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Shortness of Breath & Breaking bad news. Sophie Lord. jg - 38m. PC : shortness of breath, reduced exercise tolerance HPC : 3-4 month history of cough Worsening of symptoms over previous 3 days Struggling to work Non smoker Attended GP 3 weeks previously - referred for chest X-ray. PMH :
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Shortness of Breath & Breaking bad news Sophie Lord
jg - 38m • PC: shortness of breath, reduced exercise tolerance • HPC: • 3-4 month history of cough • Worsening of symptoms over previous 3 days • Struggling to work • Non smoker • Attended GP 3 weeks previously - referred for chest X-ray
PMH: • Non-Hodgkin’s lymphoma aged 8 • Osteosarcoma (left humerus) aged 13 • Surgery • Chemotherapy
O/E: • Dyspnoeic at rest • Tachypnoeic & tachycardic • SpO2 91% on air • ?reduced air entry left upper lobe
Investigations: • Bloods: raised WCC, CRP and elevated D-dimer • CXR (from primary care): • Large, well defined mass in left upper lobe • ‘Highly suspicious’ - urgent CT recommended
Patient’s understanding: • ‘Something not quite right’ • No previous chest x-rays to compare with • CT needed due to this
Plan: • Discussion with consultant • Repeat CXR - no acute change • Discussion with patient (& mother): • Admission (requiring supplementary O2) • Explanation of CXR findings • Informed specialist cancer nurse
CT showed 10cm mass in left lung, with early atrial invasion • Referred to cardio-thoracic surgery & oncology teams at Leeds • Weekly echocardiograms • Awaiting PET scan
Re-attended A&E 2 weeks later: • Experienced left sided chest pain and palpitations • Troponin positive - admitted to MAU • Cardiac arrest whilst an inpatient • Resuscitated, intubated and transferred to Leeds • Died on ICU with family present
Breaking bad news • "Any information which adversely and seriously affects an individual's view of his or her future" • Test of communication skills • Emotional and stressful for both the doctor and the patient • Ethical and legal obligations to provide patients with as much information as they desire • Doctors cannot withhold medical information
SPIKES model • Developed by Robert Buckman, Professor of Oncology & Walter Baile, psychiatrist • Six steps • Goal is to enable the clinician to fulfil four objectives: • Gathering information from the patient • Transmitting the medical information • Providing support to the patient • Eliciting the patient’s collaboration in developing a strategy or treatment plan for the future
s - Setting up the interview • Arrange privacy • Involve significant others • Sit down • Make connection with the patient • Manage time constraints and interruptions
P - assessing the patient’s Perception • “Before you tell, ask” • Use open-ended questions to create a picture of how the patient perceives the situation • Use this information to correct misinformation and tailor the bad news to what the patient understands • Determines if there is any ‘illness denial’
I - Obtaining the patient’s invitation • How much information would the patient like to know? • Discussing information disclosure at the time of ordering tests
k - giving knowledge & information to the patient • Warning • Avoid medical jargon • Avoid excessive bluntness • Small chunks of information • Check patient understanding periodically
E - addressing the patient’s emotions with empathic responses • Observe • Identify the emotion • Identify the reason for the emotion • Demonstrate to the patient you have done so
S - strategy & summary • Understanding reduces fear • Summarise the discussion • Strategy for future care • Time for questions • Written information
Questions? Thank you
