Getting bad news
5 ways to cope with bad news
No one is immune from bad news or disappointment in life. So, when you do get it, how do you process the information, deal with it, and move on with your life unscathed?
Share on PinterestWhatever the bad news you have received, there are strategies you can try to help you cope with the situation.During your lifetime, you may encounter many forms of bad news at separate times or even simultaneously.
For example, you may experience job loss, a relationship breakup, miscarriage, a shocking diagnosis from a doctor, the death of a loved one, or any other upheaval that life throws at you.
No matter what the bad news is that you have received, it can be devastating, jarring, and sometimes turn your world upside down.
Receiving bad news of any form can have an instant effect on your body and cause your flight-or-fight response to kick in quickly. Your adrenaline may start pumping and your mind may begin to race to several worst-case scenarios in seconds.
Furthermore, you may need to manage all the consequences that come with the bad news — such as looking for a new job, paying bills, doctors appointments, or informing friends and family, as well as coping with the way the news affects you both physically and mentally.
Everyone responds to tension and trauma differently, but know that steps can be taken to tackle the mountain ahead, deal with the bad news, adopt coping mechanisms, and make the situation less traumatic.
Medical News Today have put together some tips for how to cope when faced with bad news.
Receiving concerning news can trigger a seemingly endless spiral of negative emotion. And, when confronted with negative emotion, it can be very tempting to try to resist acknowledging the dark emotions to protect yourself.
Share on PinterestAccepting your negative emotion can help you to feel better in the long-term.Research that was carried out by the University of California, Berkeley, found that attempting to avoid your negative emotion can, in fact, cause you more stress than confronting it head-on.
The researchers led three separate studies online and in the laboratory and found that embracing darker moods, instead of resisting them, can help you to feel better in the long run.
The participants who habitually accepted their negative emotions actually experienced fewer negative emotions and, therefore, improved psychological health compared with those who avoided negative emotion.
The scientists explained that our approach to emotional reactions is essential for our well-being. Individuals who accept negative emotions without trying to change them are better equipped to deal with stress.
In a very similar way to avoiding negative emotions, many people who encounter bad news enter an “avoidance mode.” Avoidance mode involves attempting to shut out everything in your mind that is associated with the unwelcome news.
Share on PinterestRepeat exposure to the bad news to neutralize the effect on your mood.
Most of the time, avoiding the situation at hand is counterintuitive and, ultimately, leads to you thinking about it more.
Fighting the urge to think about your bad news can lead to tension in your stomach, shoulders, and chest, a distraction from completing tasks, and chronic stress, digestive problems, and lethargy.
Your brain is more able to deal with negative news than you might realize. It is by processing and digesting experiences that you can let them go and move on.
Tel Aviv University in Israel revealed that repeat exposure to a negative event could neutralize its effects on your thoughts and mood.
The researchers say that if, for example, you read a newspaper article about a tragedy before you go to work, it is better to read the article thoroughly and repeatedly expose yourself to that information than read the headline and attempt to not think about the event.
By having repeat exposure to the bad news, you will feel freer to continue to go about your day without any adverse effects and be in a better mood.
Other research by the University of Arizona in Tucson agrees with the concept of repeat exposure.
The team found that in situations that cause significant distress — such as a romantic breakup or divorce — repeatedly reflecting on the situation could speed up emotional recovery.
You’ve accepted your negative emotion and repeatedly reflected on the stressful news, so what now? Sometimes, reframing the way you think about the bad news can help you to view the situation in a new light and improve your overall perspective.
Share on PinterestReframe your negative thoughts to improve your overall perspective.
While you can’t always be in control of all of the situations that happen to you in life, you can use a technique called cognitive reframing to alter your reaction to the things that happen to you and the way you view the situations, which, as a consequence, will change the way you experience them.
The idea of cognitive framing is to find a more positive interpretation of an expected adverse event. Cognitive reframing challenges you to highlight the positive sides of a challenging situation and identify a brighter side to the event rather than just seeing the negative.
For example, if you just lost your job, instead of focusing on the mistakes that were made in your role that lead to your current unemployment, look at the situation as an opportunity to try new things and creatively explore different work alternatives that might be more fulfilling.
