Docs promote a better way to deliver bad news
Method builds trust, reduces unneeded treatment
Perhaps there is no more difficult moment in medicine than when a doctor tells a patient about a cancer diagnosis, a failed treatment, or other bad news. While nothing can take away the pain and high emotion of that event, two physicians are determined to help physicians handle that task compassionately and appropriately.
How physicians deliver bad news can affect patient trust and satisfaction as well as quality of care, says Walter F. Baile, MD, chief of psychiatry at the University of Texas, M.D. Anderson Cancer Center in Houston. "It’s extremely stressful to give bad news, especially when the outcome is very guarded. There may be a tendency to sugarcoat the bad news or give incomplete information or be vague so the impact of being the messenger is lessened.
"While that may work in the short run, in the long run, the patient may come to feel that the physician wasn’t being truthful," he says. "We need to teach doctors skills to support the patient at the same time they break bad news, so the physician doesn’t have to feel he’s just the bearer of bad news but that he can do something psychologically therapeutic."
Baile and Toronto oncologist Robert Buckman, MD, PhD, FRCPC, developed workshops and CD-ROM and video sets that take a step-by-step approach to teaching an empathetic approach to delivering bad news. Buckman is also a professor at the University of Toronto.
Patients want direct information so they can make choices, say Baile and Buckman. But they also need their feelings acknowledged in a caring way.
Training is often lacking
Surprisingly, most oncologists don’t receive any special training in how to break bad news, although their work obviously requires such difficult conversations often. "It’s like not training firefighters in handling heat," says Buckman, who has been studying the issue since 1984.
When physicians feel uncomfortable about such conversations, they may act in ways that lessen their own anxiety but which are not necessarily best for patients, says Baile. "Those physicians who aren’t able to say, It’s really not going to be in your best interest to have chemotherapy because it’s not going to prolong your life,’ end up giving chemotherapy at the end of life and actually depriving them of the quality of life they could have," he says.
Patients also need information that enables them to give informed consent and participate in decision making. But they need to hear comforting words that reassure them that their physician understands their feelings, says Buckman. Openly acknowledging a patient’s emotional reaction "actually does make coping and resolving better."
Buckman and Baile developed a protocol they call SPIKES to help physicians remember the steps involved in sensitively delivering bad news. (See box at left.) Following the protocol, physicians first ask patients to give their perception of their medical situation and how much detailed information they would like to hear. If a patient breaks down or expresses anger or other emotions after hearing the news, the physician verbally acknowledges that empathetically.
"It’s not a wishy-washy, touchy-feely thing," says Buckman. "It’s a straight interview technique in which you acknowledge the patient’s emotion, you identify the cause or the source of the emotion, and you respond in a way that shows you made the connection between one and two."
Patients want their emotions to be addressed, says Baile. "They’re grateful for your having let them know that you acknowledge their distress. It’s validating."
Role-playing uses real situations
Now Buckman and Baile are trying to determine how best to deliver their message to physicians.
A study of intensive physician workshops using role-playing showed good acceptance of the technique from physicians.1 Participants reported feeling more confident with 18 of 21 items related to breaking bad news, such as handling patient’s emotional reactions and responding empathetically to patients’ feelings.
Other studies also show a link between communication skills and patients’ responses. Researchers at Johns Hopkins University School of Hygiene and Public Health in Baltimore found that breast cancer patients feel less anxiety when a doctor acknowledges their emotional state. A statement of compassion that takes as little as 40 seconds also makes the patients feel the doctor is more caring and sensitive, the researchers found.2
Doctors can learn to veer from the purely biomedical discussion to connect on a personal level, say Baile and Buckman. One key component of their workshops involves role-playing, in which physicians act out actual situations that they had identified from their own practice.
"[All physicians have] a troublesome case that bothers them," says Baile, "[such as] people they got attached to that they had to tell there was no more effective treatment — breaking bad news to kids. [The role-playing] is really centered on the experiences that the physicians bring to the workshops."
Role-playing gives physicians a chance to better understand their patients’ perceptions. "Since the physicians play their own patients, they get into their shoes," says Baile. "You can’t help but in a way experience some of the patient’s reaction, emotions, and feelings."
The physicians have held workshops and lectures at annual conferences of the American Society for Clinical Oncology, based in Alexandria, VA. They also filmed 45 scenarios that are presented on the CD-ROM and video set.
Meanwhile, studies have begun on how the SPIKES protocol impacts physician behavior and patient satisfaction, says Buckman. The Toronto oncologist says he can see the difference these techniques make to patients. "In two or three years’ time, we’ll have evidence that using the SPIKES protocol improves patient satisfaction," he predicts.
Editor’s note: For a copy of the four CD-ROM set ($175) and five-video set ($59 each or $239 for the set) of A Practical Guide to Communication Skills in Clinical Practice, contact Medical Audio Visual Communications, 2315 Whirlpool St., Suite 240, Niagara Falls, NY 14305. Telephone: (800) 757-4868. Fax: (905) 602-8720. E-mail: [email protected]. A Pocket Guide to Communication Skills is also available summarizing the major points. ($2.50 each, minimum order of 10. Discounts for volume purchases.)
References
1. Baile WF, Kudelka AP, Beale EA, et al. Communication skills training in oncology. Cancer 1999; 86:887-897.
2. Fogarty LA, Curbow BA, Wingard JR, et al. Can 40 seconds of compassion reduce patient anxiety? J Clin Oncol 1999; 17:371-379.
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