Breaking of Bad News

					 BREAKING OF BAD
      NEWS
DR OJIRIGHO AKPONOJIVI
        EUGENE
DEPARTMENT OF FAMILY
       MEDICINE
       PRETEST QUESTIONS
1. Which of the following is not a mnemonic used
   in breaking bad news.
A) FICA
B) ABCDE
C) SPIKES
D) BREAKS
E) SAD NEWS
       PRETEST QUESTIONS
2. Which of the following is a ‘Don’t’ in breaking
   bad news
A. Mental rehearsal
B. Giving a tissue
C. Share it over the phone
D. Eye contact
E. Holding hands
       PRETEST QUESTIONS
3. Which of the following is not part of the
   ABCDE model of breaking bad news?
A) Advance preparation
B) Build a relationship
C) Communicate well
D) Discuss common ideas
E) Encourage emotions
                    OUTLINE
   INTRODUCTION
   HISTORICAL PERSPECTIVE
   GOALS OF THE BAD NEWS INTERVIEW
   BARRIERS TO BREAKING BAD NEWS
   PROTOCOLS/MODELS IN BBN
   RESPONSE TO BAD NEWS
   WHAT NOT TO DO IN BBN
   CLINICAL SCENARIO
   REVIEW OF EARLIER CASES
   PICTURES TELL A LOT
   ROLE OF THE FAMILY PHYSICIAN
   MULTIDISCIPLINARY APPROACH
   CHALLENGES IN GOPD/BSUTH
   RECOMMENDATIONS
   MNEMONICS
   QUOTES
   REFERENCES
        INTRODUCTION
The bad news about breaking bad
 news is that bad news is bad
 news 1

