Breaking

Let your light shine. Be the source of strenght and courage

 Foundation :
Patient-Centered Care
Soul

Emotion Patient Mind

• Health professionals do not

deal only with the diseases or Body
laboratory findings ; they deal
with people
 What is Bad News ?
• Any information which adversely and seriously
affects an individual's view of his or her future
• Any news that client does not want to hear
• Any situation fostering sense of hopelessness
 Example of Bad News

• Life threatening illness

- Ex : cancer, HIV
• Chronic illness with systemic impact and long-life treatment
- Ex : SLE
• Degenerative conditions
- Ex : Alzhaeimer
• Multiple congenital anomaly and/or Mental retardation in
children
- Ex : Down syndrome + atresia ani
 General Principle about
Patient’s Right

• The right of information which is accurate and true

• The right to decide how much information they feel
they need and a right not to receive information
• The right to decide who should be present during
the consultation i.e family members/significant others
• The right to decide who should be informed about
their condition and what information that other
person (s) should receive
6-5
Remember about Ethical Principles !

• Requires that in a healthcare context, health

Principle of professional recognize and support the
autonomy unique values, priorities and preferences
of patients

Principle of • Requires that health professionals ‘do

good’ for the patient, they actively
beneficience concerned for patient well being

Principle of non • Requires that health professionals ‘do no

harm’, they avoid or minimize harm to patient
maleficience
 Ethical Problem of Telling the Truth in
Breaking Bad News

• The capacity and the circumstances of every

patients are unique. Some situation where it is
more important to sensitively communicate with
patient in a way that is meaningful to them.
• When the doctors/caregivers believe that telling the
truth about their illness risk seriously harming
them, they may withhold the information.
Advantages of Breaking Bad News Skill

Improve wellbeing
Improve the
(Emotional &
Quality of Life
Spiritual)

Increase
Promote comfort adherence to
doctor’s advice
 Please...feel sensitive with
your patient’s symptoms
• General Weakness
- Fatique
• Pain
- Common, complex
• Respiratory Symptoms
- Shortness of breath, coughing, wheezing
• Gastrointestinal Symptoms
- Nausea, constipation, pressure ulcer
• Psychological Symptoms
- Depression, delirium, anxiety

From Johnson DC, Kassner CT, Houser J, Kutner JS. Barriers to effective symptom
management in hospice. J Pain Symptom Manage 2005;29:69-79.
 Stages of Grief-DABDA
(Kubler-Ross, 1969)

• Denial
• Anger
• Bargaining
• Depression
• Acceptance
Maslow’s Hierarchy of Patient with Advance Disease
 Nuclear needs of patients

1. Spiritual
2. Dignity
3. Realistic hope
4. Respect
 How to break bad News with “SPIKES”
(Buckman, 1992)

• Setting, Listening Skills

• Patient’s Perception
• Invite patient to share Information
• Knowledge transmission
• Explore Emotion and Emphatize
• Summarize and Strategies
 Setting , Listening Skills

• Arrange for some privacy

• Involve significant others (family members)- with
permission from the patient
• Sit down. Sit down help us relax.
• Make connection with the patient (eye contact, listen
carefully, touch the patients when they feel
comfortable)
• Manage time constraints and interruptions (silent
your gadget please)
 Assesing the Patient’s Perception

• Before discussing the medical findings, the clinician uses

open-ended questions to create a reasonably accurate
picture of how the patient perceives the medical situation
• Example :
• “Apakah sebelumnya ibu sudah pernah mendapatkan informasi
tentang kemungkinan penyebab dari kondisi ibu ?
• “Apakah ibu sudah faham kenapa harus ada pemeriksaan ini?”
• “Apakah ibu sudah pernah membaca informasi mengenai
pemeriksaan ini atau kondisi ibu ini?”
 Invitate patient to share Information

• While a majority of patients express a desire for full

information about their diagnosis, prognosis, and details of
their illness, some patients do not
• Remember stages of Grief from Kubler Ross on previous
slide
• Some patients are still standing at denial until bargaining
phase
• Do not impose your explanation to your patient. Arrange
another appointment (Respect for autonomy)
• Example : “Ibu...jika sekarang saya menjelaskan hasil pemeriksaan
ini, ibu tidak berkeberatan kan ?
 Knowledge Transmission

• Warning the patient that bad news is coming may lessen the shock
that can follow the disclosure of bad news and may facilitate
information processing
• Example of warning shot: “Maaf ibu, saya harus mengatakan bahwa hasil
pemeriksaan darah dan sumsum tulang ibu ini tidak begitu baik (pause-diam
sejenak)....kami menemukan ada sejenis kelainan darah”
• Giving medical facts but try to use too much nontechnical words
(avoid medical jargon) like biopsi, metastase jauh etc.
• When the prognosis is poor, avoid using phrases that indicated
pessimism such as “Kami menyerah....kami sudah tidak bisa berbuat
apa apa lagi”
 Explore Emotions and Emphatize

• F = FEELINGS related to the illness, especially fears

- Saya mengerti berita ini tidak terlalu baik dan mungkin membuat ibu khawatir.
(pause)
• F = FUNCTIONING, the illness’ impact on daily life
- Apakah ibu khawatir penyakit ini mempengaruhi hidup ibu ?
Atau apakah ibu khawatir penyakit ini mempengaruhi orang-orang di sekitar
ibu?
• E = EXPECTATIONS of the doctor & the illness
- Apa harapan ibu terhadap saya dan tim disini ?

Remember about emphatic response in previous Lecture !!!

 Summarize and Strategy

• Patients who have a clear plan for the future are less likely
to feel anxious and uncertain.
• Before discussing a treatment plan, it is important to ask
patients if they are ready at that time for such a discussion.
• Presenting treatment options to patients when they are
available is not only a legal mandate in some cases , but it
will establish the perception that the physician regards their
wishes as important.
 Another Concept of Breaking Bad News

ABCDE
•Advanced Preparation
•Build a therapeutic environment
•Communicate well
•Deal with patient and family reactions
•Encourage and validate emotions