Breaking bad news

Knowing how to Break Bad News well is an essential skill for OSCEs but more crucially for future clinical practice. From an early stage, doctors find themselves in situations where they need to convey difficult news to patients and/or relatives.

Bad or distressing news is never easy to hear, but having someone deliver the news well can make the person receiving the news feel respected, cared about and supported going forwards.

Clinical Communication – General Tips

Prepare for the consultation (see ‘setting’ below)

This would also involve sufficient background reading to ensure you are up to date with the patient’s past medical history and recent events.

Introduction:

  • Check you have the correct patient – confirm they are happy to be called by their name e.g. Joanna or Mrs Smith.
  • Introduce your full name and role and purpose of the interview (e.g. ‘I have been asked to speak to you about some recent investigations you have had’)
  • If you are seeing the patient instead of their usual doctor – apologise for the change/explain that you are stepping in for whatever reason. They may be expecting to have the conversation with someone else.
  • Gain consent – check they are happy to discuss the topic with you
  • Mention confidentiality if relevant

 

Display active listening skills:

  • Maintain an appropriate level of eye contact throughout
  • Open, relaxed, yet professional body language (uncrossed legs and arms, leaning slightly forward in chair)
  • Nodding, acknowledging what the patient says
  • Avoid interrupting the patient

 

Try to establish a rapport with your patient:

  • Ask how they are, offer them a seat/glass of water
  • Empathise with any emotion they display/verbalise and acknowledge the difficulty/stress of situations they could be experiencing (watch them carefully)
  • Listen and respond to the things they say

Structuring the consultation 

SPIKES is an effective way to structure your consultation. (Baile et al., 2000)¹

SETTING

A comfortable, quiet and private room

  • Although this is not always possible, make sure you have at least some privacy, and that the patient and family have somewhere to sit. Bad news should never be broken standing in a corridor!
  • Have tissues available
  • Ensure both you and the patient/relative are sitting down
  • Arrange the chairs if necessary, e.g. at approx. 45 degree angles to each other – avoiding physical barriers between you and the patient (for example, a desk)
  • Ensure you have uninterrupted time during the meeting (beepers, phones turned off)

 

Who else do you want in the room?

  • Other healthcare workers can provide support in breaking the diagnosis, for example, nurse specialists
  • Ask the patient if they want anyone to be with them – Would you prefer to have a family member or friend here?”. Likewise, if there is someone else already in the room, check to see if your patient would prefer to be told alone.

 

PERCEPTION

Discuss the events leading up to now: scans, biopsies etc

Discuss any symptoms the patient may have been experiencing up to this point

Establish what the patient already knows or is expecting

Establish the patient’s current emotional state and if there is anything particular on the patients mind (any ideas, concerns or expectations the patient might have)

  • “Could you tell me what’s happened so far?”

Here you could agree with the patient and say something like ‘Yes, the reason we wanted to do the tests were so we could find out why you have been experiencing the symptoms you just described to me. Were you aware of what sort of things the investigations might show?

The patient may or may not have been made aware of the possible diagnoses.

If they don’t know of the possible diagnoses – you could say something like this ‘ Symptoms like the ones you’ve been describing can sometimes be as a result of an infection, but sometimes they can be as a result of more serious underlying conditions’  This can also act as a warning shot.

 

INVITATION

Check if the patient wants to receive their results today – in an OSCE setting the answer will always be that they want to know the information now. However, on the wards be aware that some patients who may recognise the news may not be what they hoped for, may want to put it off until family are present, or after a holiday or family occasion etc

  • “I have the result here today, would you like me to explain it to you now?”

 

KNOWLEDGE

Ensure you deliver the information in sizeable chunks, and regularly check for understanding.

Use a warning shot to indicate that you have unfortunate news:

  • “As you know we took a biopsy/did a scan, and unfortunately the results were not as we hoped”

 

Allow a large pause if necessary, so the patient is able to digest what you have told them.

