad news to patients:
  • Know your patient: Know a little bit about your patient, especially if they need family around when receiving the news. When possible, break the news in private.
  • Your body language speaks volumes before you break the news. Maintain a vibe that says, ‘I am here for you’.
  • Maintain eye contact while talking; and sit at the same level so as not to be formidable.
  • Breaking the news: Be direct, but compassionate. You can say “we did everything we could”, concerning loss of a patient. If a hospice patient, you can remind them that it was a peaceful death.
  • Absorption: Give patients a few moments to understand and assimilate what you have just said.
  • Scientific data: Some patients would like to see proof of illness—lab results, imaging studies, or treatment options . You could say that “This is obviously a lot to take in now, but I would like you to know that there are some options that we can talk about…” You could have a specialist to provide more information or invite the patient to get a second opinion, if doubtful.
  • Knick Knack: Have tissue ready at all times. Be calm and collected, enunciate properly, and speak slowly. Always know where the exit is—although this has not been my experience, some patients have been known to be violent, so know when to go for help. Ngozi Mezu-Patel, MD Infectious Diseases, Kent General Hospital, Dover, Delaware.
Reflection 3
It is easy to tell your patients that you see their perspective, but going through the motions of having heard yourself what you have just told them can really open your eyes. It was not until I tried to schedule my life as a dialysis patient that I realized what I had been telling my patients. To integrate 4 hour treatments three times a week opened my eyes to the independence, travel, work, privacy and freedom that were at stake. I now ask my patients about the rest of their lives and what is most important for them. This lets them know that they are seen as more than a disease, and that we are working with them to make their lives work, not just their kidneys. -R. Allan Jhagroo MD, Division of Nephrology, University of Wisconsin, Madison.

Communicating News About Serious Illness, End of Life or Palliative Care

Respect Spirituality in End of Life Communication:
Death comes to all, yet the fore-warning in medical illness does not seem to allay the fear, shock or uncertainties about prognosis, extent of suffering, and end of life decisions . The best antidote for patients’ uncertainties is effective communication [36]. Discussing death may be difficult for physicians due to a sense of personal failure, fear of how the family will react, or personal insecurities about mortality. For clinicians to be thorough and compassionate, their care must extend beyond the physical realm to the spiritual [37, 38]. Some patients want to discuss beliefs about the soul after death with their health care providers [39, 40]. Always offer patients spiritual care according to their religious affiliation, [41] as spiritual beliefs vary with each religious sect. Regardless of religious inclinations or lack thereof, there is a universal belief in love and compassion shared by all human beings, especially when in need of healing of physical or emotional pain .
To Speak or Not to Speak:
Sometimes, words are unnecessary in times of grief or delivery of bad news; and a presence, quiet empathy, tears, touch or a hug is equally effective. People express grief in various ways, like apathy, anger, denial, sadness, or a smile. This individual right of expression should be respected, not judged. Understanding and compassion is all patients and families need from their health care providers.
Withdrawal of Life Support is Not a Withdrawal of Care:
It can be extremely difficult for families of patients in the intensive care unit (ICU) to cope emotionally as they transition from thinking there may be a cure to, the next time, facing ­palliative care or imminent death [36, 42]. Although a physician has no obligation to provide futile care, patient care continues compassionately through helping the family cope with the loss. “Do not resuscitate orders” must be clear and ­unambiguous. Withdrawal life support should be done after open and honest discussions with the family and medical team. Health care professionals should provide the highest quality of terminal and palliative care for dying babies just as in adults [43]. Respecting families’ end of life wishes , allowing them at the bedside during terminal procedures, providing time to gather other loved ones for support, and compassionate care of the patient and family help bring closure, peace and acceptance to the grieving family, and reassure them that “everything was done”.
Ethics of Communication in Perinatal and Neonatal Care:
With advances in neonatal and obstetric care, premature infants are surviving at younger gestational ages, bringing a unique set of clinical, moral and ethical challenges. Extremely premature infants have severe neurodevelopmental disability, [44] including cognitive deficits, hearing loss , cerebral palsy, and blindness that can affect them up to adolescence [45] and beyond. The ethical principles of autonomy, beneficence, non-maleficence, and justice, [46] apply to fetuses or infants facing a life-limiting diagnosis as well as their mothers. Caring for infants in neonatal intensive care units requires extraordinary sensitivity, extreme responsibility, and heroic compassion [47]. Physicians should present facts in an honest and unbiased way, avoiding grossly grim or falsely optimistic information . Find out what the family knows, before giving information in simple language devoid of excessive medical jargon, remaining supportive of the family’s decision. Parents and medical staff are both advocates in considering the ‘best interest’ of the child. In complex ethical situations or when conflicts arise between parents’ and physicians’ desires for the child, a referral should be made to the hospital ethics committee for a formal consensus . Good palliative care entails a systematic multidisciplinary coordination of services to avoid communication breakdowns, [4850] provide direction for clinicians and appropriate follow-up [51].

-Practical Reflections on Breaking Bad News in Special Situations

Reflection # 1
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Nov 16, 2015 | Posted by in General Dentistry | Comments Off on Communicating Bad News in the Health Care Organization
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