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Don't:
Preparation:
· doctor to put aside own “baggage” and personal feelings wherever possible
· summarise where things have got to date, check with the patient
· negotiate agenda
· assess the patient’s understanding first: what the patient already knows, is
thinking or has been told
· give warning first that difficult information coming e.g. "I'm afraid we have
some work to do...." "I'm afraid it looks more serious than we had hoped...."
· do not give too much information too early; don’t pussyfoot but do not
overwhelm
· watch the pace, check repeatedly for understanding and feelings as you proceed
· use language carefully with regard given to the patient's intelligence, reactions,
emotions: avoid jargon
· allow for “shut down” (when patient turns off and stops listening) and then give
time and space: allow possible denial
· check understanding of information given ("would you like to run through what
are you going to tell your wife?")
· be aware of unshared meanings (i.e. what cancer means for the patient
compared with what it means for the physician)
· having identified all the patient’s specific concerns, offer specific help by
breaking down overwhelming feelings into manageable concerns, prioritising and
distinguishing the fixable from the unfixable
· give hope tempered with realism (“preparing for the worst and hoping for the
best”)
· ally yourself with the patient (“we can work on this together ...between us”) i.e.
co-partnership with the patient / advocate of the patient
· safety net
Bad news is any information that changes a person's view of the future in a negative
way . It is often associated with a terminal illness such as cancer.(2)
1. Getting started :
* The physical setting ought to be private, with both physician and patient
comfortably seated.
* You should ask the patient who else ought to be present, and let the patient decide
(studies show that different patients have widely varying views on what they would
want).
* It is helpful to start with a question like, "How are you feeling right now?" to
indicate to the patient that this conversation will be a two-way affair.
By asking a question such as, "What have you already been told about your illness?"
you can begin to understand :
* what the patient has already been told ("I have lung cancer, and I need surgery"),
* or how much the patient understood about what's been said ("the doctor said
something about a spot on my chest x-ray"),
* the patients level of technical sophistication ("I've got a T2N0 adenocarcinoma"),
* and the patient's emotional state ("I've been so worried I might have cancer that I
haven't slept for a week").
* It is useful to ask patients what level of detail you should cover. For instance, you
can say, "Some patients want me to cover every medical detail, but other patients
want only the big picture--what would you prefer now?" This establishes that there is
no right answer, and that different patients have different styles. Also this question
establishes that a patient may ask for something different during the next
conversation.
* Decide on the agenda before you sit down with the patient, so that you have the
relevant information at hand.
* The topics to consider in planning an agenda are: diagnosis, treatment, prognosis,
and support or coping. However, an appropriate agenda will usually focus on one or
two topics.
* For a patient on a medicine service whose biopsy just showed lung cancer, the
agenda might be: a) disclose diagnosis of lung cancer; b) discuss the process of
workup and formulation of treatment options ("We will have the cancer doctors see
you this afternoon to see whether other tests would be helpful to outline your
treatment options").
* Give the information in small chunks, and be sure to stop between each chunk to
ask the patient if he or she understands ("I'm going to stop for a minute to see if you
have questions").
* Long lectures are overwhelming and confusing.
* Remember to translate medical terms into English, and don't try to teach
pathophysiology.
* If you don't understand the patient's reaction, you will leave a lot of unfinished
business, and you will miss an opportunity to be a caring physician.
* Learning to identify and acknowledge a patient's reaction is something that
definitely improves with experience, if you're attentive, but you can also simply ask
("Could you tell me a bit about what you are feeling?").
* At this point you need to synthesize the patient's concerns and the medical issues
into a concrete plan that can be carried out in the patient's system of health care.
* Outline a step-by-step plan, explain it to the patient, and contract about the next
step.
* Be explicit about your next contact with the patient ("I'll see you in clinic in 2
weeks") or the fact that you won't see the patient ("I'm going to be rotating off service,
so you will see Dr. Back in clinic").
* Give the patient a phone number or a way to contact the relevant medical
caregiver if something arises before the next planned contact.
* ensuring privacy
* allowing adequate time,
* assessing patients' understanding,
* giving information about diagnosis and prognosis simply and honestly, avoiding
euphemisms,
* encouraging patients to express feelings,
* being empathic,
* giving a broad but realistic time-frame concerning prognosis,
* arranging a review.
(B) Dr. Robert Arnold, an internist and communications expert at the University of
Pittsburgh, suggested: (4)
· "Name your emotions. And then acknowledge he doesn't have to have the same
ones."
· Be direct. "Say 'Help me understand your story,' or 'Are you the kind of person
who likes to know all the details?"'
· "Figure out what kind of doctor your patient wants you to be."
(C) SPIKES: A mnemonic for breaking bad news to patients by Baile and colleagues
etting up
erception
nvitation
nowledge
motions
www.postgradmed.com/issues/2002/09_02/editorial_sep.htm
(D) The ABCDE Mnemonic for Breaking Bad News by Rabow and McPhee
http://www.aafp.org/afp/20011215/1975.pdf
Other helpful phrases and questions are :
· "I wish I had better news" (as opposed to "I'm sorry, I have bad news"),
In general, it is better simply to wait for the person to stop crying. If it seems
appropriate, you can acknowledge it ("Let's just take a break now until you're ready to
start again") but do not assume you know the reason for the tears (you may want to
explore the reasons now or later). Most patients are somewhat embarrassed if they
begin to cry and will not continue for long. It is nice to offer kleenex if they are
readily available (something to plan ahead); but try not to act as if tears are an
emergency that must be stopped, and don't run out of the room--you want to show that
you're willing to deal with anything that comes up. (6)
Finally it is obvious that acquiring the skill of breaking bad news greatly required
because 'How a physician delivers bad news may affect patients' understanding of and
adjustment to the news as well as their satisfaction with their physician'. (2)
The limits of medicine assure that patients cannot always be cured. These are
precisely the times that professionalism most acutely calls the physician to provide,
hope and healing for the patient. (7)