Good morning, everybody. My name is Michael Pearl. As some of you already know, I'm a gynecologic oncologist and palliative care specialist at Stony Brook, New York. I was asked to re-give a talk that I'd given previously about difficulty with communication or breaking bad news. That's what we'll talk about today. I have no conflicts to disclose that would have any impact on this discussion. I'll get rid of this somehow. I don't quite know how to make it go away. We'll stash it up there. Let's start with a clinical vignette that came up at one of the echo tumor boards within the last month. The patient is a 58-year-old multiparous postmenopausal woman who has HIV and has been on antiretroviral therapy since 2007. She presented to the facility with generalized weakness, loss of appetite, abdominal pain, and distension and was found to have a large cervical mass. A biopsy of the mass demonstrated squamous cell carcinoma. A CT scan demonstrated a heterogeneously enhancing nodulin mass in the left adnexa with vascular receptations that was quite large, 18.4 by 10.5 by 20 centimeters, and a cyst within the right adnexa measuring almost two centimeters in greatest diameter. Because of the presence of the ovarian mass, she was taken to the operating room, at which time 500 cc of ascites was removed. The left ovarian mass measured 30 by 15 centimeters. The right ovarian mass measured five by five centimeters. The uterus was about 16 centimeters. There was a tumor outside of the gynecologic track within the vascular uterine space and across the peritoneum. The final pathology demonstrated metastatic squamous cell carcinoma consistent with the cervical primary. Obviously, quite unusual and obviously, quite extensive. She was lost to follow-up for several months and then represented with generalized body weakness, further loss of appetite, and swelling of her lower limbs. On physical exam, she had had marked weight loss. There was inguinal lymphadenopathy palpable in both groins, and the lower legs were edematous bilaterally. She had a fungating cervical mass extending to the parametrium. On re-imaging, she had extensive left DVT. She had inguinal adenopathy on the left, and she had bilateral grade three hydronephrosis with a cervical mass that actually wasn't cervical. It was vaginal apex because she'd had her hysterectomy. Clearly, that patient's about to face very bad news. We always start out with definitions. What is bad news? There are a number of different definitions. These are two that are reasonable. First, bad news is any information which adversely and seriously affects an individual's view of his or her future. Bad news is also difficult to define because those of us in medical interactions appraise the information subjectively as either good, neutral, or bad. Thus, almost any news has a potential to be good, neutral, or bad. Telling a woman that she's pregnant when she has been trying to get pregnant for a year is obviously good news. Telling a woman who's pregnant when she has 14 children already and has no desire to be pregnant again may be bad news. News is bad to the extent that it results in a cognitive, behavioral, or emotional deficit in the patient receiving the news that persists for some time after that news is received. Here's an example on how to break bad news badly. Just hang with me for a moment. Oh, anybody hear it? No. All right, that's unfortunate. Well, sometimes you have to hit the, normally if you're sharing a screen, you'd have to stop sharing and then hit, there's two buttons you'd have to hit so you can hear it. Like if you stop sharing and then hit share, you can hit optimize. I have to look at my screen, hold on. Yeah, well, let's, you know, let's see. So I'll stop sharing. Yeah, and then if you share again, click that button that says, before you hit optimize sound, hit both of those buttons. So share again? So you click share, but then before you hit your, it says share sound and optimize for video clip. Then it should work for your future videos as well. Oh, I see. Got it. All right, so let's go back. There we go. Yep. Thank you, Susan. You're welcome. Hello, ma'am. Hello, doctor. Mm-hmm. Ms. Flores? Yes. So what's your body been telling you? Well, I get very, very tired. 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, let's get right down to it. Mrs. Flores, you have invasive breast cancer. It's metastatic to your lymph nodes. It's estrogen receptor positive, which is a good thing because you will respond to hormonal therapy. What? I can't have cancer? No one in my family has cancer. Are you sure? The next step will be for me to send you, or for you to meet with a medical oncology team 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. You have a tumor, a growth. It's serious in that it can spread and it can grow pretty quick. So pretty clearly, that was very poorly done. At some time, I guess we could probably sit down and dissect that, even the first portion of that video clip and go through the innumerable problems in that discussion, but we'll go through some of it over the rest of this conversation. So breaking bad news, obviously, is a very common experience. We do it in our health profession on a regular basis. It impacts families. It impacts the patients, obviously, and it impacts us as healthcare providers. It is a very important but highly complex communication task, and it isn't just verbal. If you saw in that video clip, the physician was sitting up on an examining table and she wasn't looking at the patient. She was focusing on her beeper that was going off. So it isn't just