3. A DEFINITION OF BAD NEWS
“any information which adversely and seriously
affects an individual’s view of his or her
future”
“eye of the beholder,”
4. Giving Bad News
• Is an important communication skill
• Is a complex communication task which
includes:-
• Responding to patients’ emotional reactions
• Involving the patient in decision making
• Dealing with the stress created
• Involvement of multiple family members
• How to give hope when situation is bleak
5.
6.
7. Giving Bad News
• It is a difficult task because:-
• It is frequent and stressful
• Most patients want to know the truth
• We are required to tell them what they
desire
• The truth is unpleasant and will upset
them
• We are anxious and fear negative
evaluation
8. Giving Bad News
• We feel a burden of responsibility for
the news
• The recipient is already distressed
• We don’t want to make things worse
• We want to be honest but not destroy
hope
• We are therefore reluctant to
deliver bad news
9. Giving Bad News
•The Good News!
• Using a plan for determining the patient’s
values, their wishes for participation in
decision making, and a strategy for addressing
their distress when the bad news is disclosed
can increase our confidence in the task.
10. Giving Bad News
•The Good News (continued)
• It may also encourage patients to participate
in difficult treatment decisions.
• Those who do so have a better quality of life.
• Clinicians who are comfortable with giving bad
news are subject to less stress and burnout.
11. Giving Bad News
•What do we want to achieve?
• To gather information from the patient.
• To provide intelligible information in accordance
with their needs and desires.
• To support them to reduce the emotional impact
and isolation experienced.
• To develop a plan for management with the input
and cooperation of the patient.
12. Doctors need to polish soft skills
to Deliver “Tough” Bad News
13. Various Strategies BBN
ABCDE
• A- ADVANCE PREPARATION
• B- BUILD ENVIRONMENT / RELATIONSHIP
• C- COMMUNICATION WELL
• D- DEAL WITH REACTION
• E- ENCOURAGE & VALIDATE EMOTIONS
15. The SPIKES Protocol
• SETTING UP the interview
• Assessing patient’s PERCEPTION
• Obtaining the patient’s INVITATION
• Giving KNOWLEDGE and information
• Addressing the patient’s EMOTIONS
• STRATEGY and SUMMARY
16. SPIKES Step 1: S
• SETTING UP the interview
• Preparation Preparation Preparation
• Plan, Privacy, Significant others
• Sitting, Non Verbal Behaviour
• Time
17. SPIKES Step 2: P
• Assessing THE PATIENT’S PERCEPTION
• Gather before you Give
• Patient’s knowledge, expectations and hopes
• What do they understand about the situation?
• Unrealistic expectations?
• What is their state of mind? Hopes?
• Opportunity to correct misinformation and
tailor your information.
18. SPIKES Step 2: P
Questions that u can ask:
could you tell me what’s happened so
far?
Do you have any ideas as to what problem
might be?
Is there anything you have been worried
about ?
19. SPIKES Step 3: I
• Obtaining the patient’s INVITATION
• Gather before you give
• How much does the patient want to know?
• Coping strategy?
• Check if the patient
• Wants to know the result now.
• Would like a family member to be
present.
20. SPIKES Step 4: K
Giving KNOWLEDGE and information to the patient
•Build up to the result-Warning shot
•Use simple language, no jargon,
•Vocabulary and comprehension of patient
•Small chunks, avoid detail unless requested
•Pause, allow information to sink in
•Wait for response before continuing
•Check understanding
•Check impact
21. SPIKES Step 5: E
• Addressing the patient’s EMOTIONS with
empathic responses
• Shock, isolation, grief
• Silence, disbelief, crying, denial, anger
• Observe patient’s responses and identify
emotions
• Offer empathic responses
22. What is Empathy?
• The capacity to recognise emotions that
are being felt by another person.
23.
24. Empathic Responses
• An indication to the patient that you
recognise what they are feeling (and why)
• Verbal and Non verbal
• Often associated with the impact of the
news rather than the understanding.
• I see that…. I appreciate …..
• Wait for response
• Clarify
25. SPIKES Step 5: E
• Acknowledge and reflect their emotions back
( including body language)
• Don’t try to solve their problem or reassure them,
just listen and summarise/bounce their concerns
back to them and expand on them .
