COMMUNICATION BETWEEN

DOCTORS, PATIENTS & THEIR

FAMILIES
BREAKING BAD NEWS

R. Sjamsuhidajat
Tjakra Wibawa Manuaba
Sutrisno Alibasyah
PERIOPERATIVE COURSE
INDONESIAN COLLEGE OF SURGEONS
INDONESIAN COLLEGE OF ANESTHESIOLOGY

DOCTOR PATIENT
RELATIONSHIP
No

more paternalistic
Should be on partnership basis
Equal position

Communication is not:
as some would say, simply good
manners, empathy, being nice or
pandering to the patients.
BUT
it offers a much more effective
consultation, and improved outcomes for
both
patients and doctors.
HOPEFULLY.NOT
The blind leading the blind?
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ISSUES IN DOCTOR PATIENT

COMMUNICATION

Why teach and learn communication

skills?

Is it important to study medical interview?

(knowledge, communication skills, problem solving,
physical examination)

Are there problems in communication between

doctors and patients? (discovering the reason for
patients attendance, gathering information, explanation &
planning, patient adherence, medico-legal issues, lack of
empathy & understanding)

Why teach and learn communication

skills?
Is

there evidence that communication

skills can overcome these problems and
make a difference to patients, doctors, and
outcomes of care (process of interview,
patient satisfaction, patient recall &
understanding, adherence, outcome)

Can you teach and learn communication skills?

Is there evidence that communication can be

taught and learned?
Is there evidence that learning is retained?
Is the prize on offer to doctors and patients worth
the effort?
Will expanding the effort on communication
skills teaching produce worthwhile rewards for
both doctors and patients?

The answers are .definitely

yes

Underlying Premises
- Communication skills teaching and learning

need to be evidence based.

- Unified approach to communication skills
teaching in medicine is needed.
- Communication skills teaching should cross
cultural and national boundaries.

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Underlying Premises..
- Coordinated approach to communication
skills teaching throughout medical education
is necessary.
- A skill, based on approach to communication
skills teaching is essential.

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HUMAN REACTION IN FACING

DISEASES WITHOUT
ANY HOPE OF RECOVERY.
Patients, Families, &
Health professionals.

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In critically ill patients :

We have to deal with stressful depressed

patient and families

We have to deal with other colleagues ,

other doctors, nurses who sometimes
are also depressed
in a very tense and depressing
situation or atmosphere!

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How human being faces critical/severe

diseases?
Emotional

Changes.

Negative

Emotional Changes ( no more

hope, anger, disbelief, rejection/ denial
and
finally acceptance.

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Emotional changes
Usually

temporary
Depending on Emotional Stability, past
experiences, psychological maturity, internal
representation, cognitive processing, traumatic
stressor and probably education?
Awareness

of Emotional reaction.
Return toward normal balance (in
majority cases)
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Severe Physical / Psychological

Injuries

Emotional Reaction

Emotional Processing
Awareness of Emotional Reaction
Returns

Towards Normal Balance

(majority of cases)

PTSD (small percentage)

DEPRESSED!

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HUMAN BEING REACTION

In Facing a Serious & Critical Disease /
TERMINAL Condition

Human reaction would be.

To Fly (to run away

From the situation)

To Fight (to face, to accept &

to cope with the condition)

Painful Intrusive Recollection

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STRESS / DEPRESSION

Suppressed into
Subconsciousness
-

Becoming chronic
Change of value system
Reappraisal
Disturbance of emotional processing
Failure to complete the emotional processing

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By Understanding The Whole

Psychological Process in Critical
Situation, e.g. Terminal Cancer
BETTER COMMUNICATION

-Clearer
-More effective & efficient communication
-Honesty & openness.
-Trust
-Mutual respect
-Politeness
-Adherence
-Collaboration.
-More accurate information
-Prevention of violent situation
-Informed consent
-Legal aspects

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RELAXED & CORRECT POSITION DURING MEDICAL INTERVIEW.

EQUAL (LEVEL) EYE CONTACT.
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BREAKING BAD NEWS.