verbal. It's your body position and everything else. And no matter how good you are at all of this, it remains highly stressful throughout the course of one's career. Why is it stressful? Well, the outcomes may be uncertain. Telling somebody that she may have cancer or that she does have cancer, you don't know what the future holds. She may be one that on the surface should be cured, but yet has a bad outcome, and on the surface may look like she's not going to do well, but does very well. The stakes are very clearly high. When you're telling somebody that they have a potentially life-threatening disorder, everything else seems to pale by comparison. Emotions run very deep. Sometimes time is of the essence. Oftentimes, we as healthcare providers have limited time within our day. And unless something is planned out, you may not have as much time as you wish to be able to speak with a patient or her family. There are cultural constraints. Here in New York, we have just about every culture on earth. Certainly, we have every language spoken on earth. That's actually a fact, that every single language spoken on earth is spoken in New York City. And so we hear, for example, we see people from all around the world with a variety of different cultures, and the constraints are different by culture. And then for most people, there's a lack of formal training in delivering bad news. But why is it important? It is important because patients want the truth. It is an ethical imperative. It is, in ethical terms, it is veracity. Otherwise, tell the truth. Here in the United States, until the 1970s, most physicians were paternalistic, and they considered giving bad news about cancer diagnosis as inhumane and damaging to the patient and her family. By the late 1970s, however, attitudes had changed, and most physicians were open to tell cancer patients their diagnosis. And by the early 1980s, surveys showed that up to 96% of patients wished to be told if they had a cancer diagnosis, and 85% wished, in those cases where the prognosis was grave, to be given a realistic estimate of their life expectancy. There's another little 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! So that's not true. Patients can handle the truth, and their families can handle the truth. It is our responsibility to tell them the truth. So lack of honesty, even if you mean well, robs patients and their families of the opportunity to make an informed choice. And if you don't tell the truth, and you're caught out in not telling the truth, it severely jeopardizes the foundation of the healthcare provider and patient relationship. So why is breaking bad news important? Well, at least here in North America, the principles of informed consent, patient autonomy, and we have too many attorneys, case law, have created a very clear ethical and legal obligation to provide patients with as much information as they desire about their illness and treatment, side effects, and consequences. We may not withhold medical information, even if we suspect that it'll have a negative effect on the patient. The recent legislation called the Cures Act, now, for example, any information that goes into the medical record is immediately available to the patient. I had a patient on Monday who saw her biopsy showing that she had newly diagnosed cancer of the ovary about six hours before I had the opportunity to view those results. And she was already calling, even before I had a chance to see the biopsy results. On the other side, a mandate to disclose the truth without any regard or concern for the sensitivity by which it is done, or the obligation to support the patients and assist them while they're making decisions will result in the patients being just as upset as if somebody lied to them. So it's been aptly suggested that the practice of deception cannot be immediately remedied by a new routine of insensitive truth-telling, kind of like the woman in that first video, just telling the patient, oh, you have cancer. So why is breaking bad news important? Because our cultural constraints impact on the ability of our jobs, us as healthcare providers, to communicate to the patient and their family. We need to be aware of each patient's cultural beliefs and their values. And as I said, for example, here in New York, we have every language spoken on the earth. And so the barriers may prevent comprehension of the information being conveyed by the health professional. Even if we use an interpreter, and we have an interpreter service that I think has every language, there is still a loss of communication when we're trying to use translators in a language in which we're not intimately familiar. The type and amount of information sought by the patient may vary according to their cultural values and beliefs. In some cultures, the patient is protected by the family, and it's our responsibility to speak to the family who then communicates with the patient. And again, information may, will lose some of its context as it's passed from person to person. The level of involvement of the family in discussions and decisions, as I said, will depend upon their cultural background. So what happens when you do it badly? So breaking bad news badly has an impact on everybody. On the patients, poor communication, especially with cancer patients, decreases clinical and psychosocial outcomes. Pain control is worse. They are less adherent to treatment recommendations. There's increased confusion over the prognosis, and the patients and their families are dissatisfied and not being involved in decision-making. It has an impact on