Fast Fact and Concept #6: Delivering Bad News Part I

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Title: Fast Fact and Concept #6: Delivering Bad News Part I

Author(s): Ambuel, B.; Weissman, D.

The "Fast Fact and Concept" provided here in its entirety provides a synopsis of the steps in Delivering Bad News. It is designed for attending faculty to use while on rounds or the start of a teaching conference. It contains tips on precepting trainees prior to an actual patient encounter.

Educational Objective(s)
Learn the basis steps in the communication skill of Delivering Bad News. Learn how to precept training physicians. Understand the importance of personal reflection.
Question: What steps do you take to prepare to give bad news before talking with the patient?

Case Scenario: You are caring for a previously healthy 52 y/o man with a new problem of abdominal pain. After conservative treatments fail, a diagnostic abdominal CT scan is done showing a focal mass with ulceration in the body of the stomach and numerous (more than 10) densities in the liver compatible with liver metastases. The radiologist feels that the findings are absolutely typical of metastatic stomach cancer. How do you prepare to discuss these test results with the patient?

Main Teaching Points:

1. Create an appropriate physical setting: A quiet, comfortable room, turn off beeper, check personal appearance, have participants, including yourself, sitting down.

2. Determine who should be present? Ask the patient whom they want to participate--clarify relationships to patient. Decide if you want others present (e.g. nurse, consultant, chaplain, social worker) and obtain patient/family permission.

3. Think through your goals for the meeting as well as possible goals of the patient.

4. Make sure you know basic information about the patient's disease, prognosis, treatment options.

5. Special circumstances: Patient not competent (developmentally delayed, dementia, etc.) Make sure legal decision-maker is present.

6. Special circumstances: Patient doesn't speak English. Obtain a skilled medical interpreter if the patient or family do not speak English. Use ATT translation service or other phone service is necessary.

Precepting self-reflection:

Residents will invariably have strong emotions when they have to give bad news. This emotional response can be heightened by various factors-a young patient, an unexpected diagnosis, a patient with whom the physician has a long-standing relationship, etc. As a preceptor, you will want to support the resident.

Key teaching points:

1. Residents may not spontaneously discuss their own emotional reaction with a preceptor, therefore you will want to introduce this topic. "This is a really hard case, how are you doing?";

2. Physicians often have strong emotional reactions when a patient encounters bad news. Normalize the experience for the resident; "Its normal to have strong feelings".

3. Three methods for coping with these feelings: Identify your feelings (anger, sadness, fear, guilt); Talk with a colleague; Keep a personal journal.

4. Role play the discussion with the resident before you go into the room; ask them to reflect on how it "feels", what is hard, what is easy. Encourage continued self-reflection.

Also See:
Fast Fact #11: Delivering Bad News Part II - Talking to Patients and Precepting Trainees

Fast Facts and Concepts are developed and distributed as part of the National Internal Medicine Residency End-of-Life Education project, funded by the Robert Wood Johnson Foundation.

Disclaimer Concerning Medical Information:
Health care providers should exercise their own independent clinical judgment. Accordingly, official prescribing information should be consulted before any product is used.
Contact: [email protected].

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman DE. Fast Fact and Concepts #6: Delivering Bad News--Part 1. June, 2000. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 2/2000

Format: Handouts

Purpose: Instructional Aid, Teaching

Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Clergy/Chaplains, Nurses, Social Workers

ACGME Competencies: Interpersonal and Communication Skills, Patient Care

Keyword(s): Adult, Giving bad news, Hope, Personal reflection

The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).