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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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