Thursday, 25 February 2010

Breaking bad news

Breaking bad news is a professional skill which is acquired by practice under supervision. It should give a clinician confidence and satisfaction rather than alarm, although it can never be painless.

The interview:
Opening:
• If possible, the patient should have someone with them.
• The interview should take place with everyone introduced, sitting in a quiet place.

Exploring and focusing:
• The doctor should find out if anything new has happened since the last encounter.
• What does the patient know and how does the patient react to it? In detail.
• The doctor should then introduce a warning that the news is bad: 'I'm afraid it looks more serious than we hoped.' Then the details.
• At this point the doctor should pause and allow the patient to think, and only continue when the patient gives some lead to follow. This pause may be a long one while thoughts go round in the patient's head, and is often accompanied by shutdown which makes patients unable to hear anything further until these thoughts settle down and allow them to re-emerge.
Only then should the doctor:
• Discover how much the patient is likely to be able to take in at this point - methods for finding this out are shown in
• Give the information without fudging, in small chunks and make sure that the patient understands each one before moving on.
• Be prepared for the patient to have disorderly emotional responses of some kind and acknowledge them early on as being what you expect and understand and wait for them to settle before continuing. The clinician must learn to judge which patients wish to be touched and which do not. You can always reach out and touch their chair.
• Watch out for shutdown; when it occurs, just wait. When the patient emerges it is best to deal with what they then say, and only after that take up the running.
• Keep pausing to allow the patient to think.
• Stop the interview if necessary and arrange to resume later.
• The clinician can emphasize that some things are fixable and others are not. A broad time frame can be given for the fixable aspects of care.
• No time frame is ever accurate for the unfixable, but the clinician must be prepared for the question: 'How long have I got?' and avoid the trap of providing a figure which is bound to be inaccurate. Rather stress the importance of ensuring that the quality of life is made as good as possible from day to day.
• The patient must be provided with some positive information and hope tempered with realism

Closing :
The clinician must be sure that:
• the patient has understood what has been discussed so far and that crucial information has been written down for the patient
• the patient knows how to contact the appropriate team member and thus has a safety net in place
• the next interview date - preferably soon - has been agreed, for what purpose and with whom
• other members of the family have been invited to meet the clinicians as the patient wishes
• written material and further sources of information are readily available
• everyone is bid goodbye, starting with the patient.

After the bad news is broken
Patients want to know if they are going to die and if so when? Will they be able to stay at home? Will they be in pain? Must they eat if they don't want to? Patients facing the end of life have different priorities from the clinicians, and need clear information about their pain and symptom control, the extent to which they can influence this and how long active treatment will continue. Settling family matters and completing unfinished business come high on their agenda, and must be reconciled with attempts at palliation or treatment, particularly if these are of uncertain benefit. It is the clinician's responsibility to mediate between the patient, other medical staff and the patients' relatives.



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