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 NewsDr. Dex--Metropolitan Medical Center
Problem 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
Solution 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
ABCDE!
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,
ABCDE! 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