us as healthcare providers as well. When we do it poorly, and oftentimes we know that we do it poorly, whether it's as we are doing it or afterwards when we reflect upon our conversations, we have a sense of failure. We didn't do our job as well as potentially we could have done our job. There is uncertainty and discomfort with not communicating as well as we think we should. If it happens often enough or severely enough, we become emotionally disengaged. I can't speak well, and so therefore I'm just not going to engage. And it leads to adverse coping mechanisms. Difficulty with communication is the elephant in the room. Oftentimes, we do withhold information when patients are dying, or it is clear that their death is approaching. At this time, communication and clear understanding between all of those involved in the patient's care, us, the patient, and the family is very critical. Patients are better informed than you believe, and they do prefer detailed information about their disease and about their prognosis. They are, like our children, much better informed than any of us believe. Even so, we, the healthcare providers, the families, and even the patients collude to avoid mentioning death or dying, even when it is very clear that the end of life is approaching. We are reluctant or unable to tell patients they're approaching the end of the life. We have an inherent uncertainty within our prognostic capabilities. We fear that we will be perceived as giving up if we talk about somebody dying. It clearly has an impact on our own sense of mortality. Denial is a wonderful thing until you poke the bubble of denial. And it affects us all. And it affects our professional skills. And at least in countries like the United States and others, there are medical legal concerns. So how to break the news to a terminal patient? Can't really just consult a textbook, but there are ways to learn how to do this. There are a number of tools, and I'm gonna go through those over the next few minutes. So the first thing is, is true in medicine, and honestly, as is true in life, is that we should actively listen. So listen to what the person is saying and then repeat it back. So what I'm hearing you say is that you want us to do everything possible to prolong your mother's life. After you've done so, then disclose. I'm worried that even with the best medical care, we won't be able to achieve your hopes. Explain why. My view of this situation is that providing IV fluids would give her at best a 5% chance of improving. Be empathetic, and I'm gonna come back to empathy versus sympathy in a little while, but be empathetic. I think anyone would feel as worried as you given these circumstances. And then reframe the conversation to get to where you need to get to based upon your professional judgment. 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 work with the patient and the family to brainstorm and try to come up with a way to bring the team together. So let's come up with a few ideas to help prepare for her death. I like this quote. An expert in breaking bad news is not someone who gets it right every time. Nobody's gonna get it right every time. He or she is merely someone who gets it wrong less often and who is less flustered when things don't go smoothly. So there are a number of different models to learn techniques for breaking bad news. Spikes, ABCDE, breaks, and there are many others. Those are just three examples, and I'll go through each one of those. The spikes model is the following. So the first thing, S, is set up the interview. Make sure that you're in a private space. Involve others, be attentive and calm. Listen, actively listen, and make sure that you have sufficient time. P is for assessing the patient's perception. Ask before you tell. Find out what the patient knows and listen to the patient's language, not just verbal, but body language. Obtain the patient's invitation by asking, how much information would you like to know? And then give knowledge. Fire a warning shot. I'm afraid, Mrs. Jones, that I don't have good news for you today. Mirror the patient's language and avoid jargon. If you go back to that little vignette we had, she, one of her many problems was that she was using too much medical ease. Give information in chunks, but then use silence and allow time for emotions. With emotions, be empathetic. Recognize that emotions are present. You're having a difficult conversation. It would be very, very unusual if emotion was not present. Listen for and identify the emotion and its root cause and show verbally or physically that you've identified that emotion and its cause. And then the final S is for strategy and summarize. So summarize the discussion, strategize for future care, make sure you schedule the next meeting and then allow time for questions. When I have an end-of-life discussion with my patients, one of the things that I always do is schedule them for a follow-up visit. Whether I believe in my heart of hearts that they're going to be able to come back for another visit I make sure that I schedule a follow-up visit, whether it's a week from then or six weeks, two months, and make sure that there's something in their schedule so that they have the perception that I'm there for them if and when they need me. With A, B, C, D, E, this is very similar. A is for advanced preparation. Make sure that you're familiar with what you're going to discuss. Make sure that you know your patient and her medical history, and make sure that you have a plan in place for how you're going to approach the conversation and the treatment and