A Budding Emergencist
Thursday, August 24, 2006
  Being Insensitive and Evasive!
My presentation I made in a few hours on "breaking bad news," following the 10/20/30 rule of Powerpoint Presentations. The audience was interns and residents at my "continuity care", part of my internship:

Breaking Bad News

Dr. Dex--Metropolitan Medical Center

Paternalistic approach
Patient's Right of Autonomy and Self-Determination
Evaluating My Own Response
Bad Outcomes—Neglect & Misunderstanding
Physician Unprepared
Balancing Informing and Empathy
Pt feelings—Abandonment, Isolation, Confusion
Lack of Follow-up

What Do We Want?
Informed Patient
Independently Seeks Solutions
Communicates Problems, Complaints
Good Follow-Up
Support Network
Maximize Quality of Life
Maximize Normal Functioning
Advance Care Directives

Advance Preparation
Arrange for Adequate Time, Privacy, and No Interruptions
Review Relevant Clinical Information
Mentally Rehearse, Phrases to Use/Avoid
Prepare Yourself Emotionally

Build a Therapeutic Relationship

What does the patient know/want to know?
Have family/support persons present
Introduce yourself to everyone
Warn the patient that bad news is coming
Use touch when appropriate
Schedule Follow-Up.

Communicate Well
Ask what the patient knows
Be “Frank” but Compassionate—avoid jargon and euphemisms
Allow for Silence and Tears; Patient's pace
Ask Patient to Verbalize Understanding
Allow Time to Answer Questions
Conclude with Summary and Plan

Deal With Patient and Family Reactions
Assess and Respond to Patient and Family Emotional Reactions; repeat at each Visit
Be Empathetic
Do not Argue With or Criticize Colleagues (including in notes!)

Encourage and Validate Emotions
Explore What the News Means to the Patient
Offer Realistic Hope according to the Patient's Goals
Use Interdisciplinary Resources
Take Care of Your Own Needs; Be attuned to the Needs of involved House Staff and Office or Hospital Personnel.

Mistakes to Avoid
Patient Confused As To Diagnosis or Plan.
Patient in Denial or Not on Board
Neglected Getting Professional Translation
Other caregivers unaware of diagnosis (ER!)
Pt in Pain or with Unresolved Questions
No Advance Care Directive
Patients' diagnosis minimized
Patient's reaction to diagnosis explored

My Own Tips
Sit Down
Make sure you're right
Confirm and Name (“Mirror”) Patient's Emotions
Delegate One Family Member
Get Translation
The Patient Is the One with The Disease
Ensure Pain Control
Ensure Medical Follow-Up
Ensure Ancillary Services—SW, Financial, Hospice, ER Packet, Support Group,

Advance preparation
Build a therapeutic environment/relationship
Communicate Well
Deal with Patient and Family Reactions
Encourage and Validate Emotions

What do you think?
-The Emergencist
I think the rest of the ER is going to get a bit backed up if you do all that stuff. :wink:

I have a post on the same topic.
No doubt. So admit, TURF to med/surg, and let them do it, and skip away happy-go-lucky! Uh, well, I just read your post about Mrs. Doe, and I must say you have a difficult position and I must say you acted admirably, a real man. I salute you, sir!

Sit down: I think it's among the most important and least considered behaviors. Docs like to assume the "superior" position. Sitting down means you see the patient as an equal. And that you're planning to take some time. I did it all the time. Wrote about it in a thingy I wrote for "graduating" surgeons finishing residencey.
You need to touch them if you are going to give them bad news, too. I prefer shoulder or knee, personally, but you have to do whatever feels right. If you give someone bad news without physically touching them, they might think you are giving them the "evil eye."

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Emergency medicine, from the beginning of a new doctor's career.

Location: Big City, Metropolis, United States

Walk softly and carry a big vocabulary. Don't be inhuman. Find and greet God in every person you meet. The patient is the one with the disease. Do not get distracted. Charity begins at home. Do good and be happy. Don't just do something, stand still. Wear sunscreen. Don't get anyone pregnant, and don't go to jail, young man. Budget your luxuries first. You don't know what you don't know. People like learning, they just don't like being taught. When in doubt, go out. When life gives you lemons, make lemonade. Honey attracts more flies than vinegar.

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