Research by the University of Notre Dame in Indiana uncovered that hitting rock bottom after losing a job could actually be beneficial and enable people to start a new chapter, create a new positive work identity, and free them from negative emotion.
In addition to cognitively reframing a negative situation, researchers from the Beckman Institute at the University of Illinois at Urbana-Champaign reported that it could be helpful to focus on contextual elements of a bad memory rather than the emotional experience.
Florin Dolcos, from the Cognitive Neuroscience Group at the University of Illinois, explained that dwelling on how hurt, sad, or embarrassed you felt during an adverse event can result in you feeling worse.
If you look away from the negative emotions and think about the context of the situation — such as a friend who was there or what the weather was like that day or any other non-emotional aspect of the memory — your mind will be taken away from the unwanted emotions that are linked with that memory.
Failing a college exam, being rejected for a job that you had your heart set on, or being belittled by a superior are just a few situations that may cause disappointment or a sense of failure.
Share on PinterestWriting a journal or blogging about bad news could help to alleviate distress.
While almost everyone will experience these setbacks at one time or another, some people are better at dealing with adversity throughout life than others. Some individuals crumble at the first hurdle, while others have the resilience that enables them to stay calm when under pressure.
The good news is that acquiring resilience and overcoming adversity can be learned, and it involves working on your thoughts and behaviors, as well as actions.
One study, for example, focused on students who had failed academically and would find access to the job market restricted with their lack of qualifications.
The study showed that by helping the students to bounce back from adversity by teaching them self-regulation skills — including goal-setting and how to adjust their path after a mishap — they were better equipped to do well in life and positively deal with any adverse situations they encountered.
Other research has also shown that blogging about social distress can help people deal with adversity.
Writing a journal or other forms of expressive writing are known to help release emotional stress. A study published by the American Psychological Association demonstrated that blogging might be an effective solution for teenagers who are facing distress.
Compared with teenagers who did nothing or wrote personal diaries, those who blogged about their social problems had improved self-esteem, social anxiety, and emotional distress.
Finally, when you are facing bad news of any kind, it is vital to be kind to yourself and look after your physical and mental health. It can be easy to neglect your well-being in times of trauma.
Share on PinterestMindfulness meditation can help to mitigate the worry of waiting for potential bad news.
Eat healthfully. Focus on eating three balanced meals each day that are all rich in fruits and vegetables. Unhealthful eating behaviors significantly boost negative mood.
Try mindfulness meditation. When bracing for bad news, rather than distracting yourself or trying to stay positive, give mindfulness meditation a go.
Mindfulness meditation enables you to focus on the present and offset the worry of waiting for news.
Research has found that even if you do not consider yourself to be a mindful person, meditation can help to tame negative emotion.
Book a massage. A study published in the Journal of Clinical Nursing illustrated that receiving hand and feet massages for 8 weeks after the death of a loved one provided some consolation and was reported to be a “worthy, early, grieving-process support option for bereaved family members.
”
When faced with bad news, as hard as might be, it is important to remain calm, stay focused on the present moment, and breathe.
5 ways to cope with bad news
No one is immune from bad news or disappointment in life. So, when you do get it, how do you process the information, deal with it, and move on with your life unscathed?
Share on PinterestWhatever the bad news you have received, there are strategies you can try to help you cope with the situation.During your lifetime, you may encounter many forms of bad news at separate times or even simultaneously.
For example, you may experience job loss, a relationship breakup, miscarriage, a shocking diagnosis from a doctor, the death of a loved one, or any other upheaval that life throws at you.
No matter what the bad news is that you have received, it can be devastating, jarring, and sometimes turn your world upside down.
Receiving bad news of any form can have an instant effect on your body and cause your flight-or-fight response to kick in quickly.
Your adrenaline may start pumping and your mind may begin to race to several worst-case scenarios in seconds.
Furthermore, you may need to manage all the consequences that come with the bad news — such as looking for a new job, paying bills, doctors appointments, or informing friends and family, as well as coping with the way the news affects you both physically and mentally.
Everyone responds to tension and trauma differently, but know that steps can be taken to tackle the mountain ahead, deal with the bad news, adopt coping mechanisms, and make the situation less traumatic.
