So first of all I'd like to thank Dr. Pearl so much for agreeing to do this talk and for Anissa for asking him yes several times several times right persistence is the key yes yes so if people want to put in the chat let people know where you're from um I think it's great for us to kind of get collaborate with each other on a regular basis so without any further ado uh Dr. Michael Pearl okay I need to are you sharing my screen back or no I didn't I stopped sharing so you just have to start it again sorry okay um so let me just close that out all right so um Nissi asked me to discuss breaking bad news um this is obviously an important topic um and since she was very persistent and wouldn't allow me to just fade into oblivion um here we go so um all right so I have no conflicts to disclose um and I'm going to start off with a little video clip so this is public this is taken from um YouTube from one of the local hospitals and this is how to break bad news badly hello ma'am miss what is this um so what's your body been telling you well I get very just very tired I get some dizziness when I get overly tired I have a lump I'm scared I want to know what the results of the test were well the reason we've been doing these tests the cbc the comprehensive metabolic panel the mammogram um let's get right down to it mrs photos you have invasive breast cancer it's metastatic to your lymph nodes uh it's estrogen receptor positive which is a good thing because you you will respond to hormonal therapy but I can't have cancer everyone in my family has cancer sure the next step will be for me to send you or for you to meet with a medical oncology team um and a general surgery they will probably recommend a mastectomy a lumpectomy and this will be followed by radiation therapy and chemotherapy do you have any questions have I gone too fast I didn't understand all I heard was breast cancer yes sorry uh you have a tumor a growth it's serious and that it can spread and it can grow pretty quickly um so it's been very insidious any more questions how can I have breast cancer I kept all my mammogram schedule I kept my check-ups so your cancer has been very insidious it's was undetectable at stage one and breast cancer is very prevalent in the hispanic population you know what I need for you to do is just to remain strong breast cancer yes I know that's the way nature is I think I'm just going to refer to the medical oncology team at this point but you know Mrs Flores I know you can bounce right back from this you're very active am I dying no you're not dying you have plenty of treatment options available in fact I'm sending you to the best medical oncologist in town I'm I guarantee you're going to be fine I'm scared doctor oh you know you're going to be fine there's plenty of cancer survivors everywhere in fact my aunt Marie she was diagnosed with breast cancer and she is doing fine I don't want to be in pain like my husband was like I said you're going to be all right I know just how you feel I've seen what cancer can do to eat you up my husband died of colon cancer so you know what the harsh treatments that are going to arise and the issues you know I'm available to help you why don't I set up a meeting with you in a couple of months say six months sorry yes You know, I'm going to cut. Okay, so hopefully all of you cringed watching that video. And hopefully by the end of this discussion, you'll be able to pick out the bits and pieces of that conversation that were still particularly bad. So to kind of drive home those points, we need to define actually what is bad news. So the first definition here is any information which adversely and seriously affects an individual's view of his or her future. That seems to be a very reasonable definition of bad news. The following definition is, at least in my opinion, a bad definition of bad news. I don't have to read it, you can read it yourself. But it's very extensive and very technical. And I put it in there because it is a formal definition of bad news, but it gives the same kind of cringy sense to a definition that we just saw in that video. So breaking bad news is a very common experience. Those of us in oncology do it probably every day. It impacts obviously the patient, but the patient's family, and it has an impact on you and the other healthcare providers with whom you work. It is a very important, probably one of the most important, complex communication tasks that we face as healthcare providers. But it isn't just a verbal activity. You don't just talk. Breaking bad news is about the situation. It's about how you hold yourself. It's about the interaction with the person to whom you're speaking. And without a doubt, it is highly stressful. And it is obviously so stressful that there are research studies, there's protocols developed, and here we are early in the morning, late in the afternoon, having a conversation about breaking bad news. So why is it so stressful? On the surface, we're just telling people information, and that's part and parcel of what we do every day. But it is extraordinarily stressful, and here at least are some reasons why. We are never certain about the outcomes. So although we can tell a patient, as that woman did, that she has metastatic breast cancer, that may be a certainty, but the outcome for her breast cancer remains uncertain. The stakes are obviously very high, and emotions run quite deep. Time is of the essence. Not only for the person breaking the bad news, we're all busy, and despite the fact that we would prefer to be able to tell people bad news with an unlimited amount of time to address their concerns, that lady's beeper was going off multiple times, and as you'll see, that's a bad thing. So her time was limited. And in addition, the patient may feel that her or his, depending on what you're working on, her or his time is also of importance. There are cultural constraints. This conversation is going out to individuals all across the world, and each culture has its own particular characteristics. Within many institutions here, for example, I care for people who come from all around the world. My culture is different than their culture and vice versa. My ability to fully understand the nuances of multiple cultures is limited as much as we try, and sometimes the cultural differences have a constraint upon how we can communicate. There is a lack of formal training. I think for many individuals, they either get no formal training during their training programs on how to communicate or how to break bad news, or there's very limited, and most of it is based upon watch, see, and do. It's the do one, see one, teach one routine, and that's problematic. Why is it important? Breaking bad news is important. I think that we will all agree on the surface that breaking bad news is an important component of what we do. Patients want the truth. It is an