 

Then provide the diagnosis:

  • (Using simple language)
  • “I’m afraid/sorry to tell you this, but the results from the investigations show you have cancer”

 

Other tips:

  • Chunk the diagnosis, pausing after each piece of information
  • After giving the diagnosis, its wise to wait for the patient to re-initiate the conversation

 

Example:

“I’m afraid it’s not the news we were hoping for Mrs Brown”

PAUSE

“Unfortunately, the lump is due to a more serious underlying cause”

PAUSE

“I’m so sorry to tell you, but you have breast cancer”

PAUSE until patient speaks, or after they seem to be ready to talk again. This may be a few minutes.

 

Make sure your tone is respectful, at a slow pace and clear

It is very natural for the patient to have an emotional reaction at this stage. They may go quiet, ask questions in disbelief, deny that this is happening, start crying, become hysterical or angry. These are all normal reactions to hearing bad news and each person will respond in their own way.

Give the patient TIME to have their emotional reaction. People often find it very uncomfortable watching patients like this but it is important to give the patient space to just react.

Questions in disbelief such as ‘This can’t be happening, can it?’ or ‘But how am I supposed to deal with this?’ are often asked to us at this stage. Make a judgement about whether you need to answer the questions directly. Saying something like ‘I’m so sorry I had to break this news to you today’ might be all you need to say at this point.

If they are making eye contact with you and asking questions like ‘So what will happen next?’ then it is probable that they are ready to receive answers to their questions.

EMOTIONS AND EMPATHY

  • Recognize and respond to emotions with acceptance, empathy and concern
  • Acknowledge and reflect their emotions and body language
  • Do not lie when the patient asks questions about prognosis – it is not kind to give false hope
  • If you do not know information, tell them that, and suggest that you can refer their case to a specialist or that more information is needed

“I’m so sorry but at this stage  I don’t have enough information to answer that. Hopefully in the next few weeks once we’ve completed other tests I can be clearer. Sorry, I can appreciate that its frustrating to be left with unanswered questions”

 

Useful phrases:

  • “ I can see this is a huge shock for you”
  • “I can see that this is not the news that you expected, I’m so sorry”

STRATEGY AND SUMMARY

  • Make a plan together to meet the patient again/inform them of what the next step is
  • Reassure the patient that they are going to/have been referred to the appropriate team of specialists who are best equipped to come up with a plan going forward
  • Try not to rush the patient to make decisions about their treatment (if possible), it is respectful and considerate to let them process what has been told to them.
  • Check the patient’s understanding
  • Summarise: Respectfully and gently repeat any important points – patients who are shocked or upset will not take in much information
  • Ensure to answer any questions or concerns that can be addressed at this stage (and listen out for any implicit ones)
  • Offer ongoing assistance to the patient should they think of any further questions – this may involve giving them details of a clinical nurse specialist.
  • Offer assistance to tell others (e.g. other family members) the bad news
  • Highlight where the patient can go to gather more information or gather any support (support groups, websites)
  • Offer written materials if relevant and available

 

Other thoughts:

  • Asking about religious preferences, and whether the patient would like the Chaplain.
  • In some situations, exploring the relatives thoughts on organ donation is a good opportunity, and people often see organ donation as their relative’s death meaning life for someone else.

 

When the consultation is over:

Be aware that breaking bad news can be emotionally challenging for us healthcare professionals also – particularly if you have built a rapport with the patient.

Think through your own thoughts, and reflect on how you’re feeling. Take time out if needed.

General points

  • Breaking bad news is not just cancer.  Other examples of breaking bad news stations that arise in future consultations may include STD results, diagnosis of type 1 diabetes, and miscarriages.
  • Think about how a patient might feel when giving them any new information about their condition, and how it may impact their lives.
  • Use the correct language – cancer is cancer, death is death. It is important that there is no ambiguity about what the diagnoses/results show.
  • Avoid euphemisms and ensure to avoid any medical jargon.

