Bad News DPR (Dr Mohr)

Question 1

A major goal of information delivery is _______.

Answer 1

to get the patient to cooperate with the recommended treatment; compliance

Question 2

Physicians generally fail to communicate information effectively due to: (3)

Answer 2

1. Poor listening skills
2. Understanding what patients already know
3. Conceptualizing the situation with the patient

Question 3

Most of the information delivered to patients tends to ______.

Answer 3

be difficult or even bad news

Question 4

Why is delivering bad news difficult? (4)

Answer 4

1. Fundamentally unpleasant
2. Lack of training/role models - not addressed during residency
3. Fear of emotional reaction
4. Concern over admitting guild or responsibility;

Question 5

Saying “I am sorry” does not equal?

Answer 5

claiming responsibility

Question 6

Delivering bad news well….(4)

Answer 6

1. Strengthens the physician-patient relationship
2. Fosters collaboration
3. Permits patients, families to cope
4. Minimizes litigation if done well

Question 7

ABCDE Mnemonic

Answer 7

A: Advanced Preparation
B: Build a Therapeutic relationship
C: Communicate Well
D: Deal with patient and family reactions
E: Encourage and Validate emotions

Question 8

Advance Preparation:

Familiarize yourself with ___.

Answer 8

relevant clinical information

Question 9

Advance Preparation:

Arrange for ____.

Answer 9

adequate time in private setting, turn pager/phone off

Question 10

Advance Preparation:

Consider the environment ____.

Answer 10

seating, tissues available

Question 11

Advance Preparation:

Mentally (or verbally) ____ and _____.

Answer 11

rehearse how you will deliver the news and Prepare emotionally (breathe)

Question 12

How to build a Therapeutic Relationship? (3)

Answer 12

1. Have a support person present
2. Introduce yourself to everyone present
3. Determine the patients’ preference for what and how much information they want

Question 13

What if the family says “don’t tell the patient”? - the family (3)

Answer 13

1. Acknowledge the families fears;
2. Ask: why not tell them?
3. Talk to the patient together

Question 14

What if the family says “don’t tell the patient”? - Legally (2)

Answer 14

1. Legal obligation to obtain informed consent from patient;

2. Law states that clinicians must provide as much information as the patient desires;

Question 15

Build a Therapeutic Relationship: Delivering the news (4)

Answer 15

1. When appropriate, foreshadow the bad news - don’t just drop the bomb
2. Use touch when appropriate
3. Avoid inappropriate humor and flip comments
4. assure your pt you will be available; schedule a follow up

Question 16

Patients will have difficulty remembering what is said _____.

Answer 16

after the initial statement

Question 17

Communicate well: (6)

Answer 17

1. Ask the pt what they know/understand
2. Speak frankly but compassionately
3. Encourage questions.
4. Have pt repeat what you have told them to check for understanding
5. Write/draw things out
6. Repeat key information, summarize and make follow up plans

Question 18

Communicate well: Things to avoid (4)

Answer 18

1. Jargon
2. Monologue (you should be promoting dialogue)
3. Vagueness
4. Confusion

Question 19

______ is paramount in dealing with patient and family reactions

Answer 19

Nonverbal Communication

Question 20

It is important to assess and respond to _____ and _____.

Answer 20

emotional reactions and be aware of patients’coping strategies

Question 21

Patient Responses: Affective/Emotional (7)

Answer 21

1. Quiet
2. Tears, sadness
3. Hopelessness
4. Anger, aggression
5. Fear
6. Anxiety
7. Relief

Question 22

Patient Responses: Cognitive (6)

Answer 22

1. Denial
2. Blame
3. Guilt
4. Disbelief
5. Shame
6. Intellectualization

Question 23

Patient Response: Physiologic (2)

Answer 23

1. Fight or Flight

2. Physically agitated

Question 24

What happens to a patient in fight or flight (high anxiety/panic) mode? (3)

Answer 24

1. Heart rate increase
2. Breathing increase/shallow
3. Thinking becomes unclear and/or simple

Question 25

Physician Responses to patients emotions: (7)

Answer 25

1. Be prepared for strong reactions of your own - self awareness and monitoring 2. Give pt time to react - wait and watch non-verbals 3. Give permission by naming the feeling (i can see that you are feeling....) 4. Acknowledge own feelings; be empathetic; it is ok to say “I’m sorry” or “I don’t know” 5. Don’t argue or criticize colleagues; avoid defending self or others 6. Monitor Pt's ability to understand information 7. Insert information as appropriate

Question 26

How to deal with the patient's emotional reactions: (3)

Answer 26

1. Mirror or reflect their emotional reactions (I would be angry too) 2. Encourage them to describe their emotions 3. Listen quietly and attentively 4. Tune into the pt's nonverbal messages

Question 27

Encourage and Validate Emotions: (5)

Answer 27

1. Offer realistic hope; discuss treatment options 2. Explore what the news means to the pt 3. Determine what support systems the pt has in place 4. Use interdisciplinary services to enhance patient care – but not to disengage from relationship 5. Attend to your own needs (self reflect/projection/ self monitoring)

Question 28

Barriers when Communicating Bad News (5)

Answer 28

1. Denying Defeat 2. Confusion instead of clarity 3. Fear of destroying hope. 4. Keeping your distance 5. disappearing

Question 29

Denying Defeat

Answer 29

- Postponing discussions until ‘absolutely sure’ | - Continuing to run tests

Question 30

Denying Defeat - Results

Answer 30

This does not allow patient to make appropriate decisions

Question 31

Confusion instead of Clarity

Answer 31

Using jargon and talking around the actual subject

Question 32

Confusion instead of Clarity - Results

Answer 32

Patients/families are often left confused

Question 33

Fear of destroying hope

Answer 33

The notion that telling the truth will destroy hope and therefore a will to live

Question 34

Fear of destroying hope - Results

Answer 34

- the Pt will believe that you think they cannot handle the situation - Instead convey confidence that patient can and will handle the situation

Question 35

Keeping your distance

Answer 35

Being professional is being detached

Question 36

Results of keeping your distance

Answer 36

pt feels abandoned

Question 37

Disappearing

Answer 37

Since physician can’t change the outcome, the physician has nothing to offer