ethical imperative. Within the field of ethics, it's veracity, meaning tell the truth. Within medicine, telling people bad news was not, at least until recently, considered important. In fact, it was just the opposite. Until the 1970s, at least in the United States, and most around the world, I think, considered that disclosing bad news, particularly about cancer diagnoses, was inhumane and damaging to the patient. That changed, and by the late 1970s, most physicians were open and considering telling patients about their cancer diagnoses. By the early 1980s, studies showed that the majority, 96% or more, of patients wished to be told if they had a cancer diagnosis, and 85%, at least in one study, wished, in situations where they had a great prognosis, to be given a very realistic estimate of how long they had to live. That was quite a change over the course of a decade, or a little bit more than a decade, from keep bad news to yourself to tell patients exactly what you knew. Here's another little video clip. I'll answer the question. You want answers? I think I'm entitled. You want answers! I want the truth! You can't handle the truth! And that's not true. Patients can handle the truth, and it is our responsibility to tell them the truth. Veracity means tell the truth, and our lack of honesty, even if we mean well, potentially robs patients and their families of their ability to make an informed choice. It also jeopardizes the foundation of our relationship with our patient. If you're caught out in a lie, even if it is a white lie, that you're withholding information because you believe you're trying to protect your patient, the patients are no longer going to believe anything else that you have to tell them. So tell them the truth. Here in the U.S., and not just U.S., but Canada, and I suspect probably most of the world, actually, the combined principles of informed consent, patient autonomy, and the case laws have come together to create very clear ethical legal obligations that we have to provide patients with as much information as they wish to know about their underlying illness, its treatment, and their side effects, and the ultimate, what we believe is their outcome. We cannot withhold medical information, even if we believe that it will have a negative effect on the patient. And I can tell you that this process is not a static process. It's dynamic. Here, we now have a law that mandates our electronic medical record notes be immediately available to the patient. So as soon as I start entering a note, if the patient is on their electronic patient portal, they have access to that information. They have access to their pathology reports, often before I even have a chance to see it. And so we can no longer withhold any medical information, regardless of how we suspect it will affect the patient. On the flip side, a mandate to disclose the truth, without regard for the sensitivity with which we do it, or the obligation to support the patients and assist them in their decision making, will result in patients becoming just as upset as if we lied to them. And as this author writes, the practice of deception cannot instantly be remedied by a new routine of insensitive truth telling. So here we are back to our topic of breaking bad news. It is important because cultural constraints, as I discussed earlier, impacts our ability to communicate to the patient and her family. We need to be aware of each patient's cultural beliefs and values, even in societies where there is a relatively homogeneous culture. Each individual has their own particular beliefs and values, and we need to be very cognizant, sensitive, and aware of those beliefs and values. There are language barriers that may prevent comprehension of the information that we're trying to communicate. I live in New York. Within New York City boundaries, every language in the entire world is spoken. So you don't have to go very far to do language studies. Everybody comes to New York City. So we have a very complex process here if somebody comes in and doesn't speak English well enough for me to be able to communicate to them. But even with the ability to speak a language, it does not mean that we truly comprehend the nuances of the information that is being communicated, say, by a translator. Individual patients may wish to have a different amount of information or a different type of information presented to them, and so we need to be very sensitive to their cultural values and beliefs. If their culture is such that they don't wish to be told or they wish their family to be told so their family can make the decisions, it is not okay for us to bulldoze forward and say, well, I'm just going to tell you everything that I know because that's my personal belief. And the level of involvement, as I was just discussing, the family and their discussions and decisions depends upon their cultural background. So what if you do it badly? That first video clip I showed you is cringeworthy. It's horrible. And it was specifically designed to be horrible. Those were actors. That wasn't a true experience. But having sat through experiences like that when I was in training, and even now when I sit through conversations with other physicians, there are times I just have to cringe inside and sometimes try to take over the conversation if I think I can do it better. So poor communication, especially with cancer patients, produces worse clinical and psychosocial outcomes. Their pain control is worse. They're less likely to adhere to their treatment. They're more confused about their prognosis and management options. And ultimately, they're dissatisfied in not becoming involved in the decision making. It also affects us as health care providers. If you do this poorly, generally there's a sense of failure. I didn't do that well. There was something wrong. That just didn't come out correct. It leaves you with a sense of uncertainty and discomfort with regards to that interaction with the patient. And ultimately, it leads to emotional disengagement. I didn't do that well. I can't do that well. I can't break bad news. I can't tell people bad news. And so I'm going to step away. I had a partner some years ago who, as a GYN oncologist, whose mother had passed away from cancer of the ovary. She, no matter what, she was one of the best surgeons, probably one of the best oncologists that I've ever had the opportunity to work with. But she couldn't tell patients that they were going to die. And she just disengaged. Emotional disengagement ultimately leads to adverse coping mechanisms. And the obvious ones, obviously, are abusing drugs, abusing alcohol, bad behaviors that are personally bad behaviors. But adverse coping mechanisms also include adverse ways of practicing medicine. So you emotionally distance from your patients. You make inappropriate decisions because you are trying to