Responding to the Patient's Emotions – How to Break News

by Mark Hughes, MD, MA

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    00:00 And anticipate that the patient will have an emotional reaction.

    00:04 You know, this is life altering, so you're expecting that they're going to be an emotional reaction.

    00:09 If you see no reaction, you'd really wonder did they hear you? Maybe you need to repeat it if you don't see any kind of reaction.

    00:17 So, best to wait for an emotional reaction, wait to see what they respond.

    00:23 Maybe it's going to be silenced, maybe it's going to be disbelief, maybe they're going to start crying straight away.

    00:29 Maybe they're going to be in denial and say, "No, no. It can't be." Maybe they're going to be angry and just show their their anger through their words and verbal and body language expressions.

    00:43 And you have to wait for that emotional reaction, because that's sort of the core feature of these encounters.

    00:49 You have to then validate that emotion through an empathic response that we'll talk about.

    00:54 Really, if you don't attend to the emotions, it's going to be difficult to discuss any other issues, or care plan in relation to this information.

    01:03 So you've got to start with the empathic response.

    01:07 And it's also important to say -- sometimes, coalition's say, "Well, I don't want to get the patient upset, because then I'm harming them, I'm causing them to be upset.

    01:19 But our role is not to prevent the emotions.

    01:22 But it's to really instead to maintain a therapeutic relationship with them in a safe environment, allow those emotions to be expressed and show that you care and you want to help them with their emotional reaction.

    01:37 If it's a situation where the emotions are not clearly expressed, you're really not sure how the patient is handling the news.

    01:44 It might be good to then ask, after that period of silence, to ask an exploratory question, to try to clarify the emotion.

    01:50 So, can you tell me what you're feeling? Any kind of silence or physical presence that you provide can be emotional, appropriate emotional response to their emotions. So, just being present to them, as an important is showing of therapy, a therapeutic relationship to them.

    02:13 So, there are a few steps when we think about an empathic response.

    02:18 First of all, there's this idea of attunement with the patient.

    02:22 So if you're so present in the encounter, that you're going to actually get a sense intuitively of what they're feeling.

    02:29 So, you're attuned to them, and what they're experiencing.

    02:34 You should observe for the emotion that they're expressing, you know, either in their facial expressions and their body language, in what they're saying, in how they're saying it.

    02:43 Observe for those emotions.

    02:45 Identify and name the emotion expressed by the patient.

    02:49 Identify the reason for the emotion.

    02:52 So legitimize, that they should be having this emotional reaction.

    02:57 Acknowledge it. And then perhaps explore what's underneath the emotion.

    03:03 So, you could say as, "I can see that this is upsetting to you.

    03:06 Can you tell me more.

    03:08 They're going to be various ways that a patient might deal with serious news.

    03:12 So different coping mechanisms by different patients.

    03:15 There might be fight or flight.

    03:17 So, the increased sympathetic tone that you get in reaction to a threat.

    03:22 So, either aggressive behavior, so the fight mode, or the fleeing, you know, wanting to leave or get out of the room.

    03:31 Those fight or flight, just reaction to the threat that's been posed by the serious news.

    03:38 Some patients might react with conservation withdrawal.

    03:41 So, shutting down. So, they just turn into themselves become silent, and maybe looking down and avoiding eye contact.

    03:51 There may be some patients that are more cognitively based.

    03:54 You know, thinking about they're more rational mindset.

    03:58 So, they're going to try to intellectualize what's going on.

    04:02 Or some other cognitive responses could be the denial.

    04:06 You know, this can't be. I'm wrong.

    04:08 There could be blame. You know, someone else did this to me.

    04:12 So, that kind of blaming reaction.

    04:15 There could be this disbelief.

    04:17 As I said, just not believing the information.

    04:20 Or there may be some patients that are accepting.

    04:22 They sort of anticipate this might be the news.

    04:25 They accepted. They then want to figure out what needs to be done about it.

    04:32 And then the other coping mechanism that most patients, if not all patients, in some way, we'll have an affective response.

    04:39 So, an emotional response, whether it's anger, fear, anxiety, shame, guilt, belief or disbelief, all of those things are showing that they're coping with it in some way. They're trying to figure out how to work with this information that you've given them.

    05:00 Again, I don't want this to be formulaic, but there are strategies that you can use in communication skills.

    05:05 There's something called the nurse mnemonic. N-U-R-S-E.

    05:09 So, let me just walk you through this as examples.

    05:12 Again, you have to learn these skills over time, that's not something that too, if you give it just says, routine.

    05:19 It may not sound genuine.

    05:21 So you've really got to practice these skills and make sure it's coming from the heart coming genuinely and how you do these things. But the N is Naming the emotion.

    05:31 So, it sounds like you were worried.

    05:34 The U is Understand the emotion.

    05:36 Now we can never fully understand what that patient is going through.

    05:40 They've got their own experience.

    05:42 But you might say something like, you know, after you've had them talk about what they're going through, if I understand you correctly, you're worried about whatever it is.

    05:51 The R in nurse is Respect the emotion.

    05:55 So, this is showing that you respect their perspective.

    05:59 I appreciate how you've been coping with this.

    06:02 The S is support.

    06:04 So again, that idea of partnership, supporting the emotion or supporting the patient, I will be there for you and your family.

    06:13 And then the E in nurse is explore the emotion.

    06:17 So this is the Tell me more.

    06:19 So, tell me more what you're thinking.

    06:21 Tell me more what you're feeling.

    06:22 Again, getting the patient to talk about what they're experiencing as they received this information.

    About the Lecture

    The lecture Responding to the Patient's Emotions – How to Break News by Mark Hughes, MD, MA is from the course Breaking Serious News and Advance Care Planning.

    Included Quiz Questions

    1. Validate the patient
    2. Ask the patient to cry
    3. Ask the patient to save their emotions for later
    4. Ask the patient to cry less
    5. Request for a nurse to come into the room
    1. Name the emotion
    2. Understand the emotion
    3. Respect the emotion
    4. Shame the emotion
    5. Evade the emotion
    1. Hallucination
    2. Fight-or-flight
    3. Fear
    4. Denial
    5. Shame

    Author of lecture Responding to the Patient's Emotions – How to Break News

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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