References

1. Baile, W., Buckman, R., Lenzi, E., Glober, G., Beale, E., & Kudelka, A. SPIKES – a six step protocol for delivering bad news: Application to the Patient with Cancer. Oncologist 2000; 5(4):302-311.

The post Breaking bad news appeared first on Geeky Medics.

Geriatric Outcome Prediction From The P.A.L.LI.A.T.E Consortium

The continuing rise in geriatric trauma cases seen at trauma centers has necessitated the creation of new infrastructure for evaluating, treating, and assessing outcomes in injured elders. The ability to predict the likely outcome after trauma is extremely important in shaping the management of these patients after discussion with them and their families. Unfortunately, the tools we have for those prognostications are rather complicated, yet rudimentary.

The gold standard to date is TRISS, which combines physiologic data (revised Trauma Score) at the time of first encounter with anatomic injury information (Injury Severity Score). This allows the calculation of a validated probability of survival (Ps).

However, TRISS is unwieldy and frequently cannot be calculated due to missing data. A consortium was created to address these shortcomings. Of course, they chose a name with an unwieldy acronym: Prognostic Assessment of Life and LImitations After Trauma in the Elderly (PALLIATE).

This group developed the Geriatric Trauma Outcome Score (GTOS) in 2015. They recently published a study comparing GTOS with the gold standard TRISS. This could be important since GTOS is easier to calculate, with less opportunity for missing data since it relies only on age, ISS, and presence of blood transfusion.

They calculated outcomes of nearly 11,000 patients at three centers, and found that GTOS worked as well as TRISS. The major advantage was that GTOS requires only three variables:

GTOS = Age + (ISS x 2.5) + (22 if blood transfused in first 24 hours)

Then, just to make your head spin a little more, the GTO score value gets plugged into this logistic model equation:

Bottom line: GTOS is helpful in some ways, but not in others. It does allow calculation of the probability of survival in elderly patients as well as traditional methods, but with more readily available data points. 

However, it is just a probability. It may predict that someone like your patient has a 3% probability of survival, but it cannot tell specifically that your patient is in the 3% vs the 97%. The consortium was trying to make it easier and more objective for clinicians to discuss care plans with family. But this is not really the case. 

And a bigger problem is that it gives us no guidance as to quality of life or level of independence for those patients who will probably survive. These factors are, by far, the most important ones when having those hard discussion with patient and/or family. We still need a tool that will guide us on functional outcomes, not just life or death.

Related posts:

Reference: A comparison of prognosis calculators for geriatric trauma: A P.A.L.LI.A.T.E. consortium study. J Trauma, publish ahead of print DOI: 10.109, 2017.

Source: http://thetraumapro.com/2017/04/24/geriatric-outcome-prediction-from-the-p-a-l-li-a-t-e-consortium/

PulmCrit- Rocketamine vs. keturonium for rapid sequence intubation

Background:  Devil in the details Airway management is a detail-oriented sport.  Minor nuances of patient positioning can be essential.  Or gentle laryngeal manipulation.  Apneic oxygenation can improve first-pass success.  Placing the pulse oximeter on the same arm as the blood pressure cuff can cause real headache.  Failure to recognize and remove dentures is an enormous […]

EMCrit by Josh Farkas.

The Easy IJ: Another Option for Difficult IV Access in Stable Patients?

Background: We have all taken care of patients in whom IV access is difficult due to a multitude of reasons including repeated prior IV access, advanced vascular disease and shock. This often creates delays in patient care, increases ED length of stay, and uses up ED staff that have other patients to care for. Many providers have resorted to using IO access, particularly in critically ill patients due to speed of establishing access.  In stable patients, however, this may be a less desirable.  Ultrasound guidance has been a great addition in these patients.  Ultrasound guided peripheral IVs and external jugular access would probably be the next “go to options” in these patients. The authors of this paper evaluate yet another option: The Easy IJ. 