avoid having to break bad news. Communication is difficult, no matter what, no matter what circumstance. Being able to communicate well is a very difficult process. Now, it is a skill and it can be learned. And I'm going to show you some techniques for doing that in a little while. But it is a very difficult process. It is crucial that we communicate well and do our best to ensure that patients and their families understand what we're trying to communicate. As I said earlier, most patients are well informed and they do wish to have detailed information about their disease and prognosis. But even so, patients, families, and their health care providers frequently collude to avoid mentioning death or dying or other forms of bad news, even when it is close to the end of life. We as health care providers are reluctant or unwilling or unable to tell patients they're approaching the end of their life, for example, because of the inherent prognostic uncertainty. We fear that we'll be perceived as giving up and our own sense of mortality and professional skills are brought into question. And then certainly in the U.S. and in other parts of the Western world, there are medical legal concerns. So there are books, there are many, many training tools, and I'm going to go through some of those with you, about how to break bad news, not just news to a terminal patient but bad news in general. So one of the tools, one of the sets of tools are the following. So listen actively, and this should be true for every interaction you have, not just breaking bad news, but listen actively. So listen to what the individual has to say, and then repeat it back to them in a way that lets them understand that you heard what they said. So, for example, what I'm hearing you say is that you want us to do everything possible to prolong your mother's life. Self-disclose, tell the patient and her family, if they're there, what you're thinking. I'm worried that even the best medical care won't be able to achieve your hopes. Explain why you're thinking that way. So my view of this situation is that providing IV fluids give her, at best, a 5% chance of improving. Be empathetic, and I'm going to come back to this several times. I think anyone would feel as worried as you, given these circumstances. And then reframe the conversation in a way to get to where you think the conversation needs to go. Now I think we should look at the issue of IV fluids as not just do we do it, but as part of the bigger picture of her care. And then brainstorm with the patient and her family. Come up with plans. Let's try to come up with a few ideas to prepare for her death. So there are a number of models. These are three that can be used to learn how to break bad news or to set the scene. But there are many others besides these three. Everybody loves acronyms, so here's three, SPIKES, ABCDE, and BRAKES. I'll start with SPIKES. SPIKES was developed by a group of individuals, one of whom actually worked here and retired just a few years ago. So this is the one that's taught within our institution most commonly. So SPIKES stands for set. So set up the interview. Perception. So we need to assess the patient's perception. Invitation means obtaining the patient's invitation to provide information. K is giving knowledge, so telling people what you know. E stands both for emotions and empathy, and empathy will keep coming back through this. And then S stands for strategy and then summarize. So, for example, set up the interview. Make sure that you have a private space. Involve others. If you're breaking bad news and you don't feel entirely comfortable, or in all honesty, if you do feel entirely comfortable, bring a friend. When I go to speak to somebody about end-of-life care or if I have to break really bad news to somebody, generally I'll bring somebody with me. It provides me with some support, and since I work in a teaching institution, it also serves as a teaching tool for my residents or the medical students. Be attentive and calm. Listen to hear. Like I said, actively listen. And make sure that you have the time to commit to doing this. Don't rush in in between rounds. Don't rush in in between patients. If you're scheduling a patient, then make sure that you schedule that patient for a sufficient amount of time so that you don't have four patients in the waiting room and you're feeling pressure to get out of the room. Make sure you turn your beeper or your cell phone off before you come into the room so that you're not interrupted. Assess the patient's perception. Always ask before you tell. Find out what the patients know. Listen to the patient's language, and it isn't just the language that they speak. Listen to what they're saying. Ask how much information would the patient like to know. And I just bluntly ask, how much do you know? Tell me what you know about your circumstances at the moment, and how much would you like me to tell you? It's a very blunt, straightforward question. I do a warning shot. I'm sorry, Mrs. Smith. I don't have good news for you today. In fact, I have some pretty bad news. Mirror their language. So how they speak is the way you speak. Don't use medical jargon. So as you heard in that initial video clip, most of the words that she used were words that you and I understand, but patients don't understand that. Give a limited amount of information at a particular time. Patients will hear, certainly if they hear, I've just been diagnosed with cancer, they don't hear anything else after you tell them cancer. Allow silence to occur. It does not mean that you have to speak. There's some interesting information studies that show that health care providers, on average, allow less than 10 seconds of silence before they jump into that silent span. So be comfortable sitting there and just allowing silence to occur. Listen and allow time for emotions. Recognize that emotions will occur and acknowledge them. Listen for and identify the underlying emotion and its cause, and then demonstrate to the patient that you've identified that emotion and its underlying cause. When you're coming to the end, summarize the discussion. Tell people what you're going to tell them, tell them, and then tell them what you've told them. So it's standard kind of lecture-type material, but that's a useful tool as well. Strategize for future care. So if you think the patient is going home on hospice and it's unlikely that you're going to see that patient again, make sure that you tell the patient that it was important that you took care of her, that it was a privilege to take care of her, that you don't believe that you will have the opportunity to see her again, but just in case, you're going to schedule an appointment for some period of time, not six months, a month, a week, something like that. Schedule the next meeting. And then at the end of it, allow time for questions. But