management options. Rehearse, prepare yourself emotionally. These are difficult conversations. Make sure that you've built a therapeutic environment in a relationship. Have family members or support persons present. Make sure that you introduce yourself, even if you already know people, and if there are other people present, ask for their names and their relationships. Again, give a warning shot. Use touch where appropriate. I firmly believe that touch is a critical component of what we do, and so I oftentimes will sit next to the patient so that I can hold a hand or touch an elbow and so at least be somewhere where I can have physical contact. And then as I said, make sure that you assure the patient that you will always be available. And oh, by the way, if the patient is going to bring somebody with them as they should, then you should bring somebody with you as well. You need a supportive person. Communicate well. Be frank, but be compassionate. Don't use medical jargon or euphemisms. Speak clearly. Allow for science and tears or emotions and proceed at the patient's pace. Sometimes it takes more than one meeting to get the information across. Have her describe her understanding and then repeat this information at subsequent visits. Deal with the patient and the family reaction. Again, there is going to be an emotional reaction to giving bad news. Be empathetic. Don't argue, or if there are other colleagues involved, don't criticize your colleagues. And then encourage and validate the emotions. Explore what the information means to that particular patient. Offer realistic hope according to the patient's goal, but be realistic and make sure that you take care of your own needs. And by the way, it isn't just you. Don't forget your staff, the nurses, the medical assistants, the other people involved in the patient's care oftentimes become connected to those patients. And when bad things happen, the staff suffer just as much as you or the patient might suffer. BRAKES is a third version. As you can see from this, it is very similar. It's just a different mnemonic. Make sure that you have the patient's background. So know the clinical history, know the family. Make sure that you are as fully aware and fluent with the patient's information as you can be. Build rapport. Allow time and space to understand the patient's concerns. Make sure that you explore. So ask for the patient's understanding and start from what the patient does know about her illness. Announce. Preface the bad news with a warning. I can't stress this one enough. Warning shots are very important. I'm really sorry, Mrs. Jones. I have bad news for you today or I'm really sorry, Mrs. Smith. I know that you hoped and go on from there. Make sure that you use non-medical language. Don't tell stories of other patients unless they're very brief and they're very specific and appropriate to the individual patient. Don't talk too long. Give no more than three pieces of information at a given time. And honestly, I think it should be less than that. And make sure you summarize the bad news and the patient's concern. Provide a written summary. And in this one, this is a very good point. So ensure that the patients are safe. It's seldom somebody that they have very bad news. They're going to die from their cancer in the next four to six weeks. Maybe they decide they don't wish to live and they're going to walk out of your office and jump off a bridge. Maybe they're so tearful that they can't drive or they're gonna drive to the local bar, get intoxicated and cause a crash. So be cognizant of the entire entirety of the patient. And then make sure you provide follow-up options. So I mentioned earlier that we were, that I talked about sympathy versus empathy. And here's just a quick cartoon to try to distinguish between those two because oftentimes they are, the terms are used interchangeably when they're not truly interchangeable. So being sympathetic, you say, I'm sorry you feel that way, means that you recognize and you understand how the person is feeling from your own perspective. Empathy on the other hand is sharing and identifying with another person's situation or feelings. I feel your pain. I've been there. I've walked in your shoes. Expressing empathy can be remembered using nurse as a mnemonic. So N stands for naming. So name it. It sounds like you're worried about pain as your cancer progresses. I wonder if you're feeling angry about your diagnosis. Be understanding and state that you're understanding. If I understand what you're saying, you're worried about how your treatments are going to affect your ability to work. Be explicit. This has been extremely difficult for you dealing with your cancer over the last six months. Be respectful. This must be a tremendous amount to deal with or I'm impressed with how well you've handled the treatments even though you've had many complications. Be supportive. Patients want to know that you're there. That you are truly there. That you're not just a physical presence. That you are there with them. I will be here with you during your treatments. Please let me know what I can do to help you. And then explore. Tell me more about your concern about the treatment side effects. Or you mentioned you're afraid about how your children will take the news. What can you tell me about this? So circling back on how to break bad news, there are technical aspects that are very straightforward. They're physical aspects. They're procedures. And once you learn them, they're not complicated. So the very first thing is to make sure that there's a private