CONDITIONING
PLANNING
EXPLANATION

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CONSIDERATION IN BREAKING BAD NEWS

SHOULD THE PATIENT BE TOLD : HE/ SHE IS

SERIOUSLY ILL or having cancer?
HOW MUCH THE PATIENT SHOULD KNOW ABOUT
HIS/ HER CONDITION.
SHOULD THE FAMILY KNOW ABOUT THE ILLNESS
HOW MUCH THE FAMILY SHOULD KNOW ABOUT
THE ILLNESS.
SHOULD PATIENT KNOW THAT HIS/ HER ILLNESS
CAN NOT BE TREATED/ CURED.
HOW MUCH THE PATIENT AND THE FAMILY
SHOULD KNOW ABOUT THIS.
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CONSIDERATION IN BREAKING BAD NEWS

DIVERGENCE BETWEEN PATIENT AND DOCTORS

PERPECTIVES PATIENT & FAMILY HOPES OF
GOOD NEWS. AND .DOCTORS NEWS (Tuckett et
al, 1985)
The Doctor must change the newshow?
MOST DOCTORS will find this duty very difficult!!!
Psychological Sequelae of BREAKING BAD NEWS
DEVASTATING and LONG LASTING (Finley &
Dallimore 1991). Many reports expressing doctors
deficiencies in this matter.
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How Much The Patient and The Family

Should know about their Critical Condition.

THE PATIENT AND THE FAMILY SHOULD KNOW

ENOUGH ABOUT their Critical Illness/ Condition.
THEY SHOULD KNOW THAT THEIR CONDITION CAN
NOT/ DIFFICULT TO BE CURED, THAT THE
PATIENT WILL DIE? (THE PATIENT OR THE FAMILY
ONLY ?).
IN THE CASE OF INDONESIA, PROBABLY THE
FAMILY SHOULD KNOW MORE?.
IN OTHER COUNTRIES (USA) THE PATIENT MUST
BE TOLD FIRST.
DO NOT EVER TELL THE PATIENT, HOW LONG HE/
SHE WILL LIVE !!!!!.
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KEY CORE SKILL FOR BREAKING BAD NEWS

EXPLANATION & PLANNING.

Preparation
Summarizing
Negotiating the Agenda
Listening
Picking up Cues
The use of Silence
Discovering the patients concern and ideas
Encouraging the expression feeling
Picking up the non verbal cues
Building rapport
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KEY CORE SKILL FOR BREAKING BAD NEWS.

Conditioning
Empathy
Acceptance
Discovering the patient starting point
Discovering the patients feeling
Gauging what and how much information to give
Discovering whether a patient is a seeker or and
avoider of information
Giving support
Giving clear jargon- free explanation
Chunking and checking information giving
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Suggestion for Breaking Bad News.

PREPARATION :
- Set Up appointment as soon as possible
- Un interrupted time
- comfortable & familiar atmosphere
- Invite spouse, family, friends as appropriate
- adequately prepared for patient background, education
situation, records.
- Doctor should put aside personal feeling.

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PLEASE NOTICE THE BARRIER BETWEEN DOCTOR PATIENT!

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PLEASE NOTICE THE POSITION OF DOCTOR PATIENT.

IT IS CLOSER, FAMILIAR, AND THERE IS NO BARRIERBETTER.

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Suggestion for Breaking Bad News.

BEGINNING THE SESSION.

- summarizing where things have reached to date
- Discover what has happened since last seen
- Calibrate how the patient is thinking/ feeling
- Negotiate an agenda.

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Suggestion for Breaking Bad News.

SHARING THE INFORMATION

- ASSESS THE PATIENTS UNDERSTANDING
- GAUGE HOW MUCH THE PATIENT WISHES TO KNOW
- GIVE WARNING .CONDITIONING I am afraid we have
some bad news to tell; I am afraid it looks more serious
than we hope
- GIVE BASIC INFORMATION, simply and honestrepeat
important points.
- Relate your information to the patients framework
- Do not give too much information too early; do not
pussyfoot but do not overwhelm
- Give information in small chunks; categorize information
- Watch the pace; check repeatedly for understanding, feeling as
you proceed.
- Use proper language, avoid jargon!
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Suggestion for Breaking Bad News.

BEING SENSITIVE TO THE PATIENT.