don't say, do you have any questions? That's not a useful tool. And patients are going to scramble and struggle. They're trying to comprehend the information that you just gave them. They don't have the ability to generate any questions. ABCD mnemonic, I'm not gonna go through in as much detail because it's functionally the same information laid out in a different fashion, but it is a different form or a different tool. So A stands for prepare and advance, advance preparation. It's the same thing. Build a therapeutic environment and relationship. That means make sure that you have some relationship with the patient. And if you read through the list on the right, you'll see that it's very similar to what I just discussed with spikes. Communicate well, same deal. Make sure that you do your best to try to communicate directly with the patient and their family. Make sure that you're capable of dealing with the patient and their family reactions. They are going to react. There's no way that you can break bad news to somebody and they won't have some sort of a reaction. So be empathetic. Assess, respond to the patient's and their family's emotional reaction. Don't argue or criticize your colleagues. This is not the time to say, well, Dr. Jones managed to cut your ureter. I never would have done that. That's not an okay thing to do. And then encourage and validate emotions. So be realistic, but don't be unrealistic. So that resident's discussion with the patient with breast cancer, she kept telling her that she's going to be fine, that she's going to bounce back and that she had every expectation that she was going to be back to normal, even though she has metastatic breast cancer. So that's unrealistic. It is important to be hopeful and not to eliminate the patient's hope, but be realistic. And then don't forget to take care of your own needs. This is a very difficult process. It is appropriate and important that you have an emotional response and it is appropriate and important that you acknowledge your own emotional response as well as the staff that may be involved and then address those emotional needs as well. Breaks is the third. And again, this should now start to look a little bit familiar. It's a very similar process because the tools are very much the same. So background, make sure that you know the patient's history. It's really unsettling to walk in and either give incorrect information or when asked a question, not know the answer. Build rapport with the patient. It is very difficult to break bad news to patients and their family if they don't know you and you don't know them. Sometimes it's unavoidable. One of the worst experiences I personally had was being called in as a intraoperative surgical consultant for a colleague who had taken a patient to OR believing that she had a fibroid, when in reality she had stage four lab myosarcoma of the uterus. He started operating, she started bleeding. And by the time I was called in, she had bled her body volume at least two or three times. And she ultimately died on the operating table for uncontrolled hemorrhage. And we had to go out and speak to her husband who thought she was coming in for a relatively straightforward hysterectomy for fibroids and let him know that his wife had died on the operating room table. So that's very difficult. I had never met him. I had no clue who he was. That's an extraordinarily complicated and difficult situation to find oneself. Explore the patient's understanding. Ask, so what do you know about what's going on? Give a warning shot. And you'll see that as a common theme throughout all of these tools. Tell people that you're going to tell them something bad. Make sure that you use non-medical language. Short words, no medical jargon. Don't give long explanations and don't discuss other patients because every patient is an individual. So that resident's bit about talking about her family isn't really appropriate. And don't give more than three major pieces of information at a time. Obviously that's flexible. If patients are really struggling, you may stop at one. If they're okay, and this is a follow-up conversation to a follow-up to a follow-up to a follow-up conversation, you may be able to give much more information. Summarize it. If possible, give a written summary. And this is an important thing is to ensure the patient's safety. Somebody drives to the hospital or drives to your clinic thinking that they're going to hear that their CT scan for their surveillance is the same as it was six months ago and everything's all normal. And you tell that person that she has multiple pulmonary meds, maybe she can't drive home. Maybe she's not capable of doing that. Some patients become suicidal. So it is our responsibility to ensure that they're safe. And then obviously provide follow-up, not just options, but follow-up appointments. Nurse mnemonic is for expressing empathy. So name. So as you're actively listening, name back to the patient or her family what you think they're feeling. So I wonder if you're feeling angry. It sounds as if you're worried about, so name it back. That lets the patients know that you've actually listened to what they've had to say and that you're aware and you're acknowledging what they're saying. Understand. So speak back to them. If I understand what you're saying, you're worried about how your treatments will affect your work. This has been extremely difficult for you. That demonstrates that you understand what they're trying to tell you. Be respectful. This is a tremendous amount to deal with, or I'm very impressed with how well you've handled the treatments. Be supportive. Make sure that you tell the patient that you're going to be there. I'll be with you all the way through. In fact, I'm going to be the one who's writing your chemotherapy orders, or I'm going to be your surgeon. I will see you every other week. Let them know that you're going to be there and then ask them and tell them that you're open to them reaching out to you for help. And then explore. So leave some open-ended time at the end of the conversation for them to express to you what their concerns are. So to summarize this portion of this, how to break bad news. This came from Vivian Von Grueningen, who's one of my colleagues, she's a GYN oncologist, also a palliative care specialist. So make sure you have a private area where everyone is seated. Bring a support network. So patients, family, or friends. I usually tell people that they could bring as many people as they wish. Can't do that right at the moment with COVID, but prior to COVID, and I assume hopefully after COVID. Bring as many people as you wish. Bring somebody for yourself. And I almost always make an attempt, or I always make an attempt, but I almost always try to bring somebody for me. And then I usually use that as an opening line to break the ice, so to