"I'm sorry to tell you ..." physicians' reports of breaking bad news.
ABSTRACT In this investigation the authors assessed what physicians do when planning for and delivering bad news to patients. Seventy-three physicians responded to a series of statements about the behaviors, thoughts, and feelings they might have had while preparing for and delivering bad medically-related news. Data were also obtained about how well they thought the transaction had gone, how much stress they had experienced, and what they thought the experience was like from the patient's perspective. Physicians reported that these transactions were only moderately stressful, with 18.1% and 18.7% indicating that preparation stress or delivery stress, respectively, were above the midpoint on the scale. Slightly over 42% of the sample indicated that the stress they experienced lasted from several hours to three or more days. Thirty-six delivery-related statements were typical (with endorsement rates of at least 80% in a given direction) for at least one of the two recall groups.
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ABSTRACT: Ambiente médico: o impacto da má notícia em pacientes e médicos – em direção a um modelo de comunicação mais efetivo médico: o impacto da má notícia em pacientes e médicos – em direção a um modelo de comunicação mais efetivo / Medical environment: bad news' impact on patients and doctors – towards an effective model of communication. Rev Med (São Paulo). 2013 jan.-mar.;92(1):13-24. RESUMO: As más notícias fazem parte da rotina dos médicos, no entanto, seu impacto em ambos os médicos e paciente, não é bem conhecido. Com esse conhecimento, os médicos seriam capazes de transmitir estas notícias de forma mais eficaz. O objetivo deste estudo é revisar o impacto fisiológico e psicológico das más notícias em ambos, médico e paciente, e estratégias para melhorar as habilidades de comunicação e minimizar estes efeitos. Ao transmitir uma má notícia, médicos podem ter um aumento na frequência cardíaca, pressão arterial e débito cardíaco de forma tão expressiva que pode ser um fator de risco para hipertensão. Alterações nos níveis de cortisol e as respostas imunes também estão relacionadas a estas situações. Médicos relataram que dar más notícias envolve um risco de perder o controle de diferentes maneiras, com relação às emoções, profissionalismo e confiança. Em relação ao impacto nos pacientes, até o momento, nenhuma pesquisa investigou os efeitos fisiológicos; entretanto, os pacientes reagem com choro, seus "corpos podem agitar" e eles podem sentir uma "sensação de frio no estômago". Os pacientes precisam de tempo para se adaptar a informação dada; eles querem que seus médicos sejam sensíveis e respondam as suas perguntas no mesmo dia, dando-lhes a sensação de que eles estão sabendo de tudo. Dados mostram desde os que de estudantes de medicina a médicos experientes sentem desconforto e despreparo em transmitir más notícias. Isso enfatiza a necessidade de um modelo eficiente para o desenvolvimento de habilidade na revelação. Questões pessoais, institucionais, de treinamento e linguagem vêm sendo reconhecidas como potenciais barreiras para a transmissão de más notícias. Estratégias que estão sendo desenvolvidas para melhorar a transmissão de más notícias incluem o uso de diretrizes como o SPIKES e programas de treinamento intensivo. Tais estratégias têm sido comprovadas para minimizar o impacto em ambos, pacientes e médicos. Assim, é necessária a inclusão destas estratégias na graduação de medicina, residência e programas de treinamento médico. ABSTRACT: Breaking bad news is part of physicians' routine; however, its impact on both doctors and patients is not well-known. With that knowledge, physicians would be able to convey such news more effectively. This study aims to review physiological and psychological impacts of breaking bad news on both doctors and patients, and strategies to improve communication skills and minimize those effects. Physicians, while breaking bad news, may have increases in heart rate, mean arterial pressure and cardiac output in such an expressive way that it might be a risk factor for hypertension. Cortisol levels and immune responses were also found to be enhanced in these situations. Doctors declared that giving bad news involved a risk of losing control in different ways, concerning emotions, professionalism and confidence. When it comes to the impact on patients, the physiological effects have not been investigated by any research, but patients react by crying, their "body may shake" and they can feel a "cold sensation in stomach". Patients need time to adjust to the information given; they want their doctor to be sensitive and to answer all their questions on the same day, giving them a sensation of knowing everything. Data have showed awkwardness and unpreparedness in conveying bad news from undergraduate medical students to experienced physicians. That emphasizes the need of an efficient model to develop physicians' skills in truth disclosure. Personal, institutional, training and language issues have been recognized as potential barriers to breaking bad news. Strategies that have been developed to improve breaking bad news include the use of guidelines such as the SPIKES; and time-intensive training programs. Such strategies have been proven to minimize the impact on both patients and doctors. Thus, the inclusion of these strategies is needed in medical undergraduate, residency and continuing medical training programs.