“Nothing travels faster than the
 speed of light with the possible
 exception of bad news, which
 obeys its own special laws”
 Douglas Adams (1952-2001) “The
 Hitch-hiker’s Guide to the Galaxy”
        INTRODUCTION Cont’d
 CLINICAL CASES
1. A 66 year old widow and a known hypertensive on
   treatment was brought to the A & E Unit of BSUTH
   with a few hours history of recent memory loss. This
   started when she received a phone call from the son
   who informed her of the death of a close relative. No
   history of loss of consciousness, no history of
   weakness of the limbs, no facial palsy and no
   difficulty with speech. Not a known psychiatric
   patient.
2. [UNTH] O.C.2 was a 60-year-old female who was
brought from the rural area to the hospital by her
youngest daughter. Following assessment by the
gynecologists, she was booked for Examination Under
Anesthesia (EUA) and excision biopsy for suspected
carcinoma of the cervix. On waking up in the recovery
room, she discovered the mass was still present. When
she enquired, she was told by a doctor on the team that
there was nothing that could be done for her. From that
moment, she became depressed and withdrawn,
refusing to speak to anyone, including her children. That
same day, she began to reject her meals, medications,
and became excessively sleepy. When our unit visited
subsequently, her condition remained unchanged. One
afternoon, four days later, her daughter discovered she
had passed on in her sleep.
      INTRODUCTION Cont’d
DEFINITION OF TERMS
Bad news may be defined as “any
 information which adversely and
 seriously affects an individual's view of
 his or her future”3
Another definition states “any news that
 drastically and negatively alters the
 patient’s view of her or his future” is bad
 news.4
         DEFINITION cont’d
Bad news is also defined as one which is
 pertaining to a situation where there is  a
 feeling of no hope, a threat to a person’s
 mental or physical well being, a risk of
 upsetting an established lifestyle or
 where a message is given which conveys
 to an individual fewer choices in his or
 her life4
Breaking bad news also known as the
 bad news interview is simply the
 process of conveying such bad news.
    EXAMPLES OF BAD NEWS
Disease recurrence
Spread of disease
Terminal disease like cancer, HIV/AIDS
Early onset Diabetes
Telling parents their child had severe
 birth asphyxia and cerebral palsy
Telling a pregnant woman of a foetal
 demise
Informing a man or woman of the death
 of a loved one
   PRIMARY VS SECONDARY BAD
             NEWS5
Primary bad news especially in cancers is
 the confirmation of the diagnosis while
Secondary bad news is the prognosis of
 the cancer and the chances of survival
Many patients view the secondary bad
 news as worse than the primary bad
 news
     HISTORICAL PERSPECTIVE
 Hippocrates (c.460 BC- c.370 BC) “concealing most
  things from the patient while you are attending to
  him. Give necessary orders with cheerfulness and
  serenity revealing nothing of the patient’s future or
  present condition. For, many patients… have taken a
  turn for the worse… by forecast of what is to come.”6
 Thomas Percival (1740–1804) was an English
  physician and author, best known for crafting
  perhaps the first modern code of medical ethics. He
  also gave a similar warning in 1803.
  HISTORICAL PERSPECTIVE cont’d
 The Code of Ethics adopted by the American
  Medical Association in 1847 was attributed officially
  to Thomas Percival. It stated, “The life of a sick
  person can be shortened not only by the acts, but also
  by the words or manner of a physician. It is, therefore,
  a sacred duty to guard himself carefully in this
  respect, and to avoid all things which have a
  tendency to discourage the patient and to depress his
  spirits.”6
 Surveys3 conducted from 1950 to 1970 revealed that
  most physicians considered it inhumane and
  damaging to the patient to disclose bad news about
  the diagnosis
  HISTORICAL PERSPECTIVE cont’d
 By the late 1970s3 most physicians were open about
  telling cancer patients their diagnosis. Studies began
  to indicate that patients also desired additional
  information. A survey3 published in 1982 of 1,251
  Americans indicated that 96% wished to be told if
  they had a diagnosis of cancer, but also that 85%
  wished, in cases of a grave prognosis, to be given a
  realistic estimate of how long they had to live.
  European patients' wishes have been found to be
  similar to those of American patients. For example, a
  study3 of 250 patients at an oncology center in
  Scotland showed that 91% and 94% of patients,
  respectively, wanted to know the chances of cure for
  their cancer and the side effects of therapy.
  HISTORICAL PERSPECTIVE cont’d
In North America, principles of
 informed consent, patient autonomy,
 and case law have created clear ethical
 and legal obligations to provide patients
 with as much information as they desire
 about their illness and its treatment.
About 60% of family members will not
 like full disclosure to patients in Nigeria
 according to questionnaires distributed
 by Olasinde7. Withholding bad news is
 still common here.
        GOALS OF THE BAD NEWS
              INTERVIEW
1. Gathering information from the patient. This allows
   the physician to determine the patient's knowledge
   and expectations and readiness to hear the bad news.
2. Provide intelligible information in accordance with
   the patient's needs and desires.
3. Support the patient by employing skills to reduce
   the emotional impact and isolation experienced by
   the recipient of bad news.
4. Develop a strategy in the form of a treatment plan
   with the input and cooperation of the patient.
     BARRIERS TO BREAKING BAD
               NEWS
 ‘MUM’ effect. Tesser3 and others conducted
  psychological experiments that showed that the
  bearer of bad news often experiences strong
  emotions such as anxiety, a burden of responsibility
  for the news, and fear of negative evaluation. This
  stress creates a reluctance to deliver bad news, which
  he named the “MUM” effect (keeping Mum about
  Undesirable Messages). The MUM effect is
  particularly strong when the recipient of the bad
  news is already perceived as being distressed
             BARRIERS Cont’d
 Blocking behaviours. The doctor should not use any
  blocking behaviors to immunize himself from the
  potential distress that he may not be able to handle.
Ø Offering premature reassurances and advices before
  addressing the main concerns of the patient,
Ø explaining the distress as normal,
Ø playing down the problems,
Ø changing the topic of discussion,
Ø cracking untimely jokes
             BARRIERS Cont’d
 No formal training on breaking of bad news in training
  institutions and hospitals for doctors and other health
  workers.
 Lack of awareness about the importance of breaking bad
  news technique. ‘Just tell it as it is.’
 Some view showing emotion as a sign of weakness.
  ‘You are a man. Why are you crying like a woman?’
  ‘Being reserved in showing emotion.’
 Socio-cultural backgrounds. ‘Pain threshold.’ ‘Some
  tribes are more expressive.’ Under/over-estimating
  emotions.
 Breaking news when you in no position to do so. Social
  media. Rumour. Propaganda.
 Language barrier. Ineffective interpreters/translators.
 Lab results are not sealed.