- Read the non-verbal cues : face, body language
silence, tears
- Allow for shut down (when patient turn off,
stop listening, silence) give time & space;
allow denial.
- Keep pausing to give patient time to ask
question.
- Gauge the patients need for further information
patient will react variously, demand
differently.
- Encourage expression of feeling : I am sorry that was
difficult for you.
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A HAUNTED SITUATION?
A PROVOCATIVE ATMOSPHERE FOR CONSULTATION?

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Suggestion for Breaking Bad News.

PLANNING & SUPPORT.

- Having identified all the patients specific concern
offer specific help by breaking down overwhelming
feeling into manageable concerns, prioritizing
- Identify a plan for what is to happen next
- Give a broad timeframe for what may lie a head.
- Give hope tempered with realism (preparing for the
worst and hoping for the best)
- Ally yourself with the patient (we can work on this
together.. Between us), i.e. co-partnership with the
patient, advocate the patient.
- Emphasize the quality of life
- Safety net.
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Suggestion for Breaking Bad News.

BEING SENSITIVE TO THE PATIENT

- Response to the patient feeling and predicament with
acceptance, empathy, and concern.
- Check the patients previous knowledge about the
information given.
- Specifically elicit all the patients concern
- Check the understanding of information given, e.g. :
would you like to run through what you are going to
tell your wife/ family
- Be aware of unshared meaning, e.g. : what cancer means
or the patient compared what it means to the physician.
- Do not afraid to show emotion & distress (physician
human being ).
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Suggestion for Breaking Bad News.

FOLLOW UP & CLOSING.

- Summarize and check with patient.
- Do not rush patient to treatment.
- Set up early further appointment, offers telephone calls,
- Identify support systems : involve relatives and friends,
religion or cultural leader or other related professional
- Offer to see/ tell spouse or others.
- Make written material available.

( Buckman1994; Faulkner 1988)

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SPECIAL ISSUES

DOCTORS should always ask questions for

themselves :
- Am I in position to give this patient accurate
information?
- Have I discovered the patients illness
framework : his thought, feeling ?
- Have I developed sufficient rapport with the
patient?.
- What is the effect on the patient of what I am
saying?
- Am I going at the pace of the patient?
- Am I being flexible, supportive and empathic?
- Am I negotiating an effective plan for the future?
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SPECIAL ISSUES

CULTURAL ISSUES.
- Cross Cultural Perspective
- Ethnic Complexities
- Do not stereotype patients
- Culture is a textured pattern of beliefs &
practices.
- Patients culture provide him/her ideas about
health and illness, notions about causality, etc
- Modern doctors very often encounter problems
relating to cultures, traditions etc.

Chugh 1993; Myerscough 1992; Eleftheriadou 1996.

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SPECIAL ISSUES

RELIGION AND SPIRITUAL GUIDANCE ARE

IMPORTANT FACTOR IN BREAKING BAD NEWS IN
CRITICALLY ILL PATIENTS, WHEN THERE IS NO
MORE HOPE FROM THE POINT OF MEDICAL VIEW.
- Religion and spiritual guidance will bring the
patient over and faster to the acceptance
phase, and giving up to the Lord the fate for
them

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Painful maybe, but a good supportive communication will h

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MAJORITY (70%) OF MEDICAL

LAW SUING IS
CAUSED BY PROBLEM
OF DOCTORS PATIENTS/ FAMILIES
COMMUNICATION

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Examples of Medical Law - Suing

Rude way of communication

Mastectomy without biopsy without sufficient
medical information.
Sterilization without proper consent.
Failure to diagnose in a very rare illness.
Operation without consent.
Reprimand for doctor who speak too much.
Multiple misconduct of a doctor
Misconduct because of profession delegation.
Etc.
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.AND MAY LORD GIVE US, THE HEALERS, THE

STRENGTH TO SEE OUR FELLOW CRITICALLY
ILL PATIENTS AS A SUFFERING HUMAN BEING,
AND THAT THEY NEED OUR BEST EFFORT AND
EXPERTISE TO HELP THEM OVERCOMING THEIR
PROBLEMS, . AND NOT TO ADD .

THANK YOU

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