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MANAGING
DIFFICULT PATIENT SITUATIONS
Whether a diagnosis
is not life threatening (eg. Diabetes) or catastrophic (eg. Cancer), settled
or uncertain many patients
interpret the
news as bad. The patient wants to be given "relevant" facts compassionately.
What is "relevant" varies, so the physician needs to ask specific questions
to learn what the patient knows and wants to know, what the patient's
health beliefs are and what the patient is capable of understanding.
Delivering bad
news is difficult because:
- We fear being
blamed
- We fear strong
emotional reactions-ours and the patient's
- Some lack practice
or training in giving news
- We may have to
confront our own fear of death or illness
- What is "bad news"
for the patient may not be for us andvice- versa
- Keep in mind that
bad news is difficult to hear. If people have strong emotional reactions
it doesn't necessarily mean that you did not deliver the news sensitively;
and a strong, appropriate emotional response is healthy.
We can learn skills
to deliver bad news by following these steps:
1. Prepare
- Attend to your
own emotions.
- Deliver news face-to-face
whenever possible.
- Have all the necessary
information at hand.
- Ensure sufficient
time and privacy.
- Explore with patient
possible outcomes prior to testing.
- Have the patient
have a significant other present.
- Tape the session
and give the tape to the patient.
2. Assess Readiness
- Assess patient's
readiness to receive bad news. "Would you like to talk about your test
results now?"
- Prepare patient
by forecasting news. "I have some difficult news for you".
3. Check
the patient's response
- Remember, what
we find most concerning may not be what's most distressing to the patient.
"What are you thinking/feeling?" "What are your concerns?"
- Give time and
opportunity to respond. Expect strong emotional responses and attend
to them before proceeding with information giving. Watch for shock
and shut down. "We have some decisions to make about how to proceed.
Are you able to discuss this now?"
- Address basic
information needs. Don't try to give too much information at once. Give
more details after patient gets out of shock.
- Goal is to achieve
a shared understanding of the problem. "Can you tell me what you understand
about your problem?"
4. Follow-up plan
- Minimize feelings
of aloneness and isolation. "I'm available" "Is there anyone else you'd
like me to speak to?" "Would you like me to call the chaplain, social
worker, etc?"
- Schedule timely
follow-up visit and be sure patient knows how to contact you in between.
We can deliver
diagnosis meaningfully by:
ASKING the patient his/her understanding of what the problem is.
Or reflect what you've heard if patient has already stated this.
TELLING the patient, "You have" or "The diagnosis is not
clear yet, but I'm concerned about"
ASKING the patient about his/her knowledge, feelings, beliefs,
and expectations.
A Reminder:
Ask
About: Knowledge
Description: Ask about understanding of your news. Adjust quantity
and type of information.
Examples: What do you already know about X?" "What questions do
you have?" "What do you want to know more about?"
Ask About:
Feelings, Emotions, Reactions
Description: Ask about inner state in response to news, or reflect
the feelings you see or hear (see PEARLS Statments below).
Examples: "What's your reaction to this?" "How are you feeling
about this?" "You look worried."
Ask About:
Beliefs, Meanings
Description: Ask about beliefs about why he/she has the problem
and/or what it means.
Examples: "Why do you think you have high blood pressure?" "What
does X mean to you?" "How will you cope with the uncertainty?"
Ask About:
Expectations
Description: Ask about expectations of future outcomes.
Examples: "What do you expect to happen in the future?"
RELATIONSHIP BUILDING
TECHNIQUES-Responding to Emotions
1. Recognize patient's
emotions: Anger, sadness, shock, fear, anxiety, happiness, grief, uncertainty,
confusion, etc. These effect patient's well being and care outcomes.
2. Show you notice by responding actively with a PEARLS (below)
statement, rather than with more questions or information.
P=Partnership
Function: Joint problem solving.
Statements: "Let's tackle this together."
E=Empathy
Function: Show understanding. Put feelings into words. Show compassion
about illness.
Statements: "That sounds hard." "You look upset" "You seem discouraged."
"I'm sorry you are ill."
A=Apology
Function: Show concern for errors, hurts.
Statements: "I'm sorry I (or others) hurt/offended/upset you."
R=Respect
Function: Value patient's choices, traits, behaviors, and special
qualities.
Statements: "I appreciate and respect yourÖ (courage, decision,
action)." "You have worked hard on this."
L=Legitimation
Function: Let the patient know that his or her response is normal
and expected. Validate his or her feelings and choices.
Statements: "Anyone would beÖ(confused, sad, irritated) by this
situation." Or "I can understand why you feelÖ"
S=Support
Function: Offer ongoing support (non-abandonment).
Statements: "I'll stick with you as long as necessary." "We'll
work together on this." "I'll be there for you." Resist the powerful temptation
to pursue clinical details when responding to emotion.
Adapted
from materials developed by the American Academy on Physician and Patient
Courses Committee
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