speak. So when I walk into a room, typically I know the patient. Sometimes I know some of their family members, but I make sure that I introduce myself. I ask them to introduce themselves and their relationship. So it isn't just, you know, hi, I'm Billy. It's, you know, please tell me who you are and what your relationship is. So hi, I'm Billy, I'm her brother. And so I wanna know who's who and what their relationship is. And then I break the ice by saying, look, if you bring a friend, I bring a friend. And then I introduce the person that's with me. And their relationship with me. Make sure that you allocate adequate time. So if I know that I have to tell somebody that her cancer has progressed, we double book a slot if it's in clinic. If it's in the hospital and I have to speak to somebody, then I don't do it on rounds. That's where I open with my warning. So I'll come by on rounds and I say, Mrs. Smith, I've got some bad news for you. I'm gonna finish rounds and I'll be back to speak to you at the end of rounds when I have enough time that I can talk to you without limitations. And if they're ill, or even if they're not ill, I always ask if it's okay to talk to them. So I'm asking their permission to speak with them. And then understand very clearly that more than one session may be required. You may not get through with the information that you feel you have to get through. You may start out by saying, I'm sorry, Mrs. Smith, your cancer has progressed, only to have Mrs. Smith break into tears and not be able to hear any more information from you. Don't force it at that point. Just say, look, I can see this is very difficult. I understand as best I can how you must be feeling. I'm here and we'll reschedule something along those lines. Be honest, be sensitive, and be straightforward. It doesn't do anybody any good to not tell them what you know and to not use the difficult words. So it is okay, again, within cultural context, but it is okay to talk about what's difficult directly. In this circumstance, talking about dying, you should be able to use the words death and dying directly. Listen without interrupting. As I said, most healthcare providers can only go eight to 10 seconds before they feel like they have to interrupt or they have to end silence. Encourage questions. It is not, do you have any questions, but allow the opportunity for patients to feel as if it's okay for them to ask questions. And when they ask questions, listen very carefully. When they ask questions, listen very carefully to the questions. Don't interrupt. Let the question finish. Think about your answer and then be as appropriate, honest, sensitive, and straightforward in answering the question. Don't discourage hope. I talked about this several times already. Don't discourage hope. Don't be unrealistic. So it means that you may need to refocus the conversation as opposed to saying, well, you're going to be fine. It is okay to say, well, your treatment's going to be rough. That's being straightforward and honest, but we're going to work on the following to help you whatever, whatever, whatever. So this is a good idea. So you might want to sit down, Mrs. Dumpty. That's a great idea. This is a bad idea. Oh, lovely little. Lovely little. I got an echo. So there are five things to at least not to do when you're delivering bad news to patients. So the first one is don't assume that you have the training to do that. All right, so Dr. Joy, can you mute yourself, please? Or Susan, can you mute her? Thank you. Don't forgo building a relationship. We talked about having to know about your patients. So they need your trust. So make sure you spend the time to learn. Make sure that you spend time and effort to make the patient feel special. Now that's not a superficial special. Make them aware that they are special, that your time and your energy and your focus at this moment is completely upon that individual and then engage with her family. Be supportive of the family and make sure that you're aware of family dynamics and cultural considerations. Don't muddle the message. So speak clearly, be direct, be honest, be straightforward. Ask how much the patient wants to know. Give her time to react. And then don't ask, do you have any questions? I brought that up several times. Don't be sympathetic, be empathetic. So we talked a little bit about effective tactics for empathetic communication using the nurse mnemonic. Reassure the patient that they're in good hands, that you're going to be there, but be self-aware in your responses. That resonant in the initial video clip was completely oblivious to how the patient was responding to her conversation. And then don't be afraid. It is not okay to walk in and be uncertain. Your patients expect that you're confident and that you're strong, and that you are skilled at what you're going to do. So don't come across as timid, afraid, insecure. And don't come across as arrogant, cocky, and overbearing, but there is a balance in between. And being timid isn't an appropriate thing. Imagine if you got onto an airplane and you had a chance to talk to the pilot and you asked the pilot, so how do you think it's going to go? And the pilot said, well, you know, this is only the first time that I've flown this way. And I'm not quite so sure how this is going to go. I at least am off that plane promptly. No matter how good you are at this, there will be conflicts. You're talking about giving bad news to individuals, whether it's end-of-life care, cancer progression, a surgical complication, some form of other bad circumstance, there is going to be conflict. So be prepared for negotiations. Assess your personal state of mind. If you're having a quote-unquote bad day, don't go in, if you can avoid it, don't go in to have a difficult conversation with a patient and her family, especially if you know or have a belief that it's going to be uncomfortable or there's a potential for conflict. Find a nonjudgmental starting point. Remember, we're all there to take care of patients. And so it shouldn't be terribly difficult to find someplace where you can meet conversationally with the patient or her family that is not in conflict. Try to reframe emotionally charged issues and search for options that satisfy both of your needs, you and your patient. And then here, as is probably true in most places, we have help. So we have outside consultants, including an ethics committee. So you can get outside help. You can call a friend. Don't do this, okay? You have a terminal, unless you're going to die, thanks for your call, click. So here's the final bit on this, and then I'll stop and leave about 10 or 15 minutes for questions. So this was taken from an article I found. The highlighted areas and the underlined areas are from me. The rest of the verbiage is from the article. And these are the important things. So I wish I could tell