Medical News Today have put together some tips for how to cope when faced with bad news.
Receiving concerning news can trigger a seemingly endless spiral of negative emotion. And, when confronted with negative emotion, it can be very tempting to try to resist acknowledging the dark emotions to protect yourself.
Share on PinterestAccepting your negative emotion can help you to feel better in the long-term.
Research that was carried out by the University of California, Berkeley, found that attempting to avoid your negative emotion can, in fact, cause you more stress than confronting it head-on.
The researchers led three separate studies online and in the laboratory and found that embracing darker moods, instead of resisting them, can help you to feel better in the long run.
The participants who habitually accepted their negative emotions actually experienced fewer negative emotions and, therefore, improved psychological health compared with those who avoided negative emotion.
The scientists explained that our approach to emotional reactions is essential for our well-being. Individuals who accept negative emotions without trying to change them are better equipped to deal with stress.
In a very similar way to avoiding negative emotions, many people who encounter bad news enter an “avoidance mode.” Avoidance mode involves attempting to shut out everything in your mind that is associated with the unwelcome news.
Share on PinterestRepeat exposure to the bad news to neutralize the effect on your mood.
Most of the time, avoiding the situation at hand is counterintuitive and, ultimately, leads to you thinking about it more.
Fighting the urge to think about your bad news can lead to tension in your stomach, shoulders, and chest, a distraction from completing tasks, and chronic stress, digestive problems, and lethargy.
Your brain is more able to deal with negative news than you might realize. It is by processing and digesting experiences that you can let them go and move on.
Tel Aviv University in Israel revealed that repeat exposure to a negative event could neutralize its effects on your thoughts and mood.
The researchers say that if, for example, you read a newspaper article about a tragedy before you go to work, it is better to read the article thoroughly and repeatedly expose yourself to that information than read the headline and attempt to not think about the event.
By having repeat exposure to the bad news, you will feel freer to continue to go about your day without any adverse effects and be in a better mood.
Other research by the University of Arizona in Tucson agrees with the concept of repeat exposure. The team found that in situations that cause significant distress — such as a romantic breakup or divorce — repeatedly reflecting on the situation could speed up emotional recovery.
You’ve accepted your negative emotion and repeatedly reflected on the stressful news, so what now? Sometimes, reframing the way you think about the bad news can help you to view the situation in a new light and improve your overall perspective.
Share on PinterestReframe your negative thoughts to improve your overall perspective.
While you can’t always be in control of all of the situations that happen to you in life, you can use a technique called cognitive reframing to alter your reaction to the things that happen to you and the way you view the situations, which, as a consequence, will change the way you experience them.
The idea of cognitive framing is to find a more positive interpretation of an expected adverse event. Cognitive reframing challenges you to highlight the positive sides of a challenging situation and identify a brighter side to the event rather than just seeing the negative.
For example, if you just lost your job, instead of focusing on the mistakes that were made in your role that lead to your current unemployment, look at the situation as an opportunity to try new things and creatively explore different work alternatives that might be more fulfilling.
Research by the University of Notre Dame in Indiana uncovered that hitting rock bottom after losing a job could actually be beneficial and enable people to start a new chapter, create a new positive work identity, and free them from negative emotion.
In addition to cognitively reframing a negative situation, researchers from the Beckman Institute at the University of Illinois at Urbana-Champaign reported that it could be helpful to focus on contextual elements of a bad memory rather than the emotional experience.
Florin Dolcos, from the Cognitive Neuroscience Group at the University of Illinois, explained that dwelling on how hurt, sad, or embarrassed you felt during an adverse event can result in you feeling worse.
If you look away from the negative emotions and think about the context of the situation — such as a friend who was there or what the weather was like that day or any other non-emotional aspect of the memory — your mind will be taken away from the unwanted emotions that are linked with that memory.
Failing a college exam, being rejected for a job that you had your heart set on, or being belittled by a superior are just a few situations that may cause disappointment or a sense of failure.
Share on PinterestWriting a journal or blogging about bad news could help to alleviate distress.
While almost everyone will experience these setbacks at one time or another, some people are better at dealing with adversity throughout life than others. Some individuals crumble at the first hurdle, while others have the resilience that enables them to stay calm when under pressure.