     PROTOCOLS/MODELS IN BBN
1.   SPIKES protocol
2.   ABCDE model
3.   Framework for breaking bad news
4.   BREAKS protocol
5.   SAD NEWS model
6.   PEWTER model
          SPIKES PROTOCOL3,8
 Developed by Walter F. Baile, Robert Buckman and
  others of The University of Texas MD Anderson
  Cancer Center, Houston, Texas, USA; and The
  Toronto-Sunnybrook Regional Cancer Centre,
  Toronto, Ontario, Canada
 Designed as a medical protocol that require the
  execution of a stepwise plan just like that for CPR,
  DKA etc., each step must be carried out and, to a
  great extent, the successful completion of each task is
  dependent upon the completion of the step before it.
 There are 6 steps represented by the mnemonic:
  SPIKES
      SPIKES PROTOCOL cont’d
STEP 1: S—SETTING UP the Interview
Ø Mental rehearsal
Ø Arrange for some privacy. An interview room is ideal.
  If one is not available, draw the curtains around the
  patient's bed. Have tissues ready.
Ø Involve significant others. Patient's choice and
  consent.
Ø Sit down. It relaxes the patient. A sign that you will
  not rush. No barriers between you & the patient. If
  you have recently examined the patient, allow them
  to dress before the discussion.
             Step 1 Cont’d
Ø Make connection with the patient. Maintaining
  eye contact may be uncomfortable but it is an
  important way of establishing rapport.
  Touching the patient on the arm or holding a
  hand (if the patient is comfortable with this) is
  another way to accomplish this.
Ø Manage time constraints and interruptions.
  Inform the patient of any time constraints you
  may have or interruptions you expect. Set your
  pager, beeps, phones on silent or ask a
  colleague to respond to your pages.
      SPIKES PROTOCOL cont’d
STEP 2: P—ASSESSING THE PATIENT'S PERCEPTION
Note: Steps 2 and 3 of SPIKES are points in the interview
  where you implement the axiom “before you tell, ask.”
Ø Before discussing findings, the clinician uses open-ended
  questions to create a picture of how the patient
  perceives the medical situation—what it is and whether
  it is serious or not. For example, “What have you been
  told about your medical situation so far?” or “What is
  your understanding of the reasons we did the CT-Scan?”.
Ø Correct misinformation and tailor the bad news to what
  the patient understands.
Ø Check for Illness denial: wishful thinking, omission of
  essential but unfavorable medical details of the illness, or
  unrealistic expectations of treatment .
      SPIKES PROTOCOL cont’d
STEP 3: I—OBTAINING
  THE PATIENT'S INVITATION
Ø While a majority of patients express a desire for full
  information about their diagnosis, prognosis, and
  details of their illness, some patients do not.
  However, shunning information is a valid
  psychological coping mechanism
Ø Discussing information disclosure at the time of
  ordering tests can cue the physician to plan the next
  discussion with the patient.
Ø If patients do not want to know details, offer
  to answer any questions they may have in the
  future or to talk to a relative or friend.
      SPIKES PROTOCOL cont’d
STEP 4: K—
  GIVING KNOWLEDGE AND INFORMATION TO
  THE PATIENT
Ø Warning the patient that bad news is coming helps.
  Examples “Unfortunately I've got some bad news to tell
  you” or “I'm sorry to tell you that…”
Ø Start at the level of comprehension and vocabulary of the
  patient.
Ø Try to use nontechnical words such as “spread” instead
  of “metastasized” and “sample of tissue” instead of
  “biopsy.”
Ø Avoid excessive bluntness (e.g., “You have very bad
  cancer and unless you get treatment immediately you are
  going to die.”)
               STEP 4 Cont’d
Ø Give information in small chunks and check
  periodically as to the patient's understanding.
Ø When the prognosis is poor, avoid using phrases
  such as “There is nothing more we can do for you.”
  This attitude is inconsistent with the fact that
  patients often have other important therapeutic goals
  such as good pain control and symptom relief.
      SPIKES PROTOCOL Cont’d
STEP 5: E—ADDRESSING
  THE PATIENT'S EMOTIONS WITH
  EMPATHIC RESPONSES
Ø Responding to the patient's emotions is one of the most
  difficult challenges of breaking bad news. Patients'
  emotional reactions may vary from silence to disbelief,
  crying, denial, or anger.
Ø An empathic response consists of four steps:
ü First, observe for any emotion on the part of the patient.
  This may be tearfulness, a look of sadness, silence, or
  shock.
ü Second, identify the emotion experienced by the patient
  by naming it to oneself. If a patient appears sad but is
  silent, use open questions to query the patient as to what
  they are thinking or feeling.
                STEP 5 Cont’d
ü Third, identify the reason for the emotion. This is
  usually connected to the bad news. However, if you
  are not sure, again, ask the patient.
ü Fourth, after you have given the patient a brief
  period of time to express his or her feelings, let the
  patient know that you have connected the emotion
  with the reason for the emotion by making a
  connecting statement. 
 EXAMPLE OF EMPATHIC RESPONSE
 Doctor: I'm sorry to say that the x-ray shows that the
  chemotherapy doesn't seem to be working [pause].
  Unfortunately, the tumor has grown somewhat.
 Patient: I've been afraid of this! [Cries]
 Doctor: [Moves his chair closer, offers the patient a
  tissue, and pauses.] I know that this isn't what you
  wanted to hear. I wish the news were better.
                STEP 5 Cont’d
q Examples of Empathic statements
o “I can see how upsetting this is to you.”
o “I can tell you weren’t expecting to hear this.”
o “I know this is not good news for you.”
o “I’m sorry to have to tell you this.”
o “This is very difficult for me also.”
o “I was also hoping for a better result.”
               Step 5 Cont’d
q Examples of exploratory questions
o “How do you mean?”
o “Tell me more about it.”
o “Could you explain what you mean?”
o “You said it frightened you?”
o “Could you tell me what you’re worried about?”
o “Now, you said you were concerned with the
  children. Tell me more.”
               STEP 5 Cont’d
q Examples of validating responses
o “I can understand how you feel that way.”
o “I guess anyone might have that same reaction.”
o “You were perfectly correct to think that way.”
o “Yes, your understanding of the reason for the tests
  is very good.”
o “It appears that you thought things through very
  well.”
o “Many other patients have had a similar experience.”
      SPIKES PROTOCOL cont’d
STEP 6: S—STRATEGY AND SUMMARY
Ø Summarize and outline the way forward. A clear plan
  for the future makes patients less likely to feel anxious
  and uncertain.
Ø Before discussing a treatment plan, it is important to ask
  patients if they are ready at that time for such a
  discussion. Presenting treatment options to patients
  when they are available is not only a legal mandate in
  some cases, but it will establish the perception that the
  physician regards their wishes as important.
Ø Sharing responsibility for decision-making with the
  patient may also reduce any sense of failure on the part
  of the physician when treatment is not successful.
  Checking the patient's misunderstanding of the
  discussion can prevent the documented tendency of
