Breaking Bad News in Crisis: A Compassionate Approach

1. Breaking Bad News to Families in Crisis: An Interdisciplinary Training Approach Utilizing Personal Values

2. Introductions School of Behavioral Health, Department of Counseling and Family Sciences • Jackie Williams-Reade, Ph.D., LMFT, Associate Professor • Elsie Lobo, M.S., MFTI, Doctoral Student • Abel ArvizuWhittemore, LMFT, Doctoral Student School of Medicine, Department of Pediatric Surgery • Joanne Baerg, M.D., Associate Professor

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Design, implement, and evaluate a training program to enhance compassionate communication skills in breaking bad news to patients and family members. • Describe relevant concepts of adult learning theory, behavioral health and medical cultures, and family systems theory as they relate to the acquisition of communication skills. • Identify areas where behavioral health and medical professionals can collaborate in interdisciplinary training interventions in integrated healthcare settings.

4. Background

5. Learning Objectives for MedFTs • Understanding of interpersonal and cultural differences between medicine and family therapy • Explain the benefits of medical family therapy to medical care stakeholders

6. Learning Objectives for Surgical Residents • Communication skills: core competency • Specific skills: rarely taught • Barriers to adequate training: a lack of curricula, time, and supervisor skill. • Holmes: the process of making patient care routine shifts the patient from status as an individual with suffering to the object of the physician’s work. Holmes CL1, Miller H2,3, Regehr G4. (Almost) forgetting to care: an unanticipated source of empathy loss in clerkship. Med Educ. 2017 Jul;51(7):732-739. doi: 10.1111/medu.13344.

7. Surgical Residency Background • Goals and Objectives: The Accreditation Council for Graduate Medical Education requirement: competency in communication and professionalism. • A recognized paucity in curricula • New requirement for resident curricula in the empathic communication of bad news. • The APD for General Surgery contacted the MFT Director • A collaborative training was created

8. Factors Contributing to the MFT and Medical Cultures: Professional Differences • Basis of Knowledge • Orientation • Paradigm • Philosophical Stance • Goals • Identity and Sovereignty • Care Provided • Client / Patient Focus • Orientation • Exposure to Clients / Patients while in Professional Training • Interventions • Time Frame of Action • View of Organizational Resources

9. Different, yet complementary cultures MFT: A culture that… • Allows for the tentativeness, “holding lightly” • Recognizes the client as expert • Values being relational • Values collaboration • Includes other core mental health professions • Acknowledges the systemic and complexity • Accommodates multiple clinical training paths / approaches • Is process oriented Medical: A culture that… • Is evidence, based, values objectivity • Recognizes well defined roles / specialties • Values individual expertise • Rewards solo practitioners • Stems from a well-established and cohesive guild • Aims for perfect outcomes • Extensively socializes its members into the profession • Is action / results oriented

10. Our Project

11. Compassion • Compassion – 2nd of our 7 values – JCHIEFS • Empathy – to feel what another is feeling, walk in their shoes • Sympathy – to feel for another’s pain, implies distance • Compassion – to be moved to action by another’s suffering • “Compassion… is the mandate that drives those of us in the healing professions to seek relief from suffering... But it must be tempered. We talk about the "wall" or "guard" that we watch develop, and even encourage, as we help students come to grips with pain and loss as a necessary part of becoming an effective professional.” ~Richard Hart, Notes from the President, March 2016

12. Breaking Bad News • BBN poorly has negative impacts on patient satisfaction, treatment decision making, and patient–provider relationships (Reed, Kassis, Nagel, Verbeck, Mahan, & Shell, 2015). • The process of BBN also affects medical professionals, producing physiologic stress responses in both novice and experienced physicians (Meunier et al., 2013). • Goal: Teach residents how to be aware of and regulate their own stress response in order to live out value of providing compassionate, competent care

13. Simulation Overview • Eight 2.5 hour educational seminars • 2 residents per session • Behavioral health training clinic using 2-way mirror and audio feed system • MedFTs as family members and trainers • Pilot study of family systems-based BBN curriculum (that we created) based on Kolb’s learning theory • May and June 2016

14. Family Systems Theory: Bowen’s Theory of Differentiation • Main goal of Bowenian therapy is to reduce anxiety by • Differentiate between thinking and reacting/feeling • Being able to live true to one’s own values • Emotional Fusion / Emotional Cutoff • Residents’ felt like they would either get lost in the patient/family pain (fusion) or they had to shut down and distance (cutoff) • Differentiation: A place in between - aware and able to regulate own emotions in order to provide compassionate, competent care