you that there's a science on delivering unpleasant news and that it can be done in a few clear, easy steps, kind of what we've talked about during this discussion, but human emotions are too complex and it doesn't work that way. The bad news about breaking bad news is that there is no one right way to do that. So no matter what, the one size fits all solution to breaking bad news, realistically is probably a waste of everyone's time. Those mnemonics and those skillsets are guidelines. You can't force all of us to fit into any one of those guidelines. They are training tools. They're training on a bicycle. It allows you to get started. It gives you some guidance as you're trying to feel your way through this process. But if you're going to use them as a specific, I have to do that in this way, in this order, in this fashion, you're going to fail. So I happen to agree with the author of this article. So instead of telling healthcare providers exactly what to do to say, like some of those things that we discussed, express your personal regrets or ask about feelings, I believe that we should focus on training to avoid the things that we know are bad. So all of us, I think, as we watched that first video clip, could identify, first off, your gestalt was that that was awful. That was a horrible approach to discussing a bad situation with a patient. But I think that all of us, if we spent the time just dissecting that video clip, could pick out the bits and pieces that made it so bad. She used medical jargon. She sat above the patient on an exam table so that she was shoulders, she was a body length above the patient. So she was looking down on that patient. She used, her beeper went off multiple times. She was very clearly trying to get out of the room. I'm just going to refer you to a medical oncologist. So we know the habits that, or the components of a discussion that are bad. So let's train us to avoid those habits. And then we can find our individual techniques that suit us and that particular patient's best and result, in this case, to the fewest number of punches to the face, but result in better outcomes, not just for the patient and her family, but to you and to the other healthcare providers that are involved in caring for your particular patients. So I will leave you with that. I think this is, when I was putting this together, this was the most important thing that I pulled out of this is that we all know what's bad. We, in our heart of hearts, we know when we're not having a good conversation and the components of that conversation. I think that the training is best utilized to recognize those bad habits, try to eliminate those bad habits, and then work on developing a skillset and comfort, knowledge, and expertise, and really emotional comfort that suits you and your patients the best. So this is the references. I'm obviously not gonna go through those, but they'll be available and Susan will make them available to everybody. There's many, many others. All you have to do, if you have access to Google, which seems like everybody in the world does, just Google breaking bad news in medicine, and you'll find an almost limitless number of articles. And then the other advice I might give is don't just, if you're going to look for training, is don't just look for breaking bad news in medicine. Breaking bad news occurs in every field of communication, business, law, you name it. And so it's worthwhile looking at outside of medicine because the techniques are there about communication and communication is a universal process. So thank you. I will stop sharing my screen, get back onto video, and open up for questions. Thank you, Michael. That was wonderful. Thank you. Anthony, I know you had a question in the chat. Oh, not, sorry, not Anthony, Vincent. Sorry, Vincent, you had a quick question. Yeah, thank you for the wonderful presentation. You're welcome. Like in our setup, we have a lot of challenges regarding breaking bad news because of the cultural beliefs and practices. My question was, is there a role of giving axiolytic after breaking the bad news to the patient? And lastly, if you don't mind, Lucia, the soft copy of the presentation, just for one person. Yeah. You know, I think that's a very, first off, that's a very, very good question. The answer to that is, as in many things, it depends. And so you need to be very aware of your individual patient and her needs. So if you believe that she would benefit from an anxiolytic, there's no harm in giving that within the appropriate circumstances. We at least tend to be very conservative with giving anxiolytics, but there are circumstances where it's fully appropriate to do that. And if you're in your medical impression with that individual patient, that a short course of an anxiolytic is appropriate, by all means. Thank you. You're welcome. Can I ask a question, Michael? Sure. Okay. Yeah. It's always a pleasure listening to you, mainly because our cultural barriers with breaking bad news. In fact, their last presentation was very about palliative care. My question is about, you talked about listening to what is being said. I attended one session sometimes back where someone said that the physician should learn to listen to what is not being said. True. Yeah. I don't know how now to mirror, I mean, to marry the two and how, what is the art of listening to what is not being said, especially by the patient. The other issue is about not talking about other patients, but occasionally or many times I've had patients asking me, have you managed any other patient in the condition similar to mine? I'm wondering, when I discuss probably the experiences and the outcomes, that would amount to talking about other patients. Thank you. Right. So the first part about listening, it is, as you said, it is just as much about listening to what they say as it is to listening to what they don't say. And you're experienced enough to have had many, many opportunities to have these conversations with patients and you start to learn, if you practice listening carefully, which is back to the act of listening, you start to learn where patients are not saying things. So for example, if I'm telling a patient that her cancer has progressed and that they no longer feel that her cancer is curable. So we're starting to talk about transitioning to hospice, for example, and she's talking back to me about making plans for her son's college graduation three years down the road. She is, she is telling me by not telling me that she's not quite ready to hear that she's going to die. So it is just as much an important tool to listen to what they're not telling you as it is to listen to what they're telling you. And if you go back to, that's, that's, that's where having a rapport or having a relationship, having prior experience with that patient so that you know, when she's speaking to