"I'm sorry to tell you ..." physicians' reports of breaking bad news.

Department of Psychology, Bucknell University, Lewisburg, Pennsylvania 17837, USA.
Journal of Behavioral Medicine (Impact Factor: 3.1). 05/2001; 24(2):205-17. DOI: 10.1023/A:1010766732373
Source: PubMed

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: To better understand the process of disclosing medical errors to patients, this research offers a case analysis using Petronios's theoretical frame of Communication Privacy Management (CPM). Given the resistance clinicians often feel about error disclosure, insights into the way choices are made by the clinicians in telling patients about the mistake has the potential to address reasons for resistance. Applying the evidenced-based CPM theory, developed over the last 35 years and dedicated to studying disclosure phenomenon, to disclosing medical mistakes potentially has the ability to reshape thinking about the error disclosure process. Using a composite case representing a surgical mistake, analysis based on CPM theory is offered to gain insights into conversational routines and disclosure management choices of revealing a medical error. The results of this analysis show that an underlying assumption of health information ownership by the patient and family can be at odds with the way the clinician tends to control disclosure about the error. In addition, the case analysis illustrates that there are embedded patterns of disclosure that emerge out of conversations the clinician has with the patient and the patient's family members. These patterns unfold privacy management decisions on the part of the clinician that impact how the patient is told about the error and the way that patients interpret the meaning of the disclosure. These findings suggest the need for a better understanding of how patients manage their private health information in relationship to their expectations for the way they see the clinician caring for or controlling their health information about errors. Significance for public healthMuch of the mission central to public health sits squarely on the ability to communicate effectively. This case analysis offers an in-depth assessment of how error disclosure is complicated by misunderstandings, assuming ownership and control over information, unwittingly following conversational scripts that convey misleading messages, and the difficulty in regulating privacy boundaries in the stressful circumstances that occur with error disclosures. As a consequence, the potential contribution to public health is the ability to more clearly see the significance of the disclosure process that has implications for many public health issues.
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    ABSTRACT: Our goal was to develop and evaluate the effectiveness of a simulation-based workshop for teaching pediatric trainees' communication skills in breaking bad news. A simulation-based workshop was developed to teach skills in breaking bad news. After a classroom-based introduction, small groups of residents participated in 3 scenarios, each starting with a simulated resuscitation, followed by 2 conversations with the patient's parent, played by actors. Each conversation was observed through a 1-way mirror and was followed by a debriefing. After the workshop, the residents completed workshop evaluations and a self-assessment. Before and after the workshop, residents were evaluated in Objective Structured Clinical Examination stations where they were required to give bad news. Two physician experts and 2 parents who personally experienced receiving bad news about their child evaluated resident performance using a previously validated communication evaluation tool. Residents' ratings of the workshop were very high for all items, and 100% of the residents reported improvement in their ability to deliver bad news after the workshop. Statistically significant improvement was found in 14 of 17 items of the evaluation tool used by experts and parents, with the parents reporting greater improvement than the experts. This reflective, simulation-based workshop successfully improved pediatric trainees' skills in having difficult conversations with families, as evaluated by the participants, by physician experts, and, most importantly, by parents who have experienced these conversations in real life.
    Simulation in healthcare: journal of the Society for Simulation in Healthcare 04/2014; · 1.59 Impact Factor
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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.
    01/2013; 92(1):13-24.