What They Did:

  • Multicenter, prospective observational study to evaluate the efficacy and safety of the easy IJ in stable ED patients with difficult intravenous access

Definition:

  • Easy Internal Jugular (IJ) Access: Placement of an 18 gauge, 4.8 cm, single-lumen catheter (the same catheter used for peripheral access) in the IJ with ultrasound guidance

Materials Required:

  • Ultrasound machine with high-frequency linear transducer
  • Chlorhexidine
  • 4.8cm, 18-gauge single-lumen catheter
  • 2 bio-occlusive adherent dressings
  • Sterile ultrasound gel
  • Loop catheter extension
  • Saline flush

Outcomes:

  • Initial success rate
  • Mean procedure time
  • Average pain score
  • Number of Skin punctures
  • Complications

Inclusion:

  • Patients requiring IV access
  • Failed attempts at establishing peripheral or external jugular vein access (Including attempts using ultrasound)
  • Ability to dilate IJ with Valsalva maneuver
  • Ability to sign written consent

Exclusion:

  • Hemodynamic instability (HR >150BPM, or MAP <60mmHg)
  • Untreated pneumothorax
  • Clinical need for triple-lumen venous catheter

Results:

  • 83 attempts in 74 patients
  • Median body mass index (BMI): 27kg/m2
  • Initial success rate: 88% (95% CI 79 – 94)
  • Mean procedure time: 4.4 min (95% CI 3.8 – 4.9)
  • Average pain score 3.9 out of 10 (95% CI 3.4 – 4.5)
  • Number of Skin Punctures:
    • One: 75%
    • Two: 19%
    • Three – Five: 6%
  • Complications:
    • Pneumothorax: 0/83 (0%)
    • Line Infection: 0/83 (0%)
    • Arterial Puncture: 0/83 (0%)
    • Loss of Patency: 10/73 (14%) successful lines

Strengths:

  • Only multicenter study to date to evaluate the Easy IJ
  • Absence of pneumothorax was confirmed by either CXR (82/83) or CT scan (1/83)
  • This is an increasing dilemma in the care of EM patients, and gives a nice simple solution, that does not take as long as Central venous access or the discomfort associated with IO in stable awake patients
  • No major patient-centered adverse events
  • Time of procedure recorded as time from skin prep to confirmation of IV. Many studies start time from when the needle hits the skin.

Limitations:

  • Absence of line infection determined by chart review in 55 out of 83 patients. If patients sought care at other facilities this would underestimate the incidence of line infection
  • All attempts at access were performed by physicians with >20 previous ultrasound guided line placements, may reduce generalizability if provider is not well versed with ultrasound
  • Primary outcome not clearly stated
  • Confidence intervals are wide relative to complication rates for the Easy IJ
  • Easy IJ catheters were left in for ≤24hrs in this study, therefore infection risk beyond 24 hours cannot be ascertained from this study
  • Unstable patients were excluded in this study, therefore cannot draw conclusions of the Easy IJ in unstable patients

Discussion:

  • The authors of the paper state that in the limited literature available on this procedure there are no documented cases of pneumothorax, neck hematoma, inadvertent arterial placement, line infection, or site infection
  • The procedure itself takes about 5 minutes which is a significantly shorter time than central line placement

Author Conclusion: “The Easy IJ was inserted successfully in 88% of cases, with a mean time of 4.4 min. Loss of patency, the only complication, occurred in 14% of cases.”

Clinical Take Home Point: In stable patients, who have had failed attempts at establishing peripheral or external jugular vein access, the Easy IJ is a rapid method of achieving short-term IV access with no major adverse patient oriented outcomes.

References:

  1. Moayedi S et al. Safety and Efficacy of the “Easy Internal Jugular (IJ)”: An Approach to Difficult Intravenous Access. JEM 2016. 51(6): 636 – 42. PMID: 27658558

Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)

The post The Easy IJ: Another Option for Difficult IV Access in Stable Patients? appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.