area and make sure that everybody is seated and that everybody is seated at the same level. Going back to our clinical vignette at the beginning of the video, she sat on an exam table much higher than the patient. That's wrong in just about every circumstance unless maybe you're a judge in a courtroom. So make sure that everybody is seated and that everybody is seated at the same level and comfortably seated. If you need extra chairs, get extra chairs. If you need a larger space, find a larger space. Invite a support network. This is crucial. Ask the patient to bring family or friends. And generally, we, pre-COVID at least, didn't place a limit. So if they wanted to bring 14 people in, we found a room that would accommodate the number of people that they wish to bring. In that circumstance, it can very rapidly descend into chaos. So as I'm starting the discussion and leading the discussion, I will say, look, there's a lot of people in here. Everybody has an opinion and we wish to hear from everybody, but please don't speak up when somebody else is speaking. Be polite and ideally identify a family spokesperson. Make sure that you bring a support person for you. You're in this, you're going to be telling somebody bad news. That has an impact on you. So make sure that you have somebody with you to help support you. Here, it's actually easy for us. I work at a teaching hospital and so I have medical students and residents. Sometimes I bring one of my partners. Sometimes I bring in a nurse. Oftentimes if the patient is in the hospital and I need to sit and have a serious discussion, I will bring the nurse that's on shift at that time and ask her or him to sit with me. Make sure that you've allocated adequate time. It is not okay to walk in and say, I'm afraid I have bad news. I've got five minutes until I have to be in the operating room. Do you have any questions? That's not okay. So make sure that you allocate, make sure you have a lot adequate time to be able to speak to the patients and then have time afterwards to deal with the aftermath. As I've said numerous times to this discussion, open with either a warning phrase or potentially a question. And I use both. I generally, especially if it's a patient who is about to have a discussion about end of life, I start by asking them if they feel well enough to have a discussion or to talk with me for a while. And then I open with, then I follow with my warning phrase, I'm afraid I don't have good news. I'm afraid I have bad news. And remember, it may take more than one session. So be prepared to break off the conversation and reschedule or schedule another session. Make sure that you talk honestly, be sensitive and straightforward. It is critically important that you're willing to talk about dying and that you're able to use the words death and dying. It is not okay to sugarcoat or dance around and say, well, you might, you may, and use whatever phrases that cover up what is truly happening. Patients want the truth. They are aware. They know that things are not going well. Don't try to hide it. Make sure that you listen with interrupting. I remember years and years and years ago, I went to a lecture and the professor was speaking about communication in healthcare. And one of the things that she said was that physicians, and I assume this is true for all healthcare providers, that physicians go less than 15 seconds before they interrupt the person to whom they're speaking. That's not okay either. So say what you have to say. And when the other person is speaking, don't interrupt. If it is clear, you know, two minutes, three minutes, four minutes, five minutes are going on and the conversation is not progressing, it is okay to try to redirect the conversation, but don't ask the patient what they think. And then as they start to speak, switch or interrupt and go on to another topic. Make sure that you encourage questions. This isn't all about you. It's about them and they have questions, I'm sure, that they may ask. But if you don't make it clear that questions are okay, they're not going to ask their questions. Do not discourage hope. I never say there's nothing left that we can do for you. I always try to say, or I try to say something along the lines of, well, it's clear that chemotherapy is no longer effective. And now it's time to change our focus. And I use, we're going to focus on quality over quantity as one of my kind of standard textbook phrases in these types of conversations. I firmly believe on a philosophical level in quality over quantity. And then on a professional medical level, I bring that up as part of the discussion. Rather than saying, well, Mrs. Jones, I'm very sorry, but there's nothing more that we can do for you. That is not a true statement. There is always, always something that you can do to help the patients and their family. So this is a good start. You might want to sit down, Mrs. Dumpty. This is a bad start. The lovely widow. So there are a number of things not to do when you're delivering bad news. So first, don't assume that you have the training simply because you're a qualified medical professional. Simply because you've gone through medical school or residency or the equivalent doesn't mean that anybody has taught you how to deliver bad news. So don't assume that you're good at this. Don't forego building the relationship with the patients. You have to earn their trust and then keep their trust. Part of doing so is learning about your patient and making the patients feel special. When I see a patient in my clinic, whether she's in for something relatively