TEALE FENNING

arunangsude2007 · Joined: 22 Feb 2007 Posts: 18

how a bad news is delivered?
what r the ways?

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 915

hi

check out nick's osce posts for this.

r
Very Happy

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Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SpR O&G Wessex Region

Nick Raine-Fenning · Posted: Sat Feb 24, 2007 10:59 pm Post subject: Re: uk practice

arunangsude2007 · Joined: 22 Feb 2007 Posts: 18

thanks a lot for your kind attention to my post

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 788

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 788

Step 1: S – SETTING up Interview- Mental rehearsal before actually starting the session helps. Review the plan on how to break the news and anticipate patient’s emotional reactions or difficult questions and plan response.

-Environment – arrange for some privacy, preferably in a room of adequate size which can accommodate a few people. Avoid giving the news in public, for example during ward rounds. It may be a good idea to have tissues ready in case the patient starts crying.

-Involve significant others – many patients wish to have someone else with them when they receive bad news. In addition, it would be a great benefit to the patient to have a nurse or social worker present during and after the bad news is delivered. This is so that after the doctor leaves, there is another member of the team with whom they can talk to about their condition.

-Sit down, same eye level – this simple technique gives the impression that the doctor is not rushing and it relaxes the patient. Ideally better not to have any barriers, such as a table, between doctor and patient.

-Make a connection with the patient – maintaining eye contact is important. Touching the patient on the arm or holding a hand (only if patient is comfortable with it) can also help establish rapport.

-Allow uninterrupted time in initial meeting – turn off pager and mobile phone. It is good practice to inform the patient of any time constraints or expected interruptions beforehand. Physicians must be on guard not to send out any non-verbal messages that he or she is in a hurry or bored, as this may cause the patient to close up and hinder future communications. For example, glancing at a watch or clock, a yawn or even suppressing one, looking away at something else happening outside the room or playing with a pen may give a negative impression.

I would usually have another staff member accompanying-- maybe the nursing staff--better if this member is already known to patient as part of the caring team! Place - Ideally a separate silent room; can arrange to be seen towards the end of hospital/clinic time-- when very few people around/ no noice. Also need to find if convenient time for patient. Ideally I would ask if the patient wants anyone else to be with or prefer to discuss without anyone else. Sitting arrangements important(not too many barriers like tables/desks inbetween) ;Uniterrupted(no telephones/children running around)

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 788

Step2- P- Assessing the Patient’s PERCEPTION- Before you tell, ask”. It is important to gauge the patient’s understanding of their condition. A question such as, “what do you know about your condition so far?” gives valuable insight into what the patient thinks and allows the physician to correct misinformation and tailor subsequent information.
It will also help determine if the patient is engaging in illness denial..
Approaching the consultation with a question such as, “could you tell me what you are hoping for? That will help me do a better job for you,” would be a good way to start exploring this issue.
I would try to see if the patient already knows something/ a little bit about the news (has he/she sensed anything); open questions--such as "Do you recall this test that we did? Or "Do you know why we did those tests?" This will also help to know if they have any misconception.

Step3-I- INVITATION
Most patients wish to hear about the diagnosis and prognosis of their condition. Firstly, we should not overwhelm the patient with information, but instead give it in small chunks at a time. If possible, it would be helpful to write or draw out information that we are trying to convey. Some patients however, do not wish to be told of their condition. Denial is a coping mechanism and we should accept that it is often an appropriate response to bad news. If the patient does not want to be informed of any details, we should offer our availability to answer any future questions should they arise.
Ideally asking them helps-- I want to tell you about the test results--Is that OK with you? Do you want to know them?Now? Later? I can fix up a time/appointment?? Anywhere else? Do you want to know everything in detail? Do you want me to just tell you the core basics?

