COMMUNICATION BETWEEN DOCTORS, PATIENTS & THEIR FAMILIES

BREAKING BAD NEWS

R. Sjamsuhidajat Tjakra Wibawa Manuaba Sutrisno Alibasyah Perioperative Course. Collegiums of Surgery & Anesthesiology. Indonesia

DOCTORS PATIENTS RELATIONSHIP.

Not

anymore paternalism Should be partnership basis. Equal

Communication is not:
as some would say, simply good manners, empathy, being nice or pandering to the patients. BUT it offers a much more effective consultation, and improved outcomes both patients and doctors. HOPEFULLY.NOT The blind leading the blind?

ISSUES IN DOCTOR PATIENT COMMUNICATION

Why teach and learn communication skills.

Is it important to study medical interview?

(knowledge, communication skills, problem solving, physical examination)

Are there problems in communication between doctors and patients. (discovering the reason for
patients attendance, gathering information, explanation & planning, patient adherence, medico-legal issues, lack of empathy& understanding)

Why teach and learn communication skills.

Is there evidence that communication skills can overcome these problems and make a difference to patients, doctors, and outcomes of care (process of interview,
patient satisfaction, patient recall & understanding, adherence, out come)

Can you teach and learn communication skills.

Is there evidence that communication can be taught and learned. Is there evidence that learning is retained. Is the prize on offer to doctors and patients worth the effort. will expanding the effort on communication skills teaching, produce worthwhile rewards for both doctors and patients.

The answers are .yes

Underlying Premises
- Communication skills teaching and learning

need to be evidence based. - Unified approach to communication skills teaching in medicine is needed. - Communication skills teaching should cross cultural and national boundaries.

Underlying Premises..
- Coordinated approach to communication skills teaching throughout medical education is necessary. - A skill, based on approach to communication skills teaching is essential.

HUMAN REACTION IN FACING DISEASE WITHOUT ANY HOPE.

Patients, Families, & Health professionals.

In Critically ill patients :

We have to deal with stressful depressed patient, and the families. We have to deal with other colleagues other doctors, nurses who sometimes are also depressed in a very tense and depressing situation or atmosphere!

How human being faces critical/ severe diseases?

Emotional Changes. Negative Emotional Changes ( no more hope, anger, disbelief, rejection/ denialand finally acceptance.

Emotional changes

Usually temporary Depending on Emotional Stability, past

experiences, psychological maturity, internal representation, cognitive processing, traumatic stressor and probably education?

Awareness of Emotional reaction. Return toward normal balance (in majority cases)

Severe Physical / Psychological Injuries

Emotional Reaction

Emotional Processing Awareness of Emotional Reaction

Returns

?
PTSD (small percentage)

Towards Normal Balance

(majority of cases)

DEPRESSED!

HUMAN BEING REACTION

In Facing a Serious & Critical Disease / TERMINAL Condition
Human reaction would be.

To Fly (to run away From the situation)

To Fight (to face, to accept & to cope with the condition)

Painful Intrusive Recollection

STRESS/ DEPRESSION

Suppressed into Subconsciousness

- Becoming chronic - Change of value system - Reappraisal - Disturbance of emotional processing - Failure to complete the emotional processing

By Understanding The Whole Psychological Process in Critical Situation/ Terminal cancer BETTER COMMUNICATION

-Clearer -More effective & efficient communication -Honesty & openness. -Trust -Mutual respect -Politeness -Adherence -Collaboration. -More accurate information -Prevention of violent situation -Informed consent -Legal aspects

RELAXING & CORRECT POSITION DURING MEDICAL INTERVIEW. EQUAL (LEVEL) EYE CONTACT.

BREAKING BAD NEWS.