  patients to overestimate the efficacy or misunderstand
  the purpose of treatment.
            ABCDE MODEL
 Developed by Michael W. Rabow and
  Stephen J. McPhee of the Division of General
  Internal Medicine, University of California at
  San Francisco, USA
 It is based on the mnemonic ABCDE
         ABCDE MODEL Cont’d
A. Advance preparation
ü Ask what the patient already knows and
   understands.
ü What is his or her coping style?
ü Arrange for the presence of a support person and
   appropriate family
ü Arrange a time and place that will be undisturbed
   (hand off beeper)
ü Prepare emotionally
ü Decide which words and phrases to use (write down
   a script)
ü Practice delivering the news
         ABCDE MODEL Cont’d
B. Build a therapeutic environment/relationship
ü Arrange a private, quiet place without interruptions
ü Provide adequate seating for all
ü Sit close enough to touch if appropriate
ü Reassure about pain, suffering, abandonment
         ABCDE MODEL Cont’d
C. Communicate well
ü Be direct ("I am sorry, have bad news")
ü Do not use euphemisms, jargon, acronyms
ü Say "cancer" or "death“
ü Allow for silence
ü Use touch appropriately
ü Ask patient to repeat his or her understanding of the
   news
ü Arrange additional meetings
ü Use repetition and written explanations or reminders
         ABCDE MODEL Cont’d
D. Deal with patient and family reactions
ü Assess patient reaction
o physiologic responses: flight/fight,
  conservation/withdrawal
o cognitive coping strategies: denial, blame,
  intellectualization, disbelief, acceptance
o affective responses: anger/rage, fear/terror, anxiety,
  helplessness, hopelessness, shame, relief, guilt,
  sadness, anticipatory grief
o Listen actively, explore feelings, express empathy
         ABCDE MODEL Cont’d
E. Encourage and validate emotions (reflect back
   emotions)
ü Correct distortions
ü Offer to tell others on behalf of the patient
ü Evaluate the effects of the news
ü Explore what the news means to the patient
ü Address further needs, determine the patient's
   immediate and near-term plans, assess suicidality
ü Make appropriate referrals for more support
ü Provide written materials
ü Arrange follow-up
ü Process your own feelings
A FRAMEWORK FOR BREAKING BAD
          NEWS10
1. Preparation:
 Ø Set up appointment as soon as possible
 Ø Allow enough uninterrupted time; if seen in surgery,
   ensure no interruptions
 Ø Use a comfortable, familiar environment
 Ø Invite spouse, relative, friend, as appropriate
 Ø Be adequately prepared re clinical situation, records,
   patient’s background
 Ø Doctor to put aside own “baggage” and personal
   feelings wherever possible
          FRAMEWORK Cont’d
2. Beginning the session / setting the scene
Ø Summarize where things have got to  date, check
   with the patient
Ø Discover what has happened since last seen
Ø Calibrate how the patient is thinking/feeling
Ø Negotiate agenda
            FRAMEWORK Cont’d
3. Sharing the information
Ø Assess the patient’s understanding first: what the patient
    already knows, is thinking or has been told
Ø Gauge how much the patient wishes to know
Ø Give warning first that difficult information coming e.g. "I'm
    afraid we have some work to do...." "I'm afraid it looks more
    serious than we had hoped....“
Ø Give basic information, simply and honestly; repeat important
    points
Ø Relate your explanation to the patient’s framework
Ø Do not give too much information too early; don’t pussyfoot
    but do not overwhelm
Ø Give information in small “chunks”; categorise information
    giving
Ø Watch the pace, check repeatedly for understanding and
    feelings as you proceed
Ø Use language carefully with regard given to the patient's
    intelligence, reactions, emotions: avoid jargon
            FRAMEWORK Cont’d
4.   Being sensitive to the patient
Ø Read the non-verbal clues; face/body language, silences, tears
Ø Allow for “shut down” (when patient turns off and stops
    listening) and then give time and space: allow possible denial
Ø Keep pausing to give patient opportunity to ask questions
Ø Gauge patient’s need for further information as you go and
    give more information as requested, i.e. listen to the patient's
    wishes as patients vary greatly in their needs
Ø Encourage expression of feelings, give early permission for
    them to be expressed: i.e. “how does that news leave you
    feeling”, “I’m sorry that was difficult for you”, “you seem
    upset by that”
Ø Respond to patient’s feelings and predicament with
    acceptance, empathy and concern
    Being sensitive to the patient
             Cont’d
Ø Check patient’s previous knowledge about
  information given
Ø Specifically elicit all the patient’s concerns
Ø Check understanding of information given ("would
  you like to run through what are you going to tell
  your wife?")
Ø Be aware of unshared meanings (i.e. what cancer
  means for the patient compared with  what it means
  for the physician)
Ø Do not be afraid to show emotion or distress
           FRAMEWORK Cont’d
5. Planning and support     
Ø Having identified all the patient’s specific concerns, offer
   specific help by breaking down overwhelming feelings
   into manageable concerns, prioritizing and
   distinguishing the fixable from the unfixable
Ø Identify a plan for what is to happen next
Ø Give a broad time frame for what may lie ahead
Ø Give hope tempered with realism (“preparing for the
   worst and hoping for the best”)
Ø Ally yourself with the patient (“we can work on this
   together  ...between us”) i.e. co-partnership with the
   patient / advocate of the patient
Ø Emphasize the quality of life
Ø Safety net
          FRAMEWORK Cont’d
6. Follow up and closing  
Ø Summarize and check with patient
Ø Don't rush the patient to treatment
Ø Set up early further appointment, offer telephone
   calls etc.
Ø Identify support systems; involve relatives and
   friends
Ø Offer to see/tell spouse or others
Ø Make written materials available
          FRAMEWORK Cont’d
 This framework for “breaking bad news” is based on
  a number of people’s work:
ü Brod et al, 1986;
ü Maguire and Faulkner, 1988;
ü Sanson-Fisher, 1992,
ü Buckman, 1994; 
ü Cushing and Jones 1995). 
 From Silverman J., Kurtz S.M., Draper
  J.  (1998)  Skills for Communicating with Patients.
  Radcliffe Medical Press  Oxford
         BREAKS PROTOCOL4
 B – Background
 R – Rapport
 E – Exploring
 A – Announce
 K – Kindling
 S – Summarize
By Vijayakumar Narayanan, Bibek
  Bista, and Cheriyan Koshy of the Department of
  Oncology and Palliative Medicine, St. Gregorios
  Medical Mission Hospital, Parumala, India
          SAD NEWS MODEL11
 S – Set up and Sit down
 A – Ask, don’t tell
 D – Deliver the news
 N – No fancy lingo
 E – Expect, permit, respond to Emotion
 W – Wait
 S – Support and Summarize
Developed by the Queens University Clinical Skills
  Program. Queens’s University in Ontario, Canada
           PEWTER MODEL12
 P – Prepare
 E – Evaluate
 W – Warn
 T – Tell
 E – Emotional response
 R – Regroup
 Developed by Kathleen Keefe-Cooperman and  Peggy
  Brady-Amoon; both are counseling experts with the
  American Counseling Association
      RESPONSE TO BAD NEWS
            (STRESS)
 The response to stressful events have 3
  components13:
Ø An emotional response, with somatic
  accompaniments
Ø A Coping strategy
Ø A Defence mechanism
RESPONSE TO BAD NEWS cont’d