Step4-) K – KNOWLEDGE
Preferably, the patient should be told of the diagnosis and prognosis truthfully in plain language but not too bluntly. For example, telling a patient, “you have leukemia and unless you get treatment you will die,” would be anxiety-provoking and inappropriate. Often times, it is good to give a ‘warning shot’ as an indication that bad news may be coming. Good examples of this include statements such as, “the test results just came back and we’re not too happy about it,” or “your chest X-ray doesn’t look very good.” This simple technique prepares the patient for subsequent worse news.
It is vital to start at the same level of comprehension and vocabulary as the patient. No technical jargon or euphemisms. For example, the term ‘spread’ may be less intimidating than ‘metastasize’ and ‘tissue sample’ could be used instead of ‘biopsy.’
Finally, when prognosis is poor, intimations that “nothing can be done” should be avoided. Even if a disease is too far advanced for curative treatment, the patient should be reassured that support will be provided to make his or her remaining life as comfortable as possible. Many terminally ill patients fear that once all forms of treatment have been exhausted, they will be abandoned. This does not have to be the case.
When interventions are limited to palliative measures, it is vital that we do not suggest that these actions are intended to cure the disease or, more importantly, allow patients to make that presumption.
After coveying information, we should allow time. Ask them what they think/know about the diagnosis-usually patients may come up with questions such as -- "What happens now?" One can decide about telling other details then or can withhold it until they recover from initial shock--can take hours! Should also be honest about availability or non-availability of treatment in that set up!

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 788

Step 5-E-Emotions-- preparing for patient's denial/anger/acceptance/tears/outburts/--realising that anger or any emotion is the reaction to the information being conveyed and not at doctor/team.
Holding hands/touching the shoulder-- keeping in mind the cultural background; having another member of a gender other than mine if necessary(and if available)--so that the patient can feel comfortable!( holding hands can be taken very differently depending on cultural background); allowing for *shut down*
If a patient becomes upset or shows anger, we should indicate that we have recognized the emotion by suggesting, “I can see you are frustrated with all these tests and treatments,” or “you must be pretty angry with the situation you are going through right now.”

Step 6- S – STRATEGY
Having a clear plan for the future will help the patient feel less anxious and more in control of his or her life. Before initiating a treatment plan, it is important to find out if the patient is ready for such a discussion. Any further discussion regarding treatment details does not have to take place at the time of the original consultation. We can schedule a follow up meeting on a fixed date and to ask the patient or family members to write down any questions they might have so that they can be answered later. It is important sician to document all communications with the patient and family members, as well as the patient’s reaction to the news. We should be concise and include the information in the patient’s medical record.
This will ensure consistent information is available for all healthcare personnel involved in patient care. Should a patient have unrealistic expectations, it may be useful to ask the patient to describe the history of the illness. This usually reveals fears, concerns and emotions that lie behind the expectations. Patients may look at cure as a way of solving different problems that are significant to them. This can range from loss of a job, an inability to care for family, loss of independence and mobility, pain and suffering and inflicting hardship on others. Expressing these concerns will help the patient acknowledge the seriousness of their condition.
After the initial meeting, it is important to arrange for a second appointment, preferably soon, at a specific time and date. Advise the patient or family to write down any questions they might have. Also, leave a telephone number at which you can be contacted.

Giving information in small chunks maybe a good idea. Calling them back later to talk about strategy if I feel they can't take it all at one go! Assuring them that all care possible in that setup would be given! Can *try* to arrange if they wish to speak to another doctor/specailist if possible!
Statements like--** We are there with you/I admire your courage/capacity to take this news** etc help. Sometimes keeping silent and allowing them to express their emotions helps.

Giving them an idea of the plan ahead, an broad estimate of time frame if possible ; supportive care, i, need for hospitalisations, further tests, general poor health etc!

Finally- Summarise and most importantly check if the patient understood everything rightly.

Nick Raine-Fenning · Posted: Mon May 28, 2007 10:07 am Post subject:

I like that - always a sucker for mnemonics Wink

It is very similar to the technique we teach.

However, this is on area / subject you simply have to be shown how to do in an OSCE environment. One of the most important things to do is to pause, listen, and acknowledege and not to interupt or force the pace. Unfortunately most people do this badly and feel they have to move the role play on to get marks - the opposite is, in fact, true.
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