minor like an abnormal pap smear, or whether she's in for terminal cancer, I always ask something personal about them. I listen carefully to what they say about that personal information. And then I write it down in my medical records so that when I see them again, I can ask them again. So if the patient says something about her grandchild or maybe her husband retired, or they'd recently took a trip, I make a note in the medical record. And then when I see that patient again, I ask. It is a tool, but it is something that I learned a long time ago. And it helps me connect with the patients. And it helps me feel as if the patients are more than just writing on a piece of paper or an electronic fits in a computer. Make sure that you engage with the family. The family are a very important component of the individual patients. They provide support. It is important to understand the dynamics and the cultural considerations. And the only way that you'll truly understand that is to engage. Don't muddle the message. Again, we've talked about it already through this conversation. Deliver the message that you have to deliver clearly, directly, and without using medical jargon and medical ease. Make sure that you identify how much patients want to know. I ask, I specifically ask. So how much do you want to know? If I'm talking about stage or I'm talking about life expectancy, I ask. And generally I have, again, standard phrases that incorporate into my discussions. And I always ask them at the beginning or tell them at the beginning, look, if you ask me a question, I assume that you want to know an honest answer and I will do my best to give you as honest an answer and as accurate an answer as I can give you. But if you don't want to know the answer, don't ask me. And it's remarkable how many times patients will say, I don't want to know my prognosis. Give the patients time to react. So if you tell them something, don't immediately go on to the next. Wait until the patient has time to react. I'm really sorry, Mrs. Smith. It looks like that mass that we saw in your CT scan, the biopsy showed that there was cancer that looks like your original cancer. So your cancer is back. And oh, by the way, we're going to start your chemotherapy next week. That doesn't give a patient any time to react to the news that her cancer is back. Don't ask, do you have any questions? So that's an interesting thing to put in there. Don't just say, do you have any questions in the midst of your conversation? Feed it in over the course of the discussion. So as you tell somebody a bit of bad news or a bit of news, ask them at that point, do you understand? Or is there something that I can make more clear rather than just say, I'm sorry, Mrs. Smith, your cancer is back. Do you have any questions? Once you say your cancer is back, their brain goes into shutdown and they don't hear anything else you have to say. And I've said earlier, don't sympathize, be empathetic. There are effective tactics for empathetic communication, the nurse mnemonic as we discussed, but there are others that are out there. Make sure that you reassure the patients and the family that they're in good hands. You should be proud and confident in your skills. Patients want to know that you're confident. Don't be arrogant, but be confident. It does patients no good if they think that you're wishy-washy or that you're uncertain. And always be self-aware in your responses to the patients. Don't be afraid. This is very difficult. Bad news is bad news. It's hard and it will remain hard for the rest of your career, but don't be afraid. Again, your patients expect that you're confident and that you're strong. They come to you because they know, they believe that you will care for them. And they want to see that you care for them. A little, I'll give you a little anecdote. So some years ago, many years ago, I was speaking with one of my patients immediately prior to surgery. She was in the holding area. And at the end of the conversation, one of the family members did what they normally do and speaks up and asks me, so doc, how many times have you done this procedure and are you any good at it? So I did what I typically do. I said, well, I've done this many, many times. And yes, I'm actually quite good at this. And I'm one of the people here that if you had this type of problem, I'm one of the people that you want taking care of you. Not arrogant, just confident. And in the bed space next door was a gentleman, a man, I don't know how gentle he was, but a man. And he overheard the conversation. And as I'm walking out, he pulls me aside and says, hey doc, can I talk to you? I said, yeah, sure. He said, that was a pretty arrogant statement you made back there. And I kind of rolled my eyes and I said, what statement was that? And he repeated my statement. And I said, well, I said, the reality is that I am good at what I do. And I am the person that at least around here, I'm one of the people that you want doing that type of procedure. And given that I was not quite so happy with the fact that he interrupted me, as I walked out the door, I turned back to him and I said, you know, I know your doctor. I said, I know the surgeon that's about to operate on you. He said, yeah. I said, he's just okay. And then I walked out the door. So make sure that you're confident. Don't be arrogant. I don't care how good you are at doing this. There are times where it's not going to go smoothly. It happens. Happens all the time. These are high stress, high anxiety circumstances. And you could know the patient and her family inside