Breaking Bad News
Just yesterday I had my video recording for the breaking bad news portion of our clinical communication skills module. I ended up having to tell this standardized patient/actor that his wife was in a serious car accident and sustained several injuries including a fractured skull, broken right clavicle, and three broken ribs. She was in a coma (GCS 4) with pupils unresponsive to light and placed on a ventilator. I had to tell him that there was a 85% chance she would die and if she did pull through, the road to recovery would be very difficult.
I order to prepare for this, I tried doing some role plays with my housemates. We went through a number of scenarios including:
1) Telling a guy who's worried that his wife will leave him because they are unable to have children that he's infertile.
2) Telling a woman she has breast cancer
3) Telling a woman that her fetus has Down Syndrome
It was really hard to try to mimic the emotions and feelings that would be running through the minds of the doctor and patient in a real life situation. Most of the time we'd end up laughing at each other as we attempted to make ourselves cry or get angry at the doctor for not being able to reverse the situation.
There's this instinct to avoid using words like "die" or "death" - even if it means being a little bit confusing or misleading. I read through this article that talks about how maybe physicians should just say, "You are dying," and stop beating around the bush with euphemisms and vague references that we hope will lessen patient distress. There were a couple examples given of what doctors say in discussion with a dying patient in a role-playing scenario that simple mean, "You are dying."
"Most people with the disease will have problems soon. Time may be short - a few weeks to a few months. My suggestion would be to prepare for the worst and hope for the best."
"Your time may be short."
"Out of a hundred people in your situation, most will have major problems in a month or so."
"It sounds like the disease is really threatening your life."
I think the bottom line is that you have to have a genuine care and love for your patient. Not the eros type of love but a phileo form - a brotherly love and compassion. Using the right words will help but at the end of the day, your actions and ability to manage the patient in a palliative care manner will come naturally from loving your neighbour as yourself...
I order to prepare for this, I tried doing some role plays with my housemates. We went through a number of scenarios including:
1) Telling a guy who's worried that his wife will leave him because they are unable to have children that he's infertile.
2) Telling a woman she has breast cancer
3) Telling a woman that her fetus has Down Syndrome
It was really hard to try to mimic the emotions and feelings that would be running through the minds of the doctor and patient in a real life situation. Most of the time we'd end up laughing at each other as we attempted to make ourselves cry or get angry at the doctor for not being able to reverse the situation.
There's this instinct to avoid using words like "die" or "death" - even if it means being a little bit confusing or misleading. I read through this article that talks about how maybe physicians should just say, "You are dying," and stop beating around the bush with euphemisms and vague references that we hope will lessen patient distress. There were a couple examples given of what doctors say in discussion with a dying patient in a role-playing scenario that simple mean, "You are dying."
"Most people with the disease will have problems soon. Time may be short - a few weeks to a few months. My suggestion would be to prepare for the worst and hope for the best."
"Your time may be short."
"Out of a hundred people in your situation, most will have major problems in a month or so."
"It sounds like the disease is really threatening your life."
I think the bottom line is that you have to have a genuine care and love for your patient. Not the eros type of love but a phileo form - a brotherly love and compassion. Using the right words will help but at the end of the day, your actions and ability to manage the patient in a palliative care manner will come naturally from loving your neighbour as yourself...
Labels: School
posted by Matt at 11:40 PM
1 Comments:
I'm a chaplain who has had to translate doctor-speak around end-of-life issues for patients at times. Keeping in mind that patients and family members really struggle to hear hard information, even when it is presented bluntly, these euphemisms are even harder to absorb and understand. I have heard a million doctors first rehash the entire course of the patients illness like they're presenting the case study, and then say, as a footnote, "there's nothing more we can do" or something similar. These euphemisms at the end of your post are indecipherable to most patients/families in crisis. For instance, "Most people with the disease will have problems soon?" or "major problems in a month or so?" Patient thinks, "What kind of problem? More pain? Worse nausea? Will I need more surgery?" Doctor says: "It sounds like the disease is really threatening your life?" Patient thinks, "Well, you're the doctor, it sounds like you're not real sure of yourself when you say 'it sounds like.' Maybe there's hope."
In the hospital, when I've been invited in to bat clean-up with the family/patient when the doctor has broken bad news, I have to actually tell the family/patient about impending death. What I say is, "What did you just hear from the doctor?" After they tell me what they heard, inevitably, their next question is, "does that mean I'm dying?" Answer, "yes. I'm afraid so. This is so hard, isn't it?" or, if they say "what did the doctor mean by that?" I tell them, as gently as possible, that it means they probably do not have long to live, will not be alive much longer, or their life is coming to an end." After giving time to allow them to begin to process this shocking information and to express themselves, there are a million ways to engage them further, giving them some sense of control, like, "What would you like to do with the time you have left?" "Is there anyone I can call for you?" "Is there anything about the end of your life/ your disease/ your medical care from here on out that concerns you/makes you anxious? What are those concerns?" "Hospice may be able to help you live as fully and comfortably as possible in the time you have left."
Just some suggestions that arise out of my experience. And you are so, so, so right about the love and compassion part!
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