EXPLANATION PLANNING CONDITIONING

CONSIDERATION IN BREAKING BAD NEWS

SHOULD THE PATIENT BE TOLD : HE/ SHE IS SERIOUSLY ILL. HOW MUCH THE PATIENT SHOULD KNOW ABOUT HIS/ HER CONDITION. SHOULD THE FAMILY KNOW ABOUT THE ILLNESS HOW MUCH THE FAMILY SHOULD KNOW THE ILLNESS. SHOULD PATIENT KNOW THAT HIS/ HER ILLNESS CAN NOT BE TREATED/ CURED. HOW MUCH THE PATIENT AND THE FAMILY SHOULD KNOW ABOUT THIS.

CONSIDERATION IN BREAKING BAD NEWS

DIVERGENCE BETWEEN PATIENT AND DOCTORS PERPECTIVES PATIENT & FAMILY HOPES OF GOOD NEWS. AND .DOCTORS NEWS (Tuckett et al, 1985) The Doctor must change the newshow? MOST DOCTORS will find this duty very difficult!!! Psychological Sequelae of BREAKING BAD NEWS DEVASTATING and LONG LASTING (Finley & Dallimore 1991). Many reports expressing doctors deficiencies in this matter.

How Much The Patient and The Family Should know about their Critical Condition.

THE PATIENT AND THE FAMILY SHOULD KNOW ENOUGH ABOUT their Critical Illness/ Condition. THEY SHOULD KNOW THAT THEIR CONDITION CAN NOT/ DIFFICULT TO BE CURED, THAT THE PATIENT WILL DIE? (THE PATIENT OR THE FAMILY ONLY ?). IN THE CASE OF INDONESIA, PROBABLY THE FAMILY SHOULD KNOW MORE?. IN OTHER COUNTRIES (USA) THE PATIENT MUST BE TOLD FIRST. DO NOT EVER TELL THE PATIENT, HOW LONG HE/ SHE WILL LIVE !!!!!.

KEY CORE SKILL FOR BREAKING BAD NEWS EXPLANATION & PLANNING.

Preparation Summarizing Negotiating the Agenda Listening Picking up Cues The use of Silence Discovering the patients concern and ideas Encouraging the expression feeling Picking up the non verbal cues Building rapport

KEY CORE SKILL FOR BREAKING BAD NEWS.

Conditioning Empathy Acceptance Discovering the patient starting point Discovering the patients feeling Gauging what and how much information to give Discovering whether a patient is a seeker or and avoider of information Giving support Giving clear jargon- free explanation Chunking and checking information giving

Suggestion for Breaking Bad News.

PREPARATION : - Set Up appointment as soon as possible - Un interrupted time - comfortable & familiar atmosphere - Invite spouse, family, friends as appropriate - adequately prepared for patient background, education situation, records. - Doctor should put aside personal feeling.

PLEASE NOTICE THE BARRIER BETWEEN DOCTOR PATIENT!

PLEASE NOTICE THE POSITION OF DOCTOR PATIENT. IT IS CLOSER, FAMILIAR, AND THERE IS NO BARRIERBETTER.

Suggestion for Breaking Bad News.

BEGINNING THE SESSION. - summarizing where things have reached to date - Discover what has happened since last seen - Calibrate how the patient is thinking/ feeling - Negotiate an agenda.

Suggestion for Breaking Bad News.

SHARING THE INFORMATION - ASSESS THE PATIENTS UNDERSTANDING - GAUGE HOW MUCH THE PATIENT WISHES TO KNOW - GIVE WARNING .CONDITIONING I am afraid we have some bad news to tell; I am afraid it looks more serious than we hope - GIVE BASIC INFORMATION, simply and honestrepeat important points. - Relate your information to the patients framework - Do not give too much information too early; do not pussyfoot but do not overwhelm - Give information in small chunks; categorize information - Watch the pace; check repeatedly for understanding, feeling as you proceed. - Use proper language, avoid jargon!

Suggestion for Breaking Bad News.