( it shows you are listening and conveys empathy)
• If there is a lot of silence, you can ask about their
emotions.
26. SPIKES Step 6: S
• STRATEGY and SUMMARY
• Are they ready?
• Involve the patient in the decision
making
• Check understanding
• Clarify patient’s goals
• Summarise
• Contract for future
27. Obstetrics
• Prenatal diagnosis and anticipation of
outcome have become the accepted
norms.
• Obstetrician and patient have been placed
in the unique opportunity of participating
to predict outcome.
• Given the responsibilities for choosing
future management.
28. Duration of scanning:
• Diagnosis often can be made within seconds
• Patient is politely informed that a thorough
ultrasound scan was performed if, following
the examination, a diagnosis of intrauterine
fetal demise or fetal anomaly is made.
29. Acknowledge the event:
• Most physicians struggle with that first descriptive
statement.
• "I am sorry but we have detected a major problem
which i need to tell you about."
• If diagnosis is clear ……….
• Show ultrasound screen to parents if they wish:
30. • Remain with the couple:
• Allow parents private time
• The couple then is allowed to return home.
31. First trimester miscarriage:
• "Blighted ovum", "vanishing twin", or "passage of tissue“
-- often are viewed by patients as insensitive
statements which deny the existence of the early
pregnancy.
• Many couples select names for their babies in the first
trimester
• Women are being provided a view of their baby as early
as 7 or 8 weeks.
• Same impact as a late pregnancy loss.
32. First trimester miscarriage:
• In some ways the loss is even more complicated
• Husbands
• Early pregnancy sensations of nauseousness and breast
tenderness as proof of the existence of the pregnancy
• Woman assumes complete responsibility for the outcome and
may out of guilt attribute the miscarriage to such activities
as having a glass of wine, or having intercourse, as her way
of assigning cause and effect.
• Blighted ovum:
• Acknowledge to the couple that the pregnancy existed and
was not in
• Fact a nonpregnancy.
33. A second trimester ultrasound diagnosis of
intrauterine fetal death or fetal structural
anomalies incapable of life:
• Most intense and most devastating moment for
this couple.
• Even though death occurs later, the moment of
loss…………………
• Couples have been forced to make choices
regarding management.
34. > 24 weeks
• Allow labor and vaginal delivery to occur unmonitored.
• Perform a cesarean section realizing that it would not
change the outcome.
• Perform tests of fetal well-being in the rare chance that
our diagnosis is incorrect and perform a cesarean
section if fetal distress is encountered.
• Vaginal delivery under fetal heart rate monitoring with
cesarean section as an option if fetal distress is
encountered.
35. Managing Patients In The Hospital
Following A Pregnancy Loss
• Anesthesia for labor must be planned which
does not sedate with the intent to allow the
patient to experience the birth, but also the
grief which accompanies that birth.
• Discomfort experienced by the patient, both
physically and emotionally, often drives care
providers to withdraw, leaving the patient
feeling isolated and lonely.
36. Many emotions surface as the
patient and her partner experience
labor for a late pregnancy loss.
• Labor as a painful experience without reward.
• Appearance of her newborn following delivery.
• Feel guilt.
• Anger, either at herself or as a protective shield against those around
her.
• Loneliness and isolation as the sensation of "why me?" Surfaces.
• Interpret this outcome as punishment for activities that they have
indulged in during their life.
37. MANAGING DELIVERY OF A
STILLBIRTH
• Care provider must be sensitive to the unique nature of this birth.
• Dead baby should be placed in a blanket immediately after
delivery.
• Stillborn baby should never be delivered into a bucket or pan or
left straddling the delivery table.
• Initial encounter with their dead baby.
• Care providers also must remember during this period that the
woman and her family are observing them as they interact with
the dead baby.
39. TAKING A PICTURE
• Photos of the dead baby provide an important
foundation for resolving grief.
• Counselling session
40. OBTAINING AN AUTOPSY
• Often provides answers to "Why did it
happen?“ and "Will it happen again?“
• Initially often refuses.
• Impression that disfiguring procedure that will
not provide new information.