 An emotional response, with somatic
  accompaniments. It consist
ü Anxiety responses with autonomic arousal leading
  to apprehension, irritability, tachycardia, increased
  muscle tension and dry mouth (assoc with a threat)
ü Depressive responses with pessimistic thinking and
  reduced activity (assoc with separation or loss)
 RESPONSE TO BAD NEWS cont’d

  Coping strategies: conscious efforts to reduce the
   emotional and somatic responses. 2 kinds:
1. Problem-solving strategies:
a. Seeking help from another person
b. Obtaining information and advice
c. Solving problems
d. Confrontation
 RESPONSE TO BAD NEWS cont’d

 2. Emotion-reducing strategies include:
a. Ventilation of emotion
b. Evaluation of the problem
c. Positive reappraisal of the problem (“Every
    disappointment is a blessing”)
d. Avoidance of the problem. It’s the most frequent
    coping strategy
RESPONSE TO BAD NEWS cont’d

 Maladaptive coping strategies: These strategies
  reduce the emotional response on the short term, but
  lead to greater difficulties in the long term. These
  include:
Ø Use of alcohol or unprescribed drugs
Ø Deliberate self-harm (drug overdose or self-injury)
Ø Unrestrained display of feelings (culture dependent)
Ø Aggressive behaviour
RESPONSE TO BAD NEWS cont’d

