Breaking Bad News

by Charles Vega, MD

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    00:01 What about the time – you know, when it's time to break bad news.

    00:05 And I think this applies to cases when the patient is about to expire and pass away.

    00:13 But I think it also applies to a patient being told they have cancer or it could even apply to patients who have lost control of their diabetes or can't go running 10 miles a day like they used to.

    00:28 I think one of the things I've learned with bad news is, really put it in the context of the patient.

    00:34 You know, terrible tragedies like mortality, cancer diagnoses, those are easy to understand, but patients can really take any change to their lifestyle or a change to their medical condition quite seriously.

    00:48 So, don't think about the way – you know, the bad news in the way you consider bad news, think of it from the patient's perspective first.

    00:55 And that will help you break bad news in a more empathic way.

    00:59 There are some general rules and some evidence-based guidelines for breaking bad news.

    01:04 First, you always want to allow enough time.

    01:07 I usually do this in an inpatient hospital setting.

    01:10 And it's really – well, it’s always busy, but it’s critical just to set aside enough time that's necessary.

    01:17 Oftentimes, it’s over the noon hour.

    01:20 And I create a private and comfortable environment.

    01:21 So, I’ll book a conference room and bring everybody who needs to be in the room in at once.

    01:27 Now, I've had – I've led family meetings that have involved over 30 family members, in which case we had to actually get – use one of the small auditoriums at our medical center to do it, to accommodate that many people.

    01:41 One thing that’s really helpful is to use leaders within the family, so that way you don't have to coordinate between 33 different people.

    01:49 That’s impossible.

    01:50 But if you can identify one to at max three folks who can determine who needs to be there at a big family meeting and get everybody together for you, that's great! Also consider other health professionals whom they know well.

    02:04 Maybe I'm not the best person to be talking about the bad news.

    02:08 I want the nursing staff there because the families, the loved ones and the patients really get to know nursing staff.

    02:15 Maybe it’s the primary care physician who can come in over a noon hour sometime.

    02:19 So that can be really helpful.

    02:20 Try to make it a team effort because that's important to be relatable to patients and their loved ones.

    02:28 Fire a warning shot.

    02:29 And what that means is let the patient know I have some bad news for you.

    02:34 So that way, they're kind of warned and emotionally ready when something – when you tell them whatever news it is.

    02:41 When you do so, be very clear.

    02:44 Don't beat around the bush.

    02:45 I'm sorry to tell you this, Mr. Smith, but your cancer has spread and we think that's going to be fatal.

    02:55 We believe there is no more treatment we can offer to cure your cancer, but we do want to make you as comfortable as possible and we will be there to support you every step of the way.

    03:05 So that's clear.

    03:07 I'm not using a lot of jargon talking about the tumor has now metastasized into your T12 level spine and it's also in your ischium.

    03:20 You want to avoid jargon.

    03:22 You want to be clear and deliver a message that the patients can really understand.

    03:27 It can go fast or slow.

    03:30 Sometimes patients are already – they’re usually more ready for bad news than we give them credit for.

    03:35 They know what's going on.

    03:37 But go at their pace.

    03:38 Allow time for tears.

    03:39 Allow time for questions.

    03:42 Emotions may run high, particularly among family members.

    03:44 Don't react to that.

    03:45 Just keep it at a nice basal level.

    03:48 And always be prepared when you go into these meetings too because there might be questions, why wasn't this tumor diagnosed earlier? And so, you want to have a little bit of sense of the patient's history before you go into a family meeting in particular.

    04:02 Importantly, you always offer hope at the end of one of these discussions.

    04:07 And how do you do that? Because. especially if you’re talking about a failed diagnosis, how do you offer hope? I gave a little bit of an insight as to how in that brief example.

    04:16 Because I talked about, we are going to make you comfortable, we are not going to let you suffer, and we will be there for you for every step along the way.

    04:25 So, you always, always end with a message of hope.

    04:28 Patients and their caregivers really appreciate that.

    04:32 Later in the day, it’s great to circle back and make sure that – see how they're doing emotionally, but also test a little bit for comprehension.

    04:40 You know, can you tell me about what you understand about your diagnosis today.

    04:44 A little bit of teach back.

    04:47 And then answer any questions they have.

    04:51 So, it's important to get the pharmacology right at the end of life.

    04:56 It's also a critical time for communication.

    05:00 It's like your final exam when it comes to communicating with empathy with patients and their loved ones.

    05:07 But when you do it and you do it right, it leads to much better outcomes where everybody feels a lot better about something that really is inevitable for all of us.

    05:16 Thank you very much.

    About the Lecture

    The lecture Breaking Bad News by Charles Vega, MD is from the course Geriatric Care.

    Included Quiz Questions

    1. In a private, comfortable setting with supporting family members and health professionals they know well
    2. In a private setting with the patient alone for confidentiality
    3. Immediately once the results have come back, regardless of location, as it is the patient's right to know as soon as possible
    4. During your usual clinic appointment with the patient to avoid any extra burden on the patient's time
    5. During a home visit, one on one with the patient
    1. Be clear and straight forward
    2. Avoid words such as "fatal" or "death" or "end of life"
    3. Explain all exam and imaging findings in full detail to assure patient has full understanding of the state of their disease
    4. Avoid calling the news you are about to deliver as "bad" or "unfortunate," so the patient doesn't feel hopeless
    5. Discuss the problems in full correct medical terminology to avoid any misinterpretation or confusion
    1. Leave the room immediately after delivering the bad news to allow the patient to process the information with his or her family in private
    2. In addition to the patient, identify 1 to 3 family leaders as primary points of contact and communication
    3. Always offer hope and assure support
    4. Make sure to allow for up to an hour to hold the meeting
    5. Follow up with the patient and family after the meeting to evaluate emotional stability and comprehension

    Author of lecture Breaking Bad News

     Charles Vega, MD

    Charles Vega, MD

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