41. MANAGEMENT OF THE PATIENT
AFTER DISCHARGE FROM THE
HOSPITAL
One week
• Most traumatic is the first night in which the family returned home.
• Cultural change– nursery, cloths,
• Support system
• Misconceptions
• Six weeks – family struggles unaided
• Important foundation for future counselling sessions
• Care provider is not disinterested, or uncomfortable with conversations
about the dead baby.
When care providers fail to provide these answers,
well intentioned family members, friends, or
lawyers can find answers
42. DIFFERENCES BETWEEN MEN AND
WOMEN
• Respond differently to pregnancy losses
• Common for a brief period of days or even
weeks following a loss
• Men tend to recover more quickly
• Women, on the other hand, will recover more
slowly with specific setbacks.
43. Get all the FACTS
Express EMPATHY and EDUCATE
Search for sources of ANGER
Have the patient RECITE back to you her
understanding of your explanation.
Evaluate the EXTENDED family response.
DOCUMENT the conversation.
45. Although ultrasound
technology in many ways has
redefined obstetrics, the
physician's rapport with his
patient will never be
displaced as the cornerstone
of medical care.
46. Having a conversation with a
family after the successful birth of
.a healthy newborn is easy
Offering a conversation with a
family after an adverse
unanticipated event draws on the
,most noble resources in medicine
.having compassion
47. References
• SPIKES – A Six-Step Protocol for Delivering Bad News:
Application to the Patient with Cancer. WF Baile, R Buckman et
al.
• The Oncologist 2000;5:302-311
• What Do I Say and How Do I Say It? Communicating Intended
and Unintended Events In Obstetrics Editors James Woods, Fay
Rosovsky Jossy Bass, San Francisco, Calif [April 2003]
• STRATEGIES FOR COMMUNICATING BAD NEWS IN OBSTETRICS
James R. Woods, Jr., M.D. Henry A. Thiede Professor and Chair
Department of Obstetrics and Gynecology University of Rochester
School of Medicine and Dentistry Rochester, New York
Editor's Notes
Outside doctors report.
As yu know we took the biopsy and unfortunately the result are ot as we hoped PAUSE AND WAIT
Im afraid/ unfortunately / im sorry to tell you it’s a tumour.
unsuspecting sonographer routinely scanning an obstetric patient discovers lack of cardiac activity in a
near-term fetus, or a blighted ovum in a patient anticipating a successful in-vitro fertilization. It is here
that a patient at 38 weeks’ gestation first reads in the face of the sonographer that her fetus has died.
What should
be said first to the parent when a major fetal anomaly or intrauterine death is discovered? Who should
relay this information to the parents? How should the counseling follow once the diagnosis is made?
What will be the reactions of parents when, over a period of only minutes, they are taken from
anticipating a healthy child to the death of their child and loss of future plans? Can the emotions of the
couple truly travel quickly enough to make this transfer as the sonographer or physician in the ultrasound
laboratory doles out the facts which represent the interpretation of the ultrasound findings?
When a very brief or cursory scan is performed followed by a
remarkable diagnosis such as intrauterine fetal death, the patient often is left with the uncertain feeling
that perhaps the physician made a mistake or the ultrasound machine was not properly calibrated.
With a diagnosis such as
intrauterine fetal death or hydrocephaly or other life-threatening condition, parents seldom will hear
much more than those few first words. It serves no purpose to begin a lengthy discussion of the findings
since the shock of this information seldom allows parents to understand or be able to ask questions.
Couples, over time, can intellectually adjust to the realization that a fetus with a major anomaly may be so severely impaired as to have no chance of any quality lifestyle. If the condition is not lethal, but requires multiple major operations with little hope that the child will live a normal lifestyle, this loss of living qualities emerges as a perinatal death in its own right.
Vaginal delivery under fetal heart rate monitoring with cesarean section as an option if fetal
distress is encountered. For many conditions such as omphalocele, gastroschisis, and various
forms of dwarfism where cesarean section has not been clearly defined as the appropriate route of
delivery, this management program has resulted in satisfied parents and reasonable outcomes.
Although ultrasound technology in many ways has redefined
obstetrics, the physician's rapport with his patient will never be displaced as the cornerstone of medical
care.