 Coping styles: when a particular coping mechanisms
  are used repeatedly by the same person in different
  situations, they are said to be a coping style. Find out
  coping styles before or during the breaking of bad
  news interview. If maladaptive, find ways to help
  like counseling.
 Vulnerability factors. Previous experience. A recent
  bad news can make patient more vulnerable.
RESPONSE TO BAD NEWS cont’d

 A Defence mechanism
They are unconscious responses to external stressors as
   well as anxiety arising from internal conflict.
In response to bad news, the most frequent mechanisms
   are:
Ø Repression
Ø Denial
Ø Displacement
Ø Projection
Ø Regression
RESPONSE TO BAD NEWS cont’d

 GRIEF REACTIONS
Ø Elisabeth Kübler-Ross (1926-2004) wrote the theory
  of the Five Stages of Grief as a pattern of
  adjustment: Denial, Anger, Bargaining, Depression,
  and Acceptance(DABDA).
Ø In general, individuals experience most of these
  stages when faced with their imminent death. The
  five stages have since been adopted by many as
  applying to the survivors of a loved one's death, as
  well.
                     “DABDA”

 Denial — "I feel fine."; "This can't be happening, not
  to me.“
 Anger — "Why me? It's not fair!"; "How can this
  happen to me?"; '"Who is to blame?“
 Bargaining — "I'll do anything for a few more
  years."; "I will give my life savings if...“
 Depression — "I'm so sad, why bother with
  anything?"; "I'm going to die soon so what's the
  point?"; "I miss my loved one, why go on?“
 Acceptance — "It's going to be okay."; "I can't fight it,
  I may as well prepare for it."
                    “DABDA”
Ø Kübler-Ross noted that these stages are not meant to
  be a complete list of all possible emotions that could
  be felt, and, they can occur in any order. Her
  hypothesis holds that not everyone who experiences
  a life-threatening/-altering event feels all five of the
  responses, as reactions to personal losses of any
  kind are as unique as the person experiencing them.
Ø Kübler-Ross suffered a series of strokes in 1995
  which left her partially paralyzed on her left side. In
  a 2002 interview with The Arizona Republic, she
  stated that she was ready for death. She died in 2004
  at her home in Scottsdale, Arizona.
    ABNORMAL GRIEF REACTION13
       (PATHOLOGICAL GRIEF)

 Grief is considered abnormal if it is
Ø Unusually intense (meet the criteria for a depressive
  disorder)
Ø Unusually prolonged (response last more than 6
  months)
Ø Delayed (the 1st stage has not occurred by 2 weeks
  after the death of the loved person)
     WHAT NOT TO DO IN BBN
 Break bad news over the phone.
 Avoid the patient.
 Leave the patient in suspense.
 Lie to the patient.
 Tell the patient if he or she doesn’t want to know.
 Interrupt excessively.
 Use jargon.
     WHAT NOT TO DO Cont’d
 Give excessive information as this causes confusion.
  (Avoid lecturing the patient)
 Collude (secrecy)
 Be judgmental. (HIV-Lifestyle, Smoking-Ca lungs,
  Infertility-Multiple TOPs)
 Give a definite time span (just say “days to weeks”
  or “months to years” etc.) Example of Libyan al-
  Megrahi (Told he had 3 months to live but lived to
  almost 3 years)
 Pretend treatment is working if it isn’t.
 Say “Nothing can be done.”
          CLINICAL SCENARIO
 Swanson’s Family Medicine Review A Problem-
  Oriented Approach 6th ed.14
Ø You are the physician caring for an 85-year-old
  woman who you have just diagnosed as having
  breast cancer. Before you had an opportunity to talk
  to the patient, her son and daughter came to your
  office to advise you that they do not wish you to tell
  their mother anything about her diagnosis. Describe
  how you would respond to the request.
                     ANSWER
 It’s important to remember who the patient is and
  what rights the patient has and does not have.
  Proceed in the following manner
Ø Assuming the mother is mentally fit, remember she
  is the patient
Ø Invite the children for a discussion. Acknowledge
  their love for their mother, then your ethical
  responsibility and that you would do so responsibly.
  Ask, ‘if they were in her shoes, won’t they want to
  know?’
Ø If they still don’t agree, include other parties like the
  hospital ethics committee
  REVIEW OF THE EARLIER CASES
1. Abnormal grief reaction. Placed on a TCAs
   (Amitryptiline 50mg nocte). Anti-depressants like
   SSRIs, TCAs, MAOIs have a role in stress disoders,
   PTSDs, and abnormal grief reactions.
2. Abnormal grief reaction. Intensity (depression).
   Don’t tell a patient that there’s nothing you can do.
   There’s always something you can do to make the
   patient feel better. Don’t give false hopes yet don’t
   destroy all hopes.
PICTURES (1)15
PICTURES (2)16
PICTURES (3)17
PICTURES (4)11
PICTURES (5)12
PICTURES (6)18
PICTURES (7)19
PICTURES (8)20
PICTURES (9)21
PICTURES (10)22
ROLE OF FAMILY PHYSICIAN (5 C’s)