The good news is that acquiring resilience and overcoming adversity can be learned, and it involves working on your thoughts and behaviors, as well as actions.
One study, for example, focused on students who had failed academically and would find access to the job market restricted with their lack of qualifications.
The study showed that by helping the students to bounce back from adversity by teaching them self-regulation skills — including goal-setting and how to adjust their path after a mishap — they were better equipped to do well in life and positively deal with any adverse situations they encountered.
Other research has also shown that blogging about social distress can help people deal with adversity.
Writing a journal or other forms of expressive writing are known to help release emotional stress. A study published by the American Psychological Association demonstrated that blogging might be an effective solution for teenagers who are facing distress.
Compared with teenagers who did nothing or wrote personal diaries, those who blogged about their social problems had improved self-esteem, social anxiety, and emotional distress.
Finally, when you are facing bad news of any kind, it is vital to be kind to yourself and look after your physical and mental health. It can be easy to neglect your well-being in times of trauma.
Share on PinterestMindfulness meditation can help to mitigate the worry of waiting for potential bad news.
Eat healthfully. Focus on eating three balanced meals each day that are all rich in fruits and vegetables. Unhealthful eating behaviors significantly boost negative mood.
Try mindfulness meditation. When bracing for bad news, rather than distracting yourself or trying to stay positive, give mindfulness meditation a go.
Mindfulness meditation enables you to focus on the present and offset the worry of waiting for news.
Research has found that even if you do not consider yourself to be a mindful person, meditation can help to tame negative emotion.
Book a massage. A study published in the Journal of Clinical Nursing illustrated that receiving hand and feet massages for 8 weeks after the death of a loved one provided some consolation and was reported to be a “worthy, early, grieving-process support option for bereaved family members.”
When faced with bad news, as hard as might be, it is important to remain calm, stay focused on the present moment, and breathe.
How to communicate bad news as effectively as possible? SPIKES protocol for reporting "bad news"
How to communicate bad news as effectively as possible? SPIKES protocol for reporting "bad news"Kotov M.A.
N.N. N.N. Petrov» of the Ministry of Health of Russia, St. Petersburg, Russia
Gushchin V.V.
Department of Surgical Oncology, Mercy Clinic, Baltimore, USA
How do you get the most out of bad news? SPIKES protocol for reporting "bad news"
Log: Endoscopic surgery. 2018;24(5): 45‑50
DOI 10.
17116/endoskop20182405145
How to quote
Kotov M.A., Gushchin V.V. How to communicate bad news as effectively as possible? SPIKES protocol for reporting "bad news". Endoscopic surgery. 2018;24(5):45‑50.
Kotov MA, Gushchin VV. How would you deliver bad news most professionally? SPIKES protocol for breaking bad news disclosure. Endoscopic Surgery. 2018;24(5):45‑50. (In Russ.).
https://doi.org/10.17116/endoskop20182405145
Authors:
Kotov M.A.
N.N. N.N. Petrov» of the Ministry of Health of Russia, St. Petersburg, Russia
All authors (2)
Read metadata
In this article, the reader will find step-by-step recommendations for reporting "bad news". The topic of professional communication seems to be relatively new for the Russian surgical audience, and the listed sequence of steps in communicating with a patient in the first part of the article may seem inapplicable in everyday practice, declarative and instructive.
Therefore, to illustrate these recommendations, the authors offer in the second part a game example from the “personal experience of a difficult conversation” after an exploratory laparotomy for a widespread inoperable tumor process with signs of peritoneal carcinomatosis. The style of this publication is unusual for an article in a scientific journal. Considering that difficult conversations are emotionally burdensome for surgeons, we decided to keep the style of the diary, which would better convey what happened in real life: the semantics of a scientific journal, when presented, could emasculate the experiences familiar to every surgeon without conveying the essence. The second part is subjected to psychological analysis and provided with comments by the author.
Key words:
SPIKES protocol
fatal diagnosis
professional conversation
medical ethics
Authors:
Kotov M.A.
N.N. N.N. Petrov» of the Ministry of Health of Russia, St.
Petersburg, Russia
Gushchin V.V.
