Wednesday, September 17, 2008

How We Break Bad News

Social Science and Medicine has a qualitative, ethnographic analysis of breaking bad news practices,** which takes aim at the standard published guidelines. The study involved observation of a palliative care service (from a hospital in Texas), as well as interviews with team members, etc. It's an interesting read, and has transcripts of some doc-patient-family interactions involving bad news (usually terminal diagnosis) disclosures and it's fascinating to get a 'fly-on-the-wall' perspective of these interactions (some were 'better' than others to be sure).

The rhetorical framework of the piece involves looking at prominent breaking bad news guidelines (e.g. the SPIKES model - Setting, Perception, Invitation, Knowledge, Empathy, and Strategy/Summary) and noting how real-life encounters don't resemble what the model implies at all. Things like the reality that bad news disclosures often aren't/can't be planned, are more than a patient-doctor dyad and often involve other family members and clinicians, and frequently don't involve one central 'piece' of bad news (the unwelcome news is often multi-part and cumulative: the scans were worse, the chemo isn't working, you are dying, time is short, you need more help than your family can provide and you can't go home safely, etc. etc.). I'm not going to belabor this much - I think most of us who both routinely break bad news and teach others (med students, residents, etc.) how to do it realize that the guideline/recommendations don't describe reality very well.

Which doesn't mean that they're bad, and all this begs the question how should we actually teach others how to do this?

A story: I have at times been involved with teaching medical students about breaking bad news - these are 2nd year students who don't have any 'real' patient-care experience. They are, in fact, taught the 'guidelines' (some iteration of the SPIKES approach) and then are thrown into a role-play in which they have to break some horrible news to a patient. The most common comment I've heard from these students has been along the lines of "I never thought this would be so tough." My initial reaction to that statement was "My God, why on earth did you ever think this would be easy?" Well I think there are two reasons:
  1. All role-playing neophytes are shocked at how it can be tough, challenging, and emotional.
  2. We taught them a guideline and they figured they'd just have to go 'by the book' and all would be well.
There's nothing you can do about (1). (2) however suggests a deficit in our pedagogy. Part of it is that even if the 'breaking bad news session' goes 'by the book' and is a linear process with a single element of 'bad news' in the setting of a patient-physician dyad it may still be (?should be) emotionally difficult and perhaps what we're not doing is preparing these young physicians for the emotional aspect of this. One of my most prominent teaching points when I do this is that emotions are OK, patients/families will be emotional, them reacting strongly to hearing life-altering news is perfectly fine and healthy (wouldn't you?), and the point of BBN 'well' is not to prevent emotions from happening. Emotions will happen. It's to 1) not make things worse by being an ass/confusing/overwhelming/distant and 2) to actually deepen a trusting doctor-patient-family relationship (particularly as that's sometimes all we've got to offer someone - a promise that we'll be there and we'll try). And if we're not preparing trainees for making it through the emotionality of these interactions then we're not teaching them anything.

Getting back to (2), then, it seems an important part of the pedagogy of BBN should be that you can do things by the book and people may still hit the ceiling (and again, why the hell not? - seems like a reasonable reaction, at least initially, to hearing devastating news - and it's clearly adaptive for some people - I frequently contemplate what I'd look like if one of my boys developed a life-threatening illness and it wouldn't be pretty).

Getting myself off that soapbox, and heading back to the guidelines and accepting that the 'process' they describe usually doesn't (and shouldn't) unfold linearly as the guidelines suggest - does that mean that they aren't helpful in teaching people how to do this? My experience is that they are incredibly helpful, and not because they outline a step-wise procedural approach to BBN (like performing a lumbar puncture or central line placement) but because they contain a lot of wisdom about the issues at play - they give med students and residents some conceptual framework for how to think about these interactions. Setting: prompts you to control what you can control, and gives some guidance for those times in which the BBN interaction really can be planned. Perception: teaches students the importance of eliciting and 'talking to' the patient/family's pre-existing base of knowledge and experience (however medically 'inaccurate' that may be). Invitation: focuses students on the empathetic task of asking/finding out/intuiting how much/what the patient/family are actually ready to hear - what they're ready for - what needs to be said today vs. the next visit (how hard/fast/if to bring down The Hammer is how my team talks about it). Etc. Etc. These are, and I feel like a tool writing this but here I am, emotional intelligence skills which can be taught to most people, and you've got to start somewhere, and most people pick up on this, and understand 'real life' BBN is a haphazard and multiple affair, especially if we teach them that.

If you're not ready to cancel your Pallimed subscription after reading this, please read more in the next post!

**I've been having deja vu as I read this article and write this post - as if I've written about it before: I searched the blog and can't find a post about this one from me, Christian, or Tom - but if we have posted on this before I'm sorry. It's a weird feeling...and for the curious out there I'd highly recommend this To the Best of Our Knowledge segment (a public radio program) on deja vu - especially the first 10 minutes.

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