 C - CONTINUOUS
 C - COMPREHENSIVE
 C - COMPASSIONATE
 C - COORDINATED
 C – COMPETENT
Ø Remember, from cradle to rocker.
MULTIDISCIPLINARY APPROACH
 Physicians
 Nurses
 Community health extension workers (CHEWS)
 Complementary and alternative medicine
  practitioners
 Social workers
 Disaster/emergency relief agencies
 Law enforcement agencies
 Religious leaders
CHALLENGES IN GOPD AND BSUTH
 NO PRIVACY
 INTERRUPTIONS: DOCTORS, NURSES, MEDICAL
  REPs, OTHER PATIENTS, HOSP STAFF, FRIENDS
 NOISE
 PATIENT LOAD AND REDUCED TIME FOR
  PATIENTS
 LAB RESULTS NOT SEALED, HANDLED BY
  PATIENTS
 LACK OF TRAINING IN BBN
 NO PROTOCOL IN PLACE FOR BBN IN
  GOPD/BSUTH
       RECOMMENDATIONS
 SIGN OUTSIDE THE DOOR OF CONSULTING ROOM
 SUBSTAFFS/MESSENGERS AT THE DOOR & FOR
  DIRECTIONS
 REDUCE INTERRUPTIONS. FIX APPOINTMENTS FOR
  VISITS (DRUG REPS). CALL AHEAD.
 ALLOCATING A PLACE FOR BBN/TISSUE ON DESKS
 TRAINING Of STAFFS ON BBN
 WORKING ON A PROTOCOL FOR BREAKING BAD
  NEWS
 WORKING ON REDUCING PATIENT
  LOAD/WAITING TIME
 SEAL LAB RESULTS. PHYSICIAN SHOULD KNOW OF
  A BAD RESULT BEFORE THE PATIENT
 MAKE RESEARCH ON A CASE BEFORE BBN
 BEAR IN MIND THE CULTURES OF OUR PEOPLE
     MNEMONICS/REMINDERS
  REMEMBER THE MNEMONICS
1. SPIKES protocol
2. BREAKS protocol
3. ABCDE protocol
4. SAD NEWS
5. PEWTER model
6. DABDA
7. 5 C’s of FAMILY MEDICINE
           MNEMONICS
v SPIKES PROTOCOL FOR BBN

 S – SETTINGS
 P – PERCEPTION
 I – INVITATION
 K – KNOWLEDGE
 E – EMOTION AND EMPATHIC RESPONSE
 S – STRATEGY AND SUMMARY
          MNEMONICS Cont’d
v ABCDE model of BBN

 A – Advance preparation
 B – Build a therapeutic environment/relationship
 C – Communicate well
 D – Deal with patient and family reactions
 E – Encourage and validate Emotions
       MNEMONICS Cont’d
v BREAKS MODEL OF BBN

 B – BACKGROUND
 R – RAPPORT
 E – EXPLORING
 A – ANNOUNCE
 K – KINDLING
 S – SUMMARIZE
          MNEMONICS Cont’d
v SAD NEWS MODEL OF BBN

 S – Set up and Sit down
 A – Ask, don’t tell
 D – Deliver the news
 N – No fancy lingo
 E – Expect, permit, respond to Emotion
 W – Wait
 S – Support and Summarize
         MNEMONICS Cont’d
v PEWTER model of BBN

 P – Prepare
 E – Evaluate
 W – Warn
 T – Tell
 E – Emotional response
 R – Regroup
          MNEMONICS Cont’d
v 5 Stages of Grief (Kübler-Ross Model)

 D - DENIAL
 A - ANGER
 B - BARGAINING
 D - DEPRESSION
 A – ACCEPTANCE
Ø Note: It can occur in any order. Some stages can be
  skipped.
MNEMONICS/REMINDERS Cont’d
v 5 C’S OF FAMILY MEDICINE:

 C - CONTINUOUS
 C - COMPREHENSIVE
 C - COMPASSIONATE
 C - COORDINATED
 C - COMPETENT
     MEMORABLE QUOTES
“ It’s important for the physician
  to remember that failure to cure
  is not the same as failing the
  patient, as palliation and good
  communication are also
  therapeutic.” 3