15. Pre-Simulation Briefing • Provide a safe learning context: Normalize BBN is difficult • Previous experiences and concerns with BBN Common worries:saying the wrong thing, want to do it perfectly, feeling too little or feeling too much, didn’t know how to fix the pain • Values • What values would you like to exude as a physician when breaking bad news? (common ones were compassion/empathy and competence) • How can you bring those values to this encounter? • SPIKES and case study

16. Simulation and Feedback – Kolb’s Four Stages of Experiential Learning • Stage I: Concrete Experience = Simulation • Stage II: Reflective Observation = “What did you do well?”“What was challenging?” • Stage III: Abstract conceptualization = Discussed values and emotional response; asked them to identify emotional responses and work to exude their value more clearly • Stage IV: Active experimentation = 2nd role play, reflection and encouragement

17. What do MFTs have to offer? (Sternlieb, 2014)

18. The Results

19. Simulation Outcomes

20. Self-Reported Outcomes

21. Resident Evaluation of Simulation

22. What Residents Learned Skills • “how much tone of voice & touch play in conveying empathy and kindness • “Learned how to approach family members and how to keep calm when things don’t go as expected” • “I am trying to listen more and explain less” • “Varying your approach by reading the patient’s family” Self-Awareness • “I’m aware of how your own anxieties change the way you come across” • It was good to hear feedback about how my own reaction was perceived: what I intended was not always what was perceived. Outcomes • “...families respond much better to direct conversation and thank me for it” • “I am much more confident in my ability to be compassionate as well as direct and not ‘sugar coat things…”

23. Questions?

24. Bibliography / References Baile, W. F., Buckman, R., Lenzi, R., Glober, G., Beale, E. A., & Kudelka, A. P. (2000). SPIKES—a six-step protocol for delivering bad news: Application to the patient with cancer. The Oncologist, 5, 302–311. http://dx.doi.org/10.1634/theoncologist. 5-4-302 Bowen, M. (1978). Family treatment in clinical practice. New York, NY: Jason Aronson. Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice Hall. Lamba, S., Offin, M., & Nagurka, R. (2013). Casebased simulation: Crucial conversations around resuscitation of the critically-ill or injured patient. MedEdPORTAL, 9, 9367. Lamba, S., Tyrie, L. S., Bryczkowski, S., & Nagurka, R. (2016). Teaching surgery residents the skills to communicate difficult news to patient and family members: A literature review. Journal of Palliative Medicine, 19, 101–107. http://dx.doi.org/10 .1089/jpm.2015.0292 Meunier, J., Merckaert, I., Libert, Y., Delvaux, N., Etienne, A. M., Liénard, A., . . . Razavi, D. (2013). The effect of communication skills training on residents’ physiological arousal in a breaking bad news simulated task. Patient Education and Counseling, 93, 40–47. http://dx.doi.org/10.1016/j.pec .2013.04.020 Meyer, E. C., Sellers, D. E., Browning, D. M., McGuffie, K., Solomon, M. Z., & Truog, R. D. (2009). Difficult conversations: Improving communication skills and relational abilities in health care. Pediatric Critical Care Medicine, 10, 352– 359. http://dx.doi.org/10.1097/PCC.0b013e 3181a3183a Peterson, E. B., Porter, M. B., & Calhoun, A. W. (2012). A simulation-based curriculum to address relational crises in medicine. Journal of Graduate Medical Education, 4, 351–356. http://dx.doi.org/ 10.4300/JGME-D-11-00204 Reed, S., Kassis, K., Nagel, R., Verbeck, N., Mahan, J. D., & Shell, R. (2015). Breaking bad news is a teachable skill in pediatric residents: A feasibility study of an educational intervention. Patient Education and Counseling, 98, 748–752. http://dx.doi .org/10.1016/j.pec.2015.02.015 White, S. J., Stubbe, M. H., Dew, K. P., Macdonald, L. M., Dowell, A. C., & Gardner, R. (2013). Understanding communication between surgeon and patient in outpatient consultations. ANZ Journal of Surgery, 83, 307–311. http://dx.doi.org/10.1111/ ans.12126

25. Post-session evaluation • - What expertise do professionals in your discipline have that can help to enhance another profession?- What are important components of Kolb's learning theory that should be included in designing a curriculum that reflects your response to the first question above.