This anger may even be directed at obstetric care providers who failed to anticipate this outcome and act in advance.
It is
important to remember that when medical professionals view the disfigured body of a stillborn baby,
that their view of the baby may be quite different from that of the parents who do not see the deformities
and malformations but, instead, view the baby they hoped would grow into an infant and toddler.
Men tend to
recover more quickly and as part of this process will engage in more activity, whether that involve taking on more work or the acquisition of new hobbies to keep them busy. Women, on the other hand, will recover more slowly with specific setbacks. At six months, on the date of the estimated date of delivery, at one year, and even at two years, the woman may experience a dramatic reoccurrence of her grief feelings, even as she is beginning to find more of a normal pattern to her activities. Providing couples this information will help them respond to these emotional changes, as each recovers at a different rate and in a different pattern.
GET ALL THE FACTS
“Mrs. ____, I have reviewed your chart and hospital course and have reconstructed the events as
follows…..” [A brief review of the entire case establishes a factual basis for the rest of the
discussion.]
E EXPRESS EMPATHY AND EDUCATE
“I speak for our entire group (Department?) in saying how sorry we are for the _______.
Medicine is an art form, not a mathematical equation. When bad things happen, it is our obligation
to examine carefully the events to understand better if this could have been prevented, whether we
should alter our practice and, as important, explore how we can help you and your family as you
move forward. My assessment of the sequence of events is as follows:…..” [Here, an educated
evaluation follows.]
A SEARCH FOR SOURCES OF ANGER
“Mrs. ____, after such a disturbing experience, it is not unusual for some people to feel angry. Do
you have those feelings, and if so, where are they directed?” [This is the hardest question the care
provider can ask. Their fear comes from feeling that if the answer is “Yes, I am angry at you, doctor,” the care provider will lose control of the conversation. Not so! This question, phrased in
the third person, may lead to a truly constructive dialog. The real issue is “What do I (the care
provider) say if they state that I was the responsible person for the bad outcome?” The follow-up
response is quite straightforward. “I am sorry you feel that way but it is understandable. Please
tell me how you arrived at that conclusion.” [Here, the care provider must listen carefully for
misinterpretations made by the patient or family members in the event that misconceptions
represent the foundation of the anger but also offer the best opportunity to correct the facts. But
what if they are correct? The initial statement in response to their anger is based on correct
conclusion is simply, “You may be correct that a different plan would have produced a better
outcome.” [See case ____] At this point, the care provider may only have honesty and
compassion as a defense. Still, used properly, they may be sufficient to avert a lawsuit.
R HAVE THE PATIENT RECITE BACK YOUR EXPLANATION
As the conversation moves toward conclusion, it is most important to evaluate how well your
explanations were understood. A simple question such as “Mrs. ___, it is very important that I
know that you have understood me and the medical issues that we have discussed. Please tell me
what your understanding of our conversation is and if there are any areas that we should repeat or
expand.”
E EVALUATE THE EXTENDED FAMILY’S UNDERSTANDING
At times, the inability of extended family members to understand the sequence of events leading to
a bad outcome produces a slow, smoldering anger that surfaces weeks or months later. To
decrease this possibility, a direct address to the family members attending such a discussion is
important. The statement might be “Many times family members feel left out when these difficult
conversations are held. You all have heard our discussion. Are there issues that you feel we
should cover in more depth?”
D DOCUMENT THE CONVERSATION
The following should be included:
1. Date and duration of conference
2. Name of care provider with titles and family members
3. A brief description of the discussion. This should include:
? Facts of the case (F), outcome and tone of conversation (E)
? Sources of anger (A)
? Level of understanding by the patient (R)
? Issues raised by extended family members (E)
? That the documentation was done immediately after the meeting (D)
4. How care providers intend to follow up with the family.
In summary, the conversation to deliver and discuss bad news after an unanticipated adverse event
need not be traumatic. Instead, with the proper structure, it can be turned into a compassionate,
constructive dialog. Having a conversation with a family after the successful birth of a healthy
newborn is easy. Offering a conversation with a family after an adverse unanticipated event draws
on the most noble resources in medicine, having compassion.