Department of Surgical Oncology, Mercy Clinic, Baltimore, USA
Close metadata
Giving unwanted information to a patient is a difficult communication task for a doctor. In the English-language medical literature, such unsolicited information is referred to as "bad news." At 1984 R. Buckman [1] published an article in the British Medical Journal in which he gave the following definition of the concept of "bad news" in relation to medicine: "Bad news is any information that can radically change the patient's view of his future." In their review article on the problem of communicating unwanted information to patients, J. Ptacek and T. Eberhardt [2] proposed to interpret the term "bad news" as "information that leads to cognitive, emotional and behavioral deficits in the person to whom this information is addressed" .
According to research, the process of delivering "bad news" is difficult both for the patient to whom the information is addressed and for the doctor who is the conductor of this information. Nevertheless, 86.8% of patients with cancer want to know all the information about the diagnosis, prognosis and treatment options [3], but doctors tell the “bad news” to the patient in full only in 43% of cases [4]. The reason for this, as a rule, is a feeling of fear and failure, lack of knowledge, difficulty in explaining scientific information to the patient in a language that is accessible to him, fear of the patient's emotions and lack of time to talk with the patient [5].
To make it easier for doctors to communicate “bad news” to patients, special protocols have been developed [1, 2, 6, 7]. They are a linear algorithm, the implementation of which step by step allows the doctor to perform four main tasks when delivering "bad news". The most famous is the SPIKES protocol developed by W. Baile et al. [7] at the MD Anderson Cancer Center, consisting of six sequential steps.
The process of communicating adverse medical information to a cancer patient can be compared to another medical procedure that requires a step-by-step plan.
In medical protocols, such as cardiopulmonary resuscitation or management of diabetic ketoacidosis, each step must be completed, and the success of the intervention depends on the successful completion of each previous step [8, 9].
Purpose of talking about bad news. The process of delivering bad news can be thought of as an attempt to achieve four goals .
First goal is to collect information from the patient. This will allow the clinician to determine the patient's knowledge, expectations, and readiness to accept bad news.
The second purpose of is to give the patient information according to his needs and concerns.
Third target - Support the patient by using skills to reduce the emotional impact and consciousness of isolation in the recipient of bad news.
The fourth and final goal of is to develop a treatment plan with the participation of the patient.
Achievement of these goals is carried out by sequential implementation of six steps, each of which is associated with a specific skill.
It is not always necessary to follow all the steps when delivering bad news, but in order to follow them, the sequence must be strictly observed.
SPIKES 6 steps
Step 1: S - SETTING UP the interview Mental rehearsal is a useful way to prepare for a stressful situation. This can be achieved by drawing up a plan for a future conversation with the patient, namely, you must know how you will respond to the patient's emotional state and difficult questions. As a bearer of bad news, you must prepare for negative emotions, despair, and responsibility for them. It is useful to remember that bad news may upset the patient, but at the same time this information will be very important for planning his future.
Some useful tips.
Set up a meeting in private. If it is not possible to talk to the patient in a separate room, the patient's bed can be fenced off with a curtain (screen).
Include significant people in the conversation.
Most patients would like someone else to participate in the conversation, but this choice must be made by the patient. When there are a lot of family members, ask the patient to leave one or two next of kin.
Sit down. The fact that you sit down next to the patient will relax him, and will also indicate that you will not be in a hurry when talking. When you are seated, there should be no barriers between you and the patient (such as a table). If you have just examined a patient, then before starting a conversation, invite him to get dressed.
Connect with the patient. Maintaining eye contact can be uncomfortable, but it is an important way to build rapport between you. Touch the patient's hand, hold his hand (if, of course, he is comfortable), or use other methods to achieve mutual understanding.
Manage time and distractions. Tell the patient that you have limited time and that you may be distracted from the conversation.
Turn off your mobile phone for the duration of the conversation and ask colleagues not to disturb you.