“Sometimes all a person needs is a
  hand to hold and a heart to
  understand”
                 REFERENCES
1. Docstoc. Breaking Bad News.
   http://www.docstoc.com/docs/132695459/Breakin
   g-bad-news1 (accessed 27 July 2013)
2. Onyeka TC. Psychosocial Issues in Palliative Care: A
   Review of Five Cases. Indian J Palliat care. 2010 Sep-
   Dec; 16(3): 123-8.
   http://www.ncbi.nlm.nih.gov/pmc/articles/PMC30
   12234/ (accessed 27 July 2013)
3. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA,
   Kudelka AP. SPIKES – A Six-Step Protocol for
   Delivering Bad News: Application to the patient with
   cancer. The Oncologist 2000; 5(4): 302-11.
   doi:10.1634/theoncologist.5-4-302 (accessed 27 July
   2013)
           REFERENCES Cont’d
4. Narayanan V, Brista B, Koshy C. ‘BREAKS’ Protocol
   for Breaking Bad News. Indian J Palliat Care
   2010;16(2):61-5. doi:10.4103/0973-1075.68401
   (accessed 27 July 2013)
5. Lang F. Breaking Bad News Lessons from cancer
   patients’ interviews.
   http://www.docstoc.com/docs/98987310/Breaking
   -Bad-News-Conversations-Addressing-End-of-Life
   (accessed 27 July 2013)
6. Jain AP, Behere P, Jain P et al (eds.) Textbook of Family
   Medicine. India: Divyesh Arvind Kothari for Paras
   Medical Publisher; 2009.
           REFERENCES Cont’d
7. Olasinde TA. Breaking Bad News. Online Journal of
   Medicine and medical Science Research. 2012;1(5): 88-90
   http://www.onlinereasearchjournals.org/JMMSR
   (accessed 27 July 2013)
8. Vandekieft GK. Palliative and End-of-Life. In: Sloane
   PD, Slatt LM, Ebell MH, Smith MA, Power DV, Viera
   AJ (eds.) Essentials of family medicine 6th ed.
   Philadelphia: Lippincott Williams & Wilkins, a
   Wolters Kluwer business; 2012. p288-9
9. Rabow MW, McPhee SJ. Beyond breaking bad news:
   how to help patients who suffer. West J Med 1999
   October;17(4):260-3
   http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1
   305864/ (accessed 27 July 2013)
          REFERENCES Cont’d
10. SkillsCascade.com A FRAMEWORK FOR
   BREAKING BAD NEWS
   http://www.skillscascade.com/badnews.htm
   (accessed 27 July, 2013)
11. CanMeds Communicator. Breaking bad news
   http://www.collaborativecurriculum.ca/en/module
   s/CanMEDScommunicator/canmeds-communicator
   -specialscenarios-02.jsp (accessed 27 July 2013)
12. Counseling Today. Breaking bad news.
   http://ct.counseling.org/2012/08/breaking-bad-
   news/ (accessed 27 July 2013)
          REFERENCES Cont’d
13. Gelder M, Harrison P, Cowen P. Shorter Oxford
   Textbook of Psychiatry. 5th ed. New York: Oxford
   University Press; 2006
14. Holland-Barkis P. How to Break bad News. In:
   Tallia AF, Scherger JE, Dickey NW (eds.) Swanson’s
   Family Medicine Review A Problem-Oriented Approach
   6th ed. Philadelphia: Mosby, Inc., an imprint of
   Elsevier Inc; 2009. p64-8
15. Irishhealth.com Breaking bad news
   http://www.irishhealth.com/article.html?id=10185
   (accessed 27 July 2013)
          REFERENCES Cont’d
16. East Midlands Cancer Network Breaking Bad News
   http://www.eastmidlandscancernetwork.nhs.uk/_
   HealthProfessionals-ServiceImprovement-
   SupportiveandPalliativeCare-
   BreakingBadNews.aspx (accessed 27 July 2013)
17. Western Australian Centre for Health Ageing
   Breaking bad news: initiation http://www.e-
   ageing.wacha.org.au/index.php?id=1416 (accessed
   27 July 2013)
18. ADAM GAULT/SCIENCE PHOTO LIBRARY
   Breaking bad news
   http://www.sciencephoto.com/media/201300/vie
   w (accessed 27 July 2013)
          REFERENCES Cont’d
19. Brill D. Being blunt works when breaking bad news.
   Australian Doctor 2 May 2012
   http://www.australiandoctor.com.au/news/latest-
   news/being-blunt-works-when-breaking-bad-news
   (accessed 27 July 2013)
20. HubPages. Tips on how to break bad news.
   http://webcache.googleusercontent.com/search?q=c
   ache:http://dwachira.hubpages.com/hub/Tips-on-
   how-to-breakbadnews (accessed 27 July 2013)
21. Buzzle. Best Ways to Break Bad news.
   http://www.buzzle.com/articles/best-ways-to-
   break-bad-news.html (accessed 27 July 2013)
          REFERENCES Cont’d
22. Irish Independent. New guide for doctors on how to
   break bad news. Independent.ie 22 April 2013.
   http://www.indepedent.ie/lifestyle/health/new-
   guide-for-doctors-on-how-to-break-bad-news-
   29211839.html (accessed 27 July 2013)
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Description: I'm an avid researcher and a creative writer. This article discusses ways of breaking bad news in health settings!