Monday, February 2, 2015

Breaking Bad News To A Patient- Medical Ethics

Breaking bad news to a patient is one of the most difficult duties for a physician. Without proper training and formal preparation the discomfort and the uncertainty associated with breaking a bad news can lead to emotional misunderstandings between the physician and the patient.

What Is Bad News?
Information that can drastically alter the life and the world of the patient is termed as a bad news.

Reasons Why It is a Difficult Task To Break Bad News?
Conveying a bad news to the patient is a skilled communication and not at all easy. There are many reasons why it is a challenging task for the physicians and doctors.

1. The amount of truth to be disclosed is subjective.
2. There is a feeling of incompetence on the part of the physician and a fear of a negative reaction from the patient and the relatives.
3. The physician is reminded of his/her own vulnerability to a terminal illness and many times they find themselves helpless over the emotional distress.
4. Lack of sufficient training in breaking bad news is a major drawback to most physicians and health care workers.

A Few Protocols To Learn For breaking Bad News:
In order to deliver a bad news to the patient in a diciplined and a structured manner different protocols have been adviced and few of them are discussed below:

SPIKES Protocol:

1. Setup: The physical setting should be comfortable and private for both the physician and the patient. After a routine introduction it is important to ask the patient if he/she needs to be alone or accompanied by some relative or a friend. The initial few phrases spoken by the physician should give an impression to the patient that there is something important to be discussed.

2. Patient Perception: The next step is to find out what the patient thinks about his/her health problem and what he/she understands so far of the condition.
example: Asking a question like do you remember why we did a colonoscopy?
Or; What have you been told about your symptoms?

3. Invitation: Even if the patient comes in to get the test results it is always important to ask if the patient is ready to know the results. Get the patient's permission to tell the news and the details they want to know.
A physician may ask by saying for example:Different patients have different styles , some may want to know the complete medical details, some just want to know get the main idea. What will you prefer? If it turns out to be something serious would you still like to know?
This gives the patient an idea that the doctor has some life changing news to deliver.

4. Give Knowledge: In this step the physician can now explain the patient precisely what the problem is, giving the news in small doses. It is important to consider explaining the diagnosis, treatment, prognosis and ways for coping and support system.

5. Manage Emotions: a patient after listening to the bad news may react with different emotions, some may go into disbelief with comments like 'its not true', 'i cannot understand you doctor' or some may start crying. others may over react with anger and get harsh with the doctor blaming them.This is the moment when the physician needs to be understanding the patients emotions and react appropriately.  Stay calm, and give the patient time to react and grieve.

6. Summarize: Summarizing the encounter and getting the patient paraphrase what they have understood and planning for a followup and answering patients concerns is very important. If the patient have any misconceptions try to correct them or if the patient seems to be very upset call them after a day or two to discuss again when he/she will be more understanding of the situation.

BREAKS Protocol:

1. Background: An effective communication depends upon the in dept knowledge of the patients problem. A physician should keep himself prepared to answer all the questions that a concerned patient may ask. Knowing the cultural, education and ethnic background of the patient is also important as different patients have different levels of understanding their problems. The physical setup with the patient should be made comfortable and there should be no interruptions.

2. Rapport: Building a good rapport is fundamental for a good physician-patient relationship. Maintaining an eye contact, listening to the patient and giving appropriate time to understand and respond all are very important.

3. Exploring: Whenever attempting to break a bad news always ask the patient how much he/she knew about the condition. In some cases the patient already be knowing most of the diagnosis. Once the patient's views and understanding is explored the physician is now prepared to give the bad news.

4. Announce: A warning statement like " i have something serious to say" or 'the results does not seem to be promising' prepares the patient to listen the news. Also it is important to ask if the patient wants to know the results or he/ she is not ready at the present moment. Announcement of the bad news must be in a straightforward simple language with no medical terminologies.

5. Kindling: People listen to their diagnosis differently. some may break into tears, some may remain completely silent and some may go into denial. Give the patient time to understand and react. Adequate space for free flow of emotions is to be given. Show empathy and ask if the patient have any questions.

6. Summarize: The physician needs to summarize the session and make sure patient has not misunderstood anything. Highlight the main points again and plan for a next appointment.

ABCDE Protocol:

1. Advance preparation.
2. Build a Therapeutic environment and relationship.
3. Communicate well.
4. Deal with patient and family reactions
5. Encourage and validate emotions.

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