Step 2: Assessing the Patient’s PERCEPTION Steps 2 and 3 of the SPIKES protocol are important points in a conversation where you follow the “ before you say - ask ." That is, before discussing a medical topic, the doctor, using open-ended questions, gets an accurate picture of how the patient perceives the situation - what he understood and how important it is for him. For example: “What will you tell about your illness until now?” or “Why do you think we performed an MRI on you?” Based on the information received, you will be able to correct the patient's misconceptions and deliver bad news, taking into account what the patient does not yet understand. It will also help to accomplish the important task of determining if the patient has some form of denial of the illness: wishful thinking; skip essential but unpleasant details about your illness; exaggerate expectations from treatment.
Step 3: I - Obtaining Patient's INVITATION While most patients want complete information about their diagnosis, prognosis, and details of their disease, some patients do not want to see the full picture. When the doctor sees that the patient is willing to receive full information about his illness, this helps to reduce anxiety when delivering bad news. However, avoidance of information is an effective psychological defense mechanism and is more likely to manifest itself in severe cases of the disease. Discussing in a conversation the information that the doctor told the patient, the doctor can simultaneously plan the further course of the conversation. Here are some examples of questions a doctor might ask a patient: "How would you like me to tell you about the results of the research?" or: "Would you like to receive a full summary of the results of the study, or would you like to summarize the results and discuss the treatment plan in detail?" If the patient does not want to know the details, invite them to ask you any questions they may have or talk to family and friends.
Step 4: K - Giving KNOWLEDGE and Information to the Patient to make it easier for you to understand the information you provide. An example of phrases that can be used for these purposes: "Unfortunately, I have bad news for you", "I'm sorry that I have to tell you ...".
First, start the conversation at the patient's level of understanding and vocabulary. Second, use common words instead of technical terms: "spread" instead of "metastasis" or "piece of tissue" instead of "biopsy." Third, don't over-simplify ("You have a very bad cancer and if you don't get immediate treatment you'll die"), as this will put the patient off, be angry with you, and tend to accuse you of being the messenger of bad news. Fourth, communicate information in small chunks and periodically check to see if the patient understands you. Fifth, if the patient's prognosis is poor, avoid phrases such as "There is nothing more we can do for you" when communicating. This position is inconsistent with the fact that patients often have other treatment goals, such as the absence of pain and other symptoms of the disease.
Step 5: Addressing the Patient’s EMOTIONS with Empathic Responses
Responding to a patient's emotions is one of the most difficult tasks in delivering bad news. Emotional reactions of the patient can be different: from silence to disbelief, crying, denial or anger. When patients learn bad news, their emotional reactions are manifested as shock, consciousness of their isolation, grief. In this situation, the doctor can support the patient, be in solidarity with him with the help of empathy (sympathy).
There are four rules for showing empathy.
First, , look for any emotion on the part of the patient. It can be tears, a sad look, silence or shock.
Second , identify the emotions the patient is experiencing. Use open-ended questions to find out what the patient is thinking and feeling.
Third, , determine the cause of these emotions. Usually they are associated with bad news. But if you are not sure about this, ask the patient about it again.
Fourth , after you have given the patient time to express their emotions, let the patient know that you are connected to the cause of those emotions. For example:
Physician: I'm sorry, the x-ray showed that chemotherapy is no longer effective [pause]. The tumor has grown in size.
Patient: I was afraid of it [crying].
Physician [moves his chair closer to the patient, offers him a handkerchief]: I know that's not what you want to hear. I wish the news was better too.
In the above dialogue, the doctor observed the patient's crying and realized that the crying was caused by bad news. He walked closer to the patient, touched his hand and waited until he regained his composure. He helped the patient feel that he understood why he was upset, and said that he understood him.
As long as emotions are strong, it is difficult to move on to discussing other issues. If the patient's agitation, distress, or despair persists, continue to express sympathy until the patient calms down.
You can also share your own feelings (“I wish the news was better”). This will express your empathy and reassure the patient of your sincerity.
However, if the patient is restrained and does not express his emotions clearly or is silent, the doctor should ask a clarifying question before responding sympathetically. When a patient tries to hide their emotions, or shows them indirectly or in a veiled way, such as anger, disappointment (“I guess I will have to suffer from chemotherapy again”), you can still respond with empathy (“I see that this news is sad For you"). Patients believe that their oncologist is an important source of psychological support, and his sympathy, explanations and confirmation of what was said is the strongest incentive to trust the doctor. Trust reduces the patient's detachment, causes solidarity and relief from the fact that his grief is shared with him.
