Communicating Bad News to Cancer Patients

1. Communicating Bad Newsto Cancer Patients Joel S. Policzer, MD, FACP, FAAHPM Sr. VP – National Medical Director VITAS Innovative Hospice Care Miami, FL

2. Bad News • any news that drastically and negatively alters the patient’s view of their future

3. Bad News • any news that drastically and negatively alters the patient’s view of their future

4. Bad News • any news that drastically and negatively alters the patient’s view of their future

6. Do You Tell? • 50 – 90% of patients want the truth • So the issue is not “do you?” • Issue is “how?”

7. Do You Tell? • In reality, patients who are dying, know they are dying • They want confirmation of their status • They want a time frame • YOU would want a time frame when your time approaches

8. Time Frames • Study looked at prognostication of three groups: • cancer patients • chemo nurses • oncologists • Looked at accuracy of estimated survival

9. Time Frames • Patients were very accurate in when they expected death to occur • Chemo nurses closely tracked the patients’ estimates • Oncologists were off by months, usually estimating many months of survival in patients that were close to death

10. Time Frames • Take home message: • if an oncologist tells you that you have months to live, you’ll probably be dead in a week

11. Time Frames • Patients do not expect: • “5:34 PM on July 21” • People want: • “a few months” • “a few weeks” • “days” • “hours”

12. Time Frames • As physicians and oncologists, if we’ve taken care of enough patients, we know in our gut, with our clinical instinct, where a patient is in their trajectory • People want to know to be able to plan • Maybe they want to live the next month in Tuscany or Provence instead of wretching in your chemo room

13. Why is this Difficult? • Social factors • Our society values youth, health, wealth • Elderly, sick and poor are marginalized • Sick and dying have less social value

14. Why is this Difficult? • Physician factors • Fear of causing pain • Uncomfortable in uncomfortable situations • Sympathetic pain due to patient’s distress

15. Why is this Difficult? • Fear of being blamed • Physicians have authority, control, privilege and status • When medical care fails patient • it’s physician’s fault • “blame the messenger”

16. Why is this Difficult? • Fear of therapeutic failure • Medical system reinforces idea that poor outcome and death are failures of ‘system’ • and by extension, our failure • “all disease is fixable” • “better living through chemistry” • We are trained to feel this way; “if only……”

17. Why is this Difficult? • Fear of medico-legal system • Everyone has “right” to be cured; • If no cure happens, someone is to blame

18. Why is this Difficult? • Fear of not knowing • “we don’t do what we don’t do well” • Good communication is a skill that is not highly valued, therefore not taught

19. Why is this Difficult? • Fear of eliciting reaction • “don’t do anything unless you know what to do if it goes wrong” • Not trained to handle reactions • Not trained to allow emotion to come out

20. Why is this Difficult? • Fear of saying “I don’t know” • We are never rewarded for lack of knowledge • Can’t know or control everything

21. Why is this Difficult? • Fear of expressing emotions • Viewed as unprofessional • Suppressing emotions increases distance • between ourselves and patients

22. Why is this Difficult? • Ambiguity of “I’m sorry” • Two meanings • “I’m sorry for you” • “I’m sorry I did this” • Easily misinterpreted

23. Why is this Difficult? • Fear of one’s own illness and death • Cannot be honest with the dying unless you accept you will die

24. So How Do We Do This??

25. Never, never, never, ever… • NEVER “assume” • To assume: to make an ASS • of U • and ME

26. If you need to know something • If you want to know something

27. If you need to know something • If you want to know something • ASK!!

28. Six Step Protocol • -arrange physical context • -find out what patient knows • -find out what patient wants to know • -share information • -respond to patient’s feelings • -plan follow-through

29. Arrange physical context • Always in person, face to face • NEVER on telephone • Assure privacy • Verify who is present • Verify who should be present • ASK

30. Arrange physical context • Remove physical barriers • Sit down • patient-physician eyes at same level • appear relaxed, not casual • (avoid ‘open 4’) • Touch patient (appropriately) • above the waist, handshake, shoulder

31. Find out what patient knows • Not just knows, but understands • Use open questions • closed questions excellent for history-taking • prevent discussion

32. Find out what patient knows • Listen effectively to response: • tells understanding, ability to understand • Repeat back what patient says • Do not interrupt • Make encouraging cues • Maintain eye contact

33. Find out what patient knows • Tolerate silences • Listen for “buried question” • question asked while you are speaking

34. Find out what patient wants to know • Ask!! • Do not allow families to run interference • If patient chooses not to know now, may ask later

35. Share the information • Plan agenda • know beforehand what information has to get across • eg diagnosis, treatment, prognosis, support • Start by aligning with what patient knows

36. Share the information • Allow patients to ‘get ready’ • Impart information in small packets • best case retention = 50% • Speak English, not “Doctor” • Verify message is received

37. Respond to feelings • Acknowledge emotions • strong emotions prevent communication • identify and acknowledge them • Learn to be comfortable with silence and with emotion

38. Respond to feelings • Range of normal reaction is wide • give latitude as much as possible • stay calm, speak softly • be gentle, yet firm • stick to basic rules of interview: • question-listen-hear-respond

39. Respond to feelings • Distinguish between adaptive and maladaptive behaviors • Adaptive Maladaptive • anger rage • crying collapse • bargaining manipulation • fulfilling an ambition impossible “quest” • fear anxiety/panic • hope unrealistic hope

40. Respond to feelings • Respond with empathic responses • “it must be very hard to…” • “you sound angry (afraid, depressed)…”

41. Respond to feelings • In the face of true conflict: act, don’t react • If you cannot change behavior, get help

42. Planning follow-through • Have plan of action • Make certain patient’s understand what is fixable and what is not • Always be honest • Patient leaves with contract: • what will happen, who to call, how to call, when to return

43. You have one chance to get this conversation right • Patient/family will remember this always • How do you want to be remembered?

44. How to Break Bad News: A Guide for Health Care Professionals • Robert Buckman, M.D. • Johns Hopkins University Press, 1992 • ISBN: 0-8018-4491-6