you, you know, you have a sense about what, you know, how that conversation should be going. And if she's leaving things out, it gives you, you should be able to pick up on that and address that. The second is, tell me again, the second question. Yeah, it's about one of the points you said was about not talking about other patients. But sometimes they ask you a question like, I have this condition now, have you managed similar patients with similar diagnosis and how has it gone? Right. So, so you're correct. That's a conversation or that's a question that comes up almost universally. Patients want to know two things. One they want to know, do you have any experience at handling this? And so they're trying to assess your level of comfort, experience, expertise in handling whatever their circumstances. And then second, they want to, they're asking for hope. You know, if there's other patients who have had similar circumstances, who've done well, that's what they want to hear. So generally, because that question comes up from patients all the time, I have a somewhat stock answer to that is yes, I have taken care of many patients with similar circumstances, but remember that every person is an individual. While some of those patients have done well, others have not done well. We don't have a way to compare you directly. And I go on from there with a conversation with the patient. So I try not to give patient vignettes. So I don't say, oh yeah, last week I took care of somebody with exactly the same story and she's doing great. That I think goes poorly, but I think it is fully appropriate to say, yes, I have cared for other women in your circumstance with similar situation. Some of those women have done well. Some of those women have not done well. Time will tell how things are going to go with you, but here's what I think. And then use that as a launching pad into a more specific discussion based upon her individual circumstances. All right. Who? Oh. Okay. Okay. Thank you. Thanks, thanks, thanks for the, for the lecture. I'm more concerned, most of the, the predictive bad news was to the patient. My concern is, can we use the same mechanism or technique to bring such a bad news to the patient's relative? Could we follow the same format? That is one. If, if for instance, that relative has the, the, the go ahead from the patient to discuss the patient, the patient's issue. That's my first question. Can we use the technique or format to bring bad news to patients relative? Because most of the lecture was about to bring bad news to the patient. Right. And yes, just, I just wanted to complete my, my question. And the, the next has to do with timing of bringing bad news. Is there a specific timing or where in the patient's treatment plan, can, can you decide to say, well, I got to let him or her know about this condition? Or is an ongoing process as the patient maybe leaves from one stage to the next stage of the disease? Those are my, my thoughts, because most of the bad news in oncology is about prognosis, outcome and so on. So do we have to wait to get at a certain point to, to bring a major bad news or as one or other event comes along the way, of course, we discuss with the patient so that the patient gets prepared gradually for whatever worst outcome that, that, that is coming. That's my thought. Okay. So, so two questions. So the first one, can you use these techniques to break bad news to patient's family is yes. First off the, the, the skillset that you learn for communication carries over to everything. It doesn't have to be just about breaking bad news. You can use the same skillset and you should be using the same skillset to tell patients good news. Really your conversations with your patients and their families should be open, honest, straightforward, not time limited, and not using medical jargon to the greatest degree and so on and so forth. So if the situation is such that the family is involved, or maybe the family are the primary caregivers, then by all means use the same, same techniques to, to speak to them. And then the second one is with regards to timing of breaking bad news. I personally think that that's an ongoing process that, you know, I start these conversations with patients when they first come to me for care. So if they come in with an advanced cancer, I'm already starting to discuss with them potential outcomes. So it's a, it's a continuum as opposed to a series of static steps along the way. Every patient is unique, your relationship with your patients is unique. And so it's, it's ultimately up to you to decide when it's appropriate to start these conversations. Anissa, you had your hand up? Yes, thank you so much, Michael, for having the time to talk to us about this. Thank you for pushing me to do it, yeah. Yeah, but I'll ask only two, okay? So the first thing is, in my practice, or in our practice in Kenya, we do see a lot of pediatric oncology cases. And I just wonder how, especially where the child is concerned, when you're trying to break the bad news to the parents about the prognosis. Do we usually involve the child? We tell the child as well? Do we make sure the parents tell them? Or just how do we go about that? And secondly, I know we mentioned this in the last session, but would you talk again about giving patients like an expiratory date? Like, for example, you have only six months to live, or three months to live, and maybe just comment a little about that. Thank you. You're welcome. So I'm probably not the best guide with regards to handling pediatric patients, because our practice has very little pediatric, young pediatrics. We take care of individuals maybe 14, 15 years old on up, because we have a very active pediatric surgical oncology and pediatric medical oncology service here, and then an overarching pediatric hospital. But having said that, the decision to involve the child in that conversation depends upon the individual child, as well as the parent's wishes. In general, children are much more in tune with what is going on than we give them credit for. Having said that, there is an emotional level of maturity that occurs, that is independent of actual calendar age. So there are very mature 10-year-olds, and very immature 15-year-olds. And how the degree to which you include that child in the conversation depends upon the child's emotional maturity, and then influenced heavily by the parents. My general belief is that it is important to include children in those conversations if those conversations directly affect their health and their care. But that is one where you have to be very cautious and very cognizant of not just the cultural impact, but the emotional maturity impact. And then the second one about prognostic information, telling patients about how long they have. That one, I try very hard not to sidestep the question, but I tell them that I don't