BEING SENSITIVE TO THE PATIENT. - Read the non-verbal cues : face, body language silence, tears - Allow for shut down (when patient turn off, stop listening, silence) give time & space; allow denial. - Keep pausing to give patient time to ask question. - Gauge the patients need for further information patient will react variously, demand differently. - Encourage expression of feeling : I am sorry that was difficult for you.

A HAUNTED SITUATION? A PROVOCATIVE ATMOSPHERE FOR CONSULTATION?

Suggestion for Breaking Bad News.

PLANNING & SUPPORT. - Having identified all the patients specific concern
offer specific help by breaking down overwhelming feeling into manageable concerns, prioritizing - Identify a plan for what is to happen next - Give a broad timeframe for what may lie a head. - Give hope tempered with realism (preparing for the worst and hoping for the best) - Ally yourself with the patient (we can work on this together.. Between us), i.e. co-partnership with the patient/ advocate the patient. - Emphasize the quality of life - Safety net.

Suggestion for Breaking Bad News.

BEING SENSITIVE TO THE PATIENT - Response to the patient feeling and predicament with
acceptance, empathy, and concern. - Check the patients previous knowledge about the information given. - Specifically elicit all the patients concern - Check the understanding of information given, e.g. : would you like to run through what you are going to tell your wife/ family - Be aware of unshared meaning, e.g. : what cancer means or the patient compared what it means to the physician. - Do not afraid to show emotion & distress (physician human being ).

Suggestion for Breaking Bad News.

FOLLOW UP & CLOSING. - Summarize and check with patient.

- Do not rush patient to treatment. - Set up early further appointment, offers telephone calls, - Identify support systems : involve relatives and friends, religion or cultural leader or other related professional - Offer to see/ tell spouse or others. - Make written material available.

( Buckman1994; Faulkner 1988)

SPECIAL ISSUES

DOCTORS should always ask questions for themselves : - Am I in position to give this patient accurate
information? - Have I discovered the patients illness framework : his thought, feeling ? - Have I developed sufficient rapport with the patient?. - What is the effect on the patient of what I am saying? - Am I going at the pace of the patient? - Am I being flexible, supportive and empathic? - Am I negotiating an effective plan for the future?

SPECIAL ISSUES

CULTURAL ISSUES. - Cross Cultural Perspective - Ethnic Complexities - Do not stereotype patients - Culture is a textured pattern of beliefs & practices. - Patients culture provide him/her ideas about health and illness, notions about causality, etc - Modern doctors very often encounter problems relating to cultures, traditions etc.

Chugh 1993; Myerscough 1992; Eleftheriadou 1996.

SPECIAL ISSUES

RELIGION AND SPIRITUAL GUIDANCE ARE IMPORTANT FACTOR IN BREAKING BAD NEWS IN CRITICALLY ILL PATIENTS, WHEN THERE IS NO MORE HOPE FROM THE POINT OF MEDICAL VIEW. - Religion and spiritual guidance will bring the patient over and faster to the acceptance phase, and giving up to the Lord the fate for them

Painful maybe, but a good supportive communication

MAJORITY (70%) OF MEDICAL LAW SUING IS CAUSED BY PROBLEM OF DOCTORS PATIENTS/ FAMILIES COMMUNICATION

Examples of Medical Law - Suing

Rude way of communication Mastectomy without biopsy without sufficient medical information. Sterilization without proper consent. Failure to diagnose in a very rare illness. Operation without consent. Reprimand for doctor who speak too much. Multiple misconduct of a doctor Misconduct because of profession delegation. Etc.

.AND MAY LORD GIVE US THE HEALERS THE STRENGTH, TO SEE OUR FELLOW CRITICALLY ILL PATIENTS AS A SUFFERING HUMAN BEING, AND THAT THEY NEED OUR BEST EFFORT AND EXPERTISE TO HELP THEM OVERCOMING THEIR PROBLEMS, .AND NOT.. TO AD

THANK YOU. TJAKRA W. MANUABA.