Breaking Bad News

Do we know how to be helpful?

Dr. Grant MacLean

Cecilia came to you complaining of nausea, epigastric pain and weight loss. You have the results of the biopsy done at gastroscopy a few days ago. Her new partner had left a message that if it is bad news please don’t tell her. She is sitting in the office waiting for you with her partner. Are you ready?

Three key parts to successfully

breaking bad news:

Is it “bad”?How to tell the “bad news”Knowing “what to tell”

Coming to see you is Vicki, a 37 year old woman who had presented

with a left supraclavicular lymph

node mass

? Lymphoma – may have a good outcome

Unfortunately she also had a verylarge hard irregular mass in the pelvis.

? Ovarian cancer – may respond well to chemotherapy

Her question: “Can you cure me”?

Next is Ken, 55, who looks well but recently had a hemicolectomy for colon cancer. He had a CT scan and wants the results – it shows widespread metastatic disease in his liver and his lungs.

“Can you cure me…I’m scared…..and I’m not sure I want to know…..but…..

…how long have I got?”

And then you are asked to see Jack, 83, with severe heart disease, presenting with painless vomiting. Yesterday he was told he had pancreatic cancer. He hates his nasogastric tube, and he wants to know:

“How soon are we going to start chemotherapy?”

In two separate studies Peter Kirk and Jean Kutner have found that patients and families want:

1. Prognostic information & honesty2. Hope

Isn’t there a conflict?

If you struggle with this conflict,

you are not alone:

Baile, Buckman et al

described an informal study of 500

oncologists at ASCO in 1998,

in which they looked at the difficulties

in breaking bad news.

• Nearly 50% admitted no training in responding to patients’ emotions.

• Nearly 50% admitted they were notcomfortable dealing with patients’ emotions.

• Nearly 50% admitted difficulty discussing the transition from active therapy to palliative care.

Rob Buckman gave us “SPIKES”

To help us break bad news.

What are the key points?

Can we avoid the horror tales.

Like the young woman who was waiting in the hospital entrance for her ride home when she saw her surgeon leaving: “When will I get the results of the biopsy?”

“I felt like crying and throwing up – and had nowhere to go…”

A Buddhist teaching is

“the wine glass is already broken”.

Enjoy the wine glass and acceptthat one day it will break.

Some of our patients have alreadyaccepted this philosophy.

If you break your partner’s favorite wine glass you may both be upset or angry…

But if there was an earthquake and all the glasses broke but the kids were OK, it may not be important.

When is “bad news” not so bad?

A few years ago I investigated Colleen for chest pain. She was on Tamoxifen for breast cancer with bone mets. The bone scan was much worse.

She was relieved – “I was scared it was my heart – I know you can die suddenly from heart disease”.

We need to check with our patients – e.g. “What do you worry about?” or even “what is the worst thing that could happen to you?”

“I am afraid of nausea…”“I hope I will not be in pain…”“I don’t want to be hooked up to a machine…”“As long as I don’t have a stroke…”“I’d rather not spend my valuable time at the cancer

clinic…”

Do you know we have a reputation

for interrupting patients before

they can say why they have come to

see us or what troubles them most?

Beckman & Frankel (1984):

in 69% of visits, the patient was

interrupted by the physician

before being able to say why they were seeing the physician!

How can we respond to the

patient’s needs

if we don’t

know them?

Kutner, 1999:

“What needs to be discussed, what might be discussed, what should be

discussed and what ought to be kept silent, are issues that require negotiation between the patient and the physician”.

Gattellari:

“…many patients cannot make

informed decisions, because they

lack knowledge of their prognosis

and alternatives to anti-cancer

treatment”.

An important message from Kutner’s study:

> 90% wanted prognostic information to help with decision making.

Only 50% wanted to know when they would die.

A modification of Rob Buckman’s “SPIKES” that can help us know what to say, as well as and how to break bad news is the strategy “RELATE”

R

E

L

A

T

E

In the right place, appear relaxed

enquire

listen

patient’s agenda

tell the truthrespond to emotions with empathy

“R” – the Right time & place

Looking at your watch, or your hand on the door knob sends the wrong message

Is now the time?

Who should be present?

Sit down. Relax and focus.

“E” - enquire

You cannot know what is

important to me unless you ask.

My values may differ from yours,

my fears may differ from yours.

IF you don’t enquire, you will not know.

“L” – and the most important is LISTEN

One of Rob Buckman’s “Ground Rules”

“To support a patient you do not have to agree with the patient’s point of view, but you do have to listen to it and identify what the patient is saying”.

“A” – the patient’s agenda

If you want to help the patient, acknowledge and focus on the patient’s agenda.

The patient may not care about the size of the lesion on the CT…..

“T” – tell the truth There are cultural differences that we need to be sensitive to, but in our culture the majority of our patients expect HONESTY

(Kutner - >90% expect the doctor to be honest) which may include “I don’t know”!

“E” – respond to the patient’s emotions with empathy

even if you are exhausted or feeling pressured for time, this may be a pivotal time in the life of the patient.

One of our problems may be notunderstanding

what hope can be & that hope can be refocussed

Contrary to modern oncology literature, not all patients measure success in life by how many days they live!

The oncologist:“I assume you hope to live longer”

The patient:“I hope I do not have to have

chemotherapy – if it is not going to add years, then I want to avoid nausea and fatigue. I hope I can preserve quality…”

Ronna Jevne offers this “definition”:

“Hope is not about everything

turning out OK; it is about

being OK with how things are”.

When Vicki asked whether I couldcure her, it was tough for us all.

She knew her cancer had spread, but she was young, with children, and she wanted to live.

What would you offer?

Unfortunately her primary was neither lymphoma nor ovarian cancer.

She had widespread cancer arising from the esophagus.

Telling the truth can be painful

for us all, but in Vicki’s situation it

helped us move to discussion about

palliative care;

She had a lot of pain, and her hope was to be free of pain.

Ken knew I could not predict when he would die. He is a mathematician, and he explained the probability of my being wrong.

So with “how long?” what did he want to know?

He knew his cancer was not curable.

He wanted information so he could make decisions, and he wanted hope.

Ken was afraid to ask “how long”

but when given a chance to

amplify, he wanted to know:

“will it hurt”?

“this may sound silly to you, but will I be alive next week

- my son is coming…”

And then there is Jack

• Frail• Serious heart disease• With pancreatic cancer – which cannot

be cured. In fact chemotherapy is unlikely to shrink his cancer or significantly impact his disease course.

Jack is wondering when chemotherapy will start.

What would you offer him?

Jack was relieved that he didn’t have to go through chemotherapy, as were his family.

They were enthusiastic about meeting the palliative care team and focussing on quality of life issues.

Lauren is in her mid thirties.Three years ago she had RT for locally advanced

ca cervix.

She complains of sacral pain, vaginal bleeding and difficulty with voiding.

She wants the CT scan results and wants to get on quickly with chemotherapy as she wants to be cured.

Pat is 50, on Carboplatin for ovarian cancer.

She is terrified of her disease.

She has come to see if it is worth continuing the chemotherapy after three courses.

She doesn’t know the results, but her CA 125 has fallen from 1200 to 45; and the CT shows complete clearing of the previously noted masses and nodes.

Your colleague has seemed a little forgetful lately.

A CT of his brain, that you ordered for him, has not been reported but you have seen it with the radiologist. He has what appear to be two metastases or tumors.