out, backwards and forwards. You could have had a perfect morning and you feel prepared. You have thought this through, you've done your reading. You've worked through a variety of skill techniques. You have a plan of action laid out and you walk in and everything goes downhill almost immediately. There's an upset family member. The patient is angry. She didn't get any sleep last night. She doesn't feel well. So conflict is going to arise no matter how good you are and no matter how well prepared. At times there's going to be conflict. So you have to be prepared for negotiations. So if going into the discussion, you're in not a good position, you've had a bad day, something else is going on. You feel angry at the world. Maybe it's best to reschedule that discussion or at the very least assess your personal state of mind. When the conflict arises, find a non-judgmental starting point that everybody can agree upon and then reframe those issues that are emotionally charged. Remember back to the techniques for delivering bad news. One of the things is to reframe. Search for options that satisfy both parties' needs. It's not always feasible and the best compromise is one that leaves everybody just a little bit unsatisfied. And then get help. You're not in this alone. Sometimes you need a colleague. Sometimes you have somebody around that has more experience or maybe less experience. Sometimes it just needs a different face. Here we have an ethics committee within the hospital so that if there is real conflict and you're unable to resolve the conflict, we can reach out to an impartial group that will come and meet with all the parties and then provide some guidance. Don't do this. You have a terminal illness and you're going to die. Thank you for your call. Beep. So I've given you a bunch of good news about breaking bad news, but there is bad news about breaking bad news. And the first one is that despite what I said earlier about the techniques, there really isn't a science that you can learn just by following a few very clear easy steps. Yes, I can outline those steps for you, but when you try to do them, it doesn't work that way all the time. Like they say, the best laid plans only last as long as the first sentence. So here's a little vignette. A physician said once that he told a guy that his sister had died in a car crash. I'm not sure that car crashes are expected unless you're doing a demolition derby, but died in a car crash. The guy became overwhelmed with grief, punched the physician right in the face. I don't think that if you worked on the spikes protocol or the brakes protocol or any of the other protocols that you would have avoided getting punched in the face. It was a grief reaction that was immediate. So the bad news about breaking bad news is that there isn't a single right way to do it. The way I do this isn't necessarily the way that you do it. And we fail when we try to develop one size fits all. It doesn't work. So giving information about techniques is all well and good. It does help. Without a doubt, it does help. But then what we really should do is try to avoid the habits that we clearly know are bad. Don't stall. Don't use medical jargon. Don't sit above or stand, even worse, above a patient. And then use the techniques and try to find the techniques that work for you. It's the same as being in the operating room. I and two of my three partners, we all trained at the same institution. Five years apart, each one of us, but we all trained at the same institution with mostly the same people. So when we're in the operating room, we do most everything similarly, but not completely. And my fourth partner trained in an entirely different institution, and she does things very, very differently. But yet the outcomes, we all get to the same end point. So as we teach the residents about surgical techniques, the residents, when they graduate, take a little bit from me, a little bit from everybody else, and then they become an individual. As you think about chemotherapy or other components of your medical life, we take a little bit from this person, a little bit from that person, and put that into us. And then as we go through, we become a unique individual as we approach things. And so I think it should be the same thing with delivering bad news. This is a skill set like any other skill set. You can learn the basics, but the only way to really learn it is to do it a bunch of times. You're going to do it badly sometimes. You're going to do it better sometimes. And make sure that you think about it each time so that you try to eliminate or at least reduce the bad things and encourage yourself to use the good things and say, oh, that worked. I'm going to try that again next time. So the last thing, and this is appropriate since we're coming to the end of the discussion, and then we can have a conversation. And the last thing is in breaking bad news, really isn't breaking bad news, but it's important. And that is being able to say goodbye to patients. So all too often, we know that a patient is terminally ill and they won't be coming back. So even though we, as we should, make an appointment for her to come back and see us in a month, you know, and they know, by the way, that they're not going to be capable of coming back for that visit, or they may have already passed away. So if you let the patient and the family leave without saying anything, it is not a good thing. The patients are perplexed. They can feel abandoned. It resonates poorly within oneself. So you know that the patient isn't going to be coming back. You didn't say