Our guest today (the first for PA month here on TOTAL EM) is Adrian Banning. She is an Evidence Based Medicine (EBM) guru and is also on the JAAPA Podcast with a previous guest, Kris Maday. Today though she is here to talk to us about breaking bad news. Something most of us are experienced with but one thing few of us do well. We combine EBM and "soft skills" to better care for our patients and families in this very difficult time.
Sometimes, difficult times will be obvious to tell. The classic example is breaking the news to family that a patient has died. It can be much more subtle though such as the ballerina or the football player who has a full ride with injuries that limit their abilities. These are the types of issues that can feel like they take away someone's identity. There are also those diagnoses like cancer or diabetes which can forever change someone's life and have a permanent impact.
The one event people will remember most is how they were told the news. That moment of hearing the bad news will stay with that individual. Most commonly, the complaint is the lack of feeling like the person telling them cared. Body language plays an important role (we all should be sitting)!
Different people will have varying ideas of what they want when they get the news which makes this all the more challenging. Experience is not enough, but formal training can truly help.
Emotion, sensitivity, and language played a very important role in the emotional memory from a study in the Irish Medical Journal regarding parents finding out a child was stillborn. Open, sensitive, and honest communication is key. The appearance of withholding information can be very devastating, especially with the relationship of that provider to the family.
Demographics may play a role such as cancer patients that are younger, female, and/or have a higher education tend to request more detailed information regarding their diagnosis and receive more emotional support based on one systematic literature review. Overall, the key part is to be culturally appropriate. There are ways to get strong cultural training. One of my favorite books is from a previous college professor called The World's Religions which focuses on the major belief systems present.
Language needs to be clear. Euphemisms such as "gone away" is not clear and "died" is more often preferred for this reason. Other words such as "shadow" or "spot" may not be as clear as stating the person has "cancer" using those words. Also, people will stop hearing most of the information once the bad news has been given. Be aware that even when giving the other information that they are probably not hearing or at least comprehending the information being given.
A great mnemonic is"SPIKES" is Buckman's famous protocol and includes the following:
Breaking bad news causes a variety of emotions. Have the proper help present. Many times having additional individuals such as a care manager, social worker, or other trained person who can stay with the family. Some may become violent or destructive and this may sometimes be anticipated. If concerned, get security but keep them out of site until needed. Many others will shut down into a quiet mode. You may simply be a witness. Silence is fine and talking is not needed. Be there for them. Do not be rushed and plan that this will take time. As long as the emotional reaction is safe, let it ride out.
We often want to say "I'm sorry" but many times "I wish" could be a better phrase such as "I wish we had better news" or "I wish there were better treatments" when giving such news. Unfortunately, "I'm sorry" can sometimes be seen as an admission of guilt or seen as an apology for a mistake. Most will be saying this as a way to express sadness but can use it in other terms. Also do not say "I understand" or "I can imagine" since you have not been through this exact situation for this exact person. This only invites conflict during this time.
It is fine if you end up crying due to the emotions. The only issue is that you do not want to become the center of attention. This is the time for that patient or family. As long as they have their time and are not being distracted by your emotions, crying or other emotional responses can be appropriate.
A highly recommended book by Adrian is called "There is No Good Care for This" which covers a lot about what to say and what not to say in situations. But in the end remember, patients do not care how much you know until they know how much you care.
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