Skills for Breaking Serious News

00:01 In this lecture, I'd like to talk about Breaking Serious or Difficult News.

00:05 I see this as related to clinical ethics, because it highlights a lot of the core values, and principles that we should be thinking about when taking care of patients.

00:14 Things like respect for that person.

00:17 Beneficence, doing what's in their best interest.

00:21 Not harming them, and how we communicate difficult news.

00:25 And also the idea of their values coming to the fore, in how we make decisions.

00:31 So what is serious or difficult news? Well, it's really any news or information, that adversely alters one expectation of the future.

00:40 So, for that patient, it's just a dramatic news that then they have to confront and deal with.

00:47 It can be serious, it can be difficult.

00:49 Some put it in the realm of it's bad news.

00:53 But really, that's all in the eye of the beholder.

00:55 It's really up to the patient to determine how is this news, this information landing with them? It could range from something as simple as canceling a test.

01:05 So they were anticipating getting a CT scan the next day, and for whatever reason, that had to be cancelled, that adversely affects them. So they're really upset about it.

01:14 It could be the diagnosis of a life altering disease.

01:18 Now, you have cancer.

01:19 You know, something really momentous and serious, that then they have to confront.

01:24 And the range of emotions that patients may experience.

01:28 And when we're going to talk about this in this lecture, could be wide ranging.

01:32 So it could be anger on the one hand, just really angry at getting this news.

01:39 It could be sadness. And, you know, they are really hit with this news, and really trying to figure out how it's going to affect their life.

01:47 So what are the skills that are going to be important when you're communicating this serious or difficult news? For the clinician, the first thing and the foremost thing is being present.

01:58 So, being in the encounter, sort of being there with the person and connecting with them.

02:05 That also means being an active listener.

02:07 So it's not just you giving information you talking, but it's you receiving information from the person, inviting them to ask questions, inviting them to talk about how this news is hitting them.

02:19 It's probably best to give information in chunks rather than a long soliloquy, where you're just talking, straight for several minutes, better to divide up the information given in little pieces, let the person react to them information, then give the next piece of information.

02:39 Always throughout the encounter, an important element is encouraging the patient to share.

02:45 So, getting them to say more getting them to say how they're feeling, getting them to say what they're thinking about when you're giving this information.

02:53 Because so many of the times these encounters are going to be emotional.

02:59 So you have to respond to emotion.

03:01 And we're going to talk about that the empathic response to the emotion that they're showing.

03:06 Or maybe feeling and not showing.

03:09 It also means I'm going to give you a framework for how to do these communication skills.

03:14 But it also means being flexible.

03:16 So you have to sort of adjust to the patient.

03:20 How they're reacting, and work on your feet, to figure out the best way to to still communicate, still stay in the encounter, still be with them, as they're receiving this news.

03:32 And one of the core goals, you know, especially toward the end of the encounter, is this idea of building partnerships.

03:38 So you're in this with them.

03:40 So demonstrating that by both your actions, your body language, as well as your words, that you are a partner with them in handling this news and figuring out what to do about it.

03:52 So, when it is not done well? You know, there are going to be some features of Breaking Bad News poorly.

04:00 So, being mechanistic. Just not really showing emotion, just being very routine and how you're presenting information, the bad bedside manner, as it were.

04:13 Sometimes it means you're dancing around a subject.

04:15 So rather than not saying something plainly, you're trying to avoid the actual details and just try to work yourself around it.

04:25 So for instance, when you know that the patient is at the end of the life that they're dying, rather than saying that explicitly saying, you are very sick.

04:34 Things are not going well. Things are not looking good.

04:36 That's not really getting to the heart of the subject of just really being clear of the patient is facing their death and you want to help them in the dying process.

04:47 Relying on medical jargon or using complex language.

04:51 So, you know we have our medical terminology.

04:54 This is adenocarcinoma rather than just saying that it's cancer.

04:58 So, using that language or relying on that one is going to affect the patient's understanding of what you're saying.

05:08 But then you're just again, being mechanistic and just giving words that have no meaning that they can't relate to.

05:16 Trying to be too much on the pathophysiology.

05:19 So explaining the whole process of what's happening in the body in this disease process, that over emphasis, again, is not what the patient needs to hear.

05:28 They need to hear the headlines, as we're going to talk about.

05:31 You need to hear that the basic facts to then know what they need to do.

05:37 Not focusing on the patient's agenda or needs.

05:39 So that's also going to be a time where that's breaking bad news poorly.

05:43 So, again, the goal of the encounter is not just you relaying information, but really trying to focus on what the patient needs, what they're telling you about the situation.

05:53 And then the other way that you can break news poorly is not addressing the emotion.

05:58 So, not just ignoring the patient's emotion, not even naming it, not even recognizing it.

06:04 Really, the heart of these encounters is the emotion and you have to make sure you address it.

06:09 So there are several concerns with breaking news poorly.

06:12 First of all, it may harm the patient, or if you're conveying this news to their family members.

06:17 Harm them that you've not properly done it and help them with their emotional reaction.

06:23 It may complicate their coping.

06:25 So if you haven't done it well, at the beginning, they're coping with the illness with the diagnosis that you've given, may be harder for them to deal with.

06:34 It may mean that you create false hope.

06:37 If they really don't have a clear understanding of what you're conveying how serious the news is, they may have this false hope of, "Well, everything's gonna be fine, everything's gonna get better." If you do it poorly, if your communication skills are lacking, that may undermine patient trust.

06:55 You know, if they say, "Well, the doctor can't even communicate to me about, you know, giving this news, how can I trust them to prescribe a medication or perform a surgery, or do a radiologic test?" You know, all these things are going to undermine their trust in you.

07:09 And the other concern is also, you know, if you don't do it well, you may feel poorly.

07:13 So that might lead to clinician burnout.

07:16 I've had experience in this myself.

07:20 A colleague, during my training in residency, had to convey the death of a loved one to family members.

07:28 And felt he did it so poorly.

07:31 He was an internal medicine, like I was.

07:33 He left the residency program.

07:36 He decided to become a radiologist because he just did not want to have to confront this idea of having to give serious news and not knowing that he was equipped to handle their emotional reaction.