goodbye. And it leaves you without closure, if you want to use the technical term, but it leaves you feeling dissatisfied as well. So make sure that you say goodbye. It is probably, almost certainly, one of the most difficult things that you're going to do. Saying goodbye to a patient's face, knowing that that patient is going to die, and that she will never be back to see you again, is one of those things that is very emotional. It will make you cry. I've been doing this for three decades now, and it still makes me cry every time I do this. I view that as a good thing. I am not so emotionally jaded that I don't feel sad when I have to say goodbye to one of my patients. So I always work at saying goodbye. Sometimes you miss. Sometimes you don't expect the patient is going to get sick that fast or not be able to come back. But if you know that the patient isn't going to come back, say goodbye. And then have a conversation, have a brief conversation. Say goodbye. Tell the patient and the family that it was a privilege to be able to care for them, and that you hope that your care has been beneficial, and that you're always there. Sometimes families come back, and they want to see you afterwards. That's okay. We make time in our schedule to allow that to happen. So it values the patient as a human, and it values you with the challenging work that you conduct as being a physician. So make sure you say goodbye. How do you do it? Well, it's similar to what we've done or we've talked about earlier in this conversation. Make sure that the time is appropriate and that the place is appropriate. Don't stand in the hallway with a bunch of other patients and healthcare providers hustling and bustling up and down the hallway and say, I'm sorry, Mrs. Smith. I don't think I'll see you again. Your cancer has progressed. And so I just wanted to say goodbye as you're walking into another patient's exam room. Do acknowledge that routine contact is ending. I'm very sorry, Mrs. Smith. I don't believe that we'll be able to see each other again. I expect that your cancer as it progresses is going to keep you from being able to come back to see me. Again, just as we talked about earlier, invite a response and monitor the patient's emotions. Generally, this is a highly emotional circumstance, but it is very appreciated by the patients. And as I said earlier, make sure that you frame the goodbye as an appreciation from you to them. Remember, they're coming to you. You didn't go out and pull them off the street. They chose to come to you. And if they came to you once and came back, they chose to stay with you. Allow the patient space to reciprocate and then be empathetic with your response. So let them be grateful. Let them be angry. Allow them to reciprocate and then be empathetic. Remember, they're dying or something bad is happening to them. Make sure that you establish an ongoing commitment. So say, you know what? We're here. I'm going to schedule an appointment for you in a month. I don't believe that you'll be able to keep that appointment, but it's here if you need it. And obviously, if you need to come and see us beforehand, we're always here to take care of you. And then once you're done, at the end of your day or that night or the weekend, make sure that you reflect on what you've accomplished with that patient. You're part of this picture and you're an integral part of this picture. Don't neglect your own feelings because if you do so, then you either establish a very thick shell that doesn't allow you to be empathetic or you develop very bad coping mechanisms, drugs, alcohol, self-destructive behavior, or at the least you become disengaged and you just don't care anymore. We're in a very privileged profession. Patients allow us access to their lives, oftentimes on the worst days of their lives. It is a privilege. So reflect upon that and make sure that you value yourself as you go through your career. We all want closure. Saying goodbye is one way to provide that closure. And this is one of my other favorite quotes. This is from the American Academy of Hospice and Palliative Medicine. It reminds us that death is a natural and inevitable end to life, that helping patients achieve an appropriate and easy passage to death is one of the most important and rewarding services that a physician can provide. I tell my new residents that I can teach. I used to think I could teach any of them to be surgeons. I don't honestly believe that's true anymore. There are some people I just can't teach to be surgeons. If you can follow a recipe in a cookbook, I can almost certainly teach you to do chemotherapy. And the rest of medicine is relatively straightforward. But being able to speak to your patients comfortably when the news is bad and helping them through the final phases of their life as they pass away to me is probably the most difficult, but one of the most important, if not the most important. And for me personally, the most rewarding service or component of my career. For me personally, this is what makes me a physician. It's not my technical skills. Those many people can do. It's being able to talk to people comfortably about very difficult topics. So this is a true statement. Don't worry. Dying is the last thing you're going to do. And with that, I will end this conversation, my lecture part of this, and then open this up to a discussion. So I'm going to get out of.

breaking bad news

communication skills

empathetic delivery

SPIKES approach

ABCDE approach

BREAKS approach

cultural considerations

patient reactions

self-care for healthcare providers