have any true way to predict how much longer they have to live. I'll give them a range, where I think pretty good at saying, look, you're going to die in the next few days, the next week. I'm pretty good at that. Once it gets past that, maybe I'm okay at telling people you have months to live, or some weeks to live. But once it gets past that, I'm lousy. And so I try very hard not to tell people you've got three months, you've got six months. I'll tell them a broader range. And then I usually, because I do a lot of joking and a lot of humor, I'll tell them that my crystal ball is upgraded to electronic, but it's in the shop getting a new processor or something like that. But that is a difficult question. There's no way that I can say, I tell them, I just can't tell you how much longer you have to live. That's not up to me, unless I know that they're going to die in the next few days. Hi, Michael. If I can add to that, this is Paula Lee. Hi, everybody. Hi, Paula. Yeah. Hi, good to see you. Nice to see you as well. Let me see. I can put my video on. I don't know. Okay. There's literature out there that says that if you say the actual months, that's all that patients remember and hear. And so I ask really permission when they're asking me point blank. And some patients really want to hear that number to prepare. They're very practical. They want to make sure they see whatever things, events that they want to get done, but then other patients, it can be very detrimental. So I actually say before I answer that question, there's sometimes information out there that says it might be detrimental because as Michael was saying, I can't predict way out months. Okay. However, I am recommending hospice care because I want you to have these resources for you. And that technically with hospice care, because patients here, you have to have a prognosis of six months to give hospice. So they know it's not good. Right. But I ask permission to the patients and I say, is the reason for, you know, tell me why you want to know that number. And then if I know that also, if it's a short period of time, I tell the patients, well, it's a short period of time. And I highly encourage if there's family members you want to see, have them come see you now, you know, don't wait a couple of months because that's what patients are doing. They're planning. Do I have time to see my son in this place or what? I say, have them come see you now. That's, that's how I address that. Okay. Thank you. David. Yeah. Thank you, Michael, for delivering this important topic as a GYN oncologist, this is an important skill set and knowledge that we need to have. My question is, I want your insight on common situations that we have here in Ethiopia. Most, many times we have patients that come with an attendant and when the attendants know about the diagnosis, they don't want you to break or they don't want us to break the news to the patient. So they say, if you tell the patient is going to, she's going to be in a more worse situation and she can't tolerate it and so on. And so always we have this difficulty of having such a conversation. So what is your insight or what is your take on these issues? Yeah, I think that's difficult. And that would be one that I think the group might have a better insight than me by myself. You know, that's, I think that's, you know, that's back to the cultural differences or the cultural nuances. Here we run into that every so often, typically with patients who come from other cultures than within the United States. You know, my personal philosophical belief and my ethical belief is that I'm obligated to tell the patient the information. And I do believe that the patients wish to know that information, but that is tempered by the fact that individuals within different cultures truly have different cultural beliefs. And so we try hard not to force that information upon patients. So if the patient comes with an attendant, a family member typically, and it is very clear that that's their cultural approach, then I respect their cultural beliefs. If I think that the patient does want to know, and I'll ask, sometimes the best way to get an answer is just to ask directly, do you wish to know this information? And if the patient tells me that she does not wish to know that information, but that it is okay for me to speak to her husband or her son, her daughter, whoever is with her, then I respect those beliefs. And we'll direct the conversation to that, to the attendant, as opposed to the patient. But I'm very interested in hearing from others. You, Dawit, how do you handle those circumstances? Or Nissi, you've been in that circumstance, you and I have spoken about that, to see how others handle those circumstances. Yeah, so what I usually do is, maybe during the first visit, I will inform the attendant, the parents, or the caregivers about the disease. And I will appoint them for a second visit, so that I will tell them the patient need to have the right to know about the disease before proceeding to treatment. So I will give the attendants to have some time to think over it. And usually in the second or third visit, they will slowly tell the patients about the disease, and it would be easier for me to fully disclose the bad news. I think that's very wise. You know, as best you can, try to incorporate the family or the other attendants as your partners. You know, remember, this is a broad process. It isn't just something that affects the patient. It affects everybody around her. It affects you and the other health care providers. And so if you view everybody as a member of a team to try to provide the best care to the patient, this is a good way to incorporate them into the process. Okay, Sue, I have to sign off. You're welcome, Dawit. It's a pleasure to see you and Anissa. I have to sign off. I have to head off to clinic. And I know I have at least one of these conversations on my schedule today, because I looked. So I will try to practice what I preach as well. So I hope everybody is doing well. Stay well. And Nissi, thank you so much for being the stimulus to put this together and update it and get it out to you. Yes. Thank you so much. I have this recorded and I'll get the slides confirmed. Michael, I can share the slides with everyone? Yes. Yeah. So I'll probably have it on our IGCS website and I'll email it to people. So thank you so much, Michael. Really appreciate it. My pleasure. Nissi, congratulations on your grant. That's a wonderful thing. I'm very proud. Thank you. Thank you so much for your help. So grateful for your help. You did it. You did it. So, all right, everybody, have a great day. Thank you, everyone. Thank you so much. Bye-bye. Thanks for organizing, Susan. Oh, sure. Of course. Bye-bye.

breaking bad news

medical setting

oncology

communication task

SPIKES

ABCDE

BRAKES

active listening

empathy

timing