Step 6: S-STRATEGY and SUMMARY
Patients who have a clear vision of their future experience less anxiety and uncertainty.
Before discussing the treatment plan, it is important to ask the patient if he is now ready for this discussion. Telling the patient about treatment options, if appropriate, is not only mandatory, but indicates that the doctor considers the patient's opinion and wishes important. In addition, sharing responsibility with the patient for decision-making may also reduce physician distress if treatment fails. A correct understanding of the patient's condition will help to avoid high expectations from treatment or misunderstanding of the goal of treatment. Physicians often feel uncomfortable discussing prognosis or treatment options with a patient if the information is unfavorable. Discomfort is created by the doctor's feelings: uncertainty about the patient's expectations, fear of destroying his hope, his own impotence in the face of an uncontrollably progressive disease, uncertainty that he can control the patient's emotions, and sometimes embarrassment at the optimistic, hopeful prognosis he gave the patient.
previously.
These difficult conversations can be facilitated by a few tricks.
First , many patients are aware of the severity of their disease and limited treatment options, but are afraid to share them or ask about the consequences. The study of the patient's knowledge, expectations and hopes (Step 2 of the SPIKES Protocol) allows the doctor, starting from them, to build a conversation. When patients have unrealistic expectations (“I was told that you work miracles”), their questions about the medical history usually reveal the fears and anxieties that lie behind these expectations. Patients may associate the resolution of various problems that are very important to them with the cure. This may include loss of a job, inability to care for a family, pain and suffering, unwillingness to be a burden to others, fear of limited mobility. The expression of these fears and concerns often allows the patient to recognize the seriousness of their condition. If the patient became sad when discussing their concerns, it would be appropriate to apply the techniques described in Step 5 of the SPIKES protocol.
Second , understanding the important specific goals that many patients have, such as symptom control, making sure they receive the best possible treatment, and ongoing care, allows the clinician to hope to achieve these goals. This can be very reassuring for patients.
An example of delivering "bad news" to a patient in clinical practice.
Operation completed. Nobody is satisfied with the result: the tumor has bound the surface of the small intestine so that it was impossible to make out where one loop ends and another begins. The CT scan of this nearly 40-year-old woman's abdomen looked much better and more innocent than the operation's abdomen. Barely legs carried away, I hope, without harm. For 3 hours of the operation, he could not move further than 2 cm from the incision. Such a patient cannot be helped by surgery.
So, the operation is over. Everyone is doing their own thing. The anesthesiologist prepares for the completion of anesthesia, the operating sister fills out the documentation, the assistants check and count the instruments, wipes and needles for the third time.
I request that the patient's family be invited into the interview room to talk about the operation. “No fluff ...”, the operating sister admonishes me, lowering her gaze. "I wouldn't want to be in your place." “It’s okay,” I say, “I don’t mind. No one will do this except me, so I even love these complex conversations.
This is only two-thirds or one-third true. You have to be a complete psychopath to love such moments. However, the truth is something else. No psychologist can replace the surgeon, who is the center of attention of the family waiting for the operation to be completed. Only the operating surgeon has the halo of a god or a devil at that moment after the operation, when the relatives find out whether their expectations were justified. Most likely for the sake of this, too, I became a surgeon. Now is the time to call for help all the professionalism that I have learned for so long, and have a conversation that my family will remember for a very long time and is likely to acquire many significant and fictional details.
Now is my chance to turn this moment into a useful channel for all participants 1 .
The technical aspects of starting a conversation are simple. I entered with a big smile, I'm glad to see everyone. He sat down on a low chair to see the majority, without avoiding a direct look, greeted everyone. He said that the patient tolerated the operation well. A sigh of relief surrounds me 2 .
I continue. I say that the operation was safe; however, my worst expectation that the obstruction symptoms are caused by a tumor and nothing can be done about it, these many times voiced fears were justified. I look at the slowly changing face of my husband, waiting for his response to this news 3 . It is, he asks. I repeat that his wife cannot be helped surgically, moreover, I do not think that we have effective methods to influence this aggressive tumor at all. I look around at everyone present: the patient's brother, eldest son, teenage daughter.
The