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ABSTRACT: Breaking bad news is a stressful experience for counselors and clients. In this article, the PEWTER (Prepare, Evaluate, Warning, Telling, Emotional Response, Regrouping) model (Nardi & Keefe-Cooperman, 200620. Nardi , T. J. and Keefe-Cooperman , K. 2006. Communicating bad news: A model for emergency mental health helpers. International Journal of Emergency Mental Health, 8: 203–207. [PubMed]View all references)is used as a guide to facilitate the process of a difficult conversation and promote client growth in a school setting. In this structured creative model, communication skills are grouped in a systemic and progressive manner that can be individualized to meet client and situational needs. PEWTER addresses the multiple factors and layers that affect the counseling situation when giving life-changing news. A case example is provided that outlines each phase of the PEWTER model.Journal of Creativity in Mental Health 07/2013; 8(3):265-277. DOI:10.1080/15401383.2013.821926
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ABSTRACT: PREFACE BY Professor Raphael Mechoulam Breast cancer is a brutal disease. About 8-9% of all women get breast cancer and it is by far the most prevalent female cancer. According to the World Health Organization breast cancer accounts for 16% of all types of cancer deaths globally. Total deaths of cancer amount to 7,600,000, whereas total breast cancer deaths are 460,000. The incidence rates of breast cancer are increasing and the reasons for this increase are not clear. Although research over the last few decades has discovered many of the mechanisms of breast cancer, we are still far away from fully understanding its devious routes. We have however learned that breast cancer is the result of several different disease pathways, each of which has to be blocked by different pharmacological agents. Numerous drugs are now available and they save millions of lives. But we know now that there is not a single drug that can be compatible for all patients. What do we know of these mechanisms? In brief, there is a subtype (named Luminal A) which is associated with the female hormone estrogen. It develops relatively slowly and the prognosis to treat this breast cancer subtype is generally good. In contrast, a second, related subtype (named Luminal B) is similar to Luminal A tumors. It is also associated with estrogen but it develops faster and the prognosis is by far not as good when compared to the Luminal A type. A third subtype (HER-2) depends on specific genes known as HER2 genes and it has an overall poor prognosis. The forth subtype is not associated with the female hormones or with the HER2 genes; it grows fast and it has a poor prognosis. The treatment of these different types of breast cancer requires different approaches. Hence the first step of modern cancer treatment today needs the establishment of the subtype by investigating the genes of the patient involved and only then should the appropriate treatment be undertaken. In this field of medicine science is indeed opening the door to more personal, individualized therapy. Indeed breast cancer associated with female hormones is treated with tamoxifen which blocks the receptor of the female hormone progesterone and specific anti-HER2 treatments result in improvements in the clinical outcome of patients with HER2- positive breast cancer. For instance Trastuzumab is efficient in early and advanced HER2 breast cancer treatment. This personal, individualized therapy will expand rapidly and maybe, just may be, the grim statistics will improve. However a major problem in cancer therapy is the rapidly formed resistance of the cancer cells to anti-cancer drugs. Cancer cells learn very fast how to get rid of the cancer drug entering the cell. They also learn very fast how to metabolize – and thus neutralize - the drug. The fight against cancer now proceeds on this front too. A very recent observation is that cannabidiol – a constituent of the plant Cannabis sativa – can block the mechanism through which the cancer cell gets rid of the anti-cancer drug. Unexpectedly, recently it was also shown that cannabidiol affects not only proliferation of cancer cells , but also interferes with two other crucial steps of breast cancer cell progression, namely invasion of other tissues and metastasization – transportation to far away organs. May be cannabidiol will lead us to novel anti-cancer drugs acting on several of the cancer mechanisms. At present however neither cannabidiol nor related drugs have been tested in human patients. In the present, excellent book Dr Zornitza Ganeva looks mostly at other aspects of the dreadful disease – the psychological effects of breast cancer on the patient: the initial shock, the slow realization of possible death, the ways to minimize the anxiety and the depression. She thoroughly discusses the existing literature on psycho-oncology and has succeeded in admirably summarizing and presenting it. This book should be seen not only as an academic book, but should also reach – and help – patients. Professor Raphael Mechoulam Head, Division of Science, Israel Academy of Sciences.12/2014; Елестра ЕООД., ISBN: 978-954-90789-7-8