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

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

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

This Fact Fact and Concept is a continuation of Fast Fact #6--Delivering Bad News; providing additional information on the process of delivering bad news and precepting trainees. This can be used during ward rounds or as a handout for a teaching conference.

Educational Objective(s):
Understand key steps in delivering bad news. Review issues surrounding bad news when precepting trainees.
Case Scenario: You are caring for a previously healthy 52 y/o man with one-month of abdominal pain and weight loss. On exam he had a 2 cm hard left supraclavicular lymph node. A CAT scan showed a focal mass with ulceration in the body of the stomach and numerous densities in the liver compatible with liver metastases. The radiologist feels that the findings are consistent with metastatic stomach cancer. How do you discuss these test results with the patient?

Main Teaching Points:
1. Determine what the patient & family knows; make no assumptions. Examples: "What is your understanding of your present condition?" "What have the doctors told you?"
2. Before presenting bad news, consider providing a brief overview of the patient's course so that every one has a common source of information.
3. Speak slowly, deliberately and clearly. Provide information in small chunks. Check reception frequently
4. Give fair warning -- "I am afraid I have some bad news" then pause for a moment.
5. Present bad news in a succinct and direct manner. Be prepared to repeat information and present additional information in response to patient and family needs.
6. Sit quietly. Allow the news to sink in. Wait for the patient to respond.
7. Listen carefully and acknowledge patient's and family's emotions, for example by reflecting both the meaning and emotion of their response.
8. Normalize and validate emotional responses: feeling numb, angry, sad, and fearful.
9. Give an early opportunity for questions, comments
10. Present information at the patient's or family's pace; do not overwhelm with detail. The discussion is like pealing an onion. Provide an initial overview. Assess understanding. Answer questions. Provide the next level of detail or repeat more general information depending upon the patient's and family's needs.
11. Assess thoughts of self-harm
12. Agree on a specific follow-up plan ("I will return later today, write down any questions"). Make sure this plan meets the patient's needs. Involve other team members in follow-up.

Precepting Points:
Residents often feel strong emotions when they have to give bad news to a patient. 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:

Also See:
Fast Fact #6: Delivering Bad News Part I

1. Buckman R. How to break bad news: A guide for health care professionals. Johns Hopkins University Press, 1992.
2. Faulkner A. Breaking bad news--a flow diagram. Palliative Medicine 1994:8;145-151.
3. Iverson, VK. Pocket protocols-Notifying survivors about sudden, unexpected deaths. Galen Press, Inc., Tuscon, Arizona, 1999.
4. Ptacek, JT, Eberhardt, TL. Breaking bad news: A review of the literature. JAMA, 157:323, 1996.
5. Sim, I. How to give bad news. http://www.med.stanford.edu

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.

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman, D. Fast Fact and Concepts #11: Delivering Bad News Part II-- Talking to Patients adn Precepting Trainees. 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: 4/2000

Format: Handouts

Purpose: 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, General Public, Graduate Students, Lawyers, Patients/Families, Nurses, Social Workers

ACGME Competencies: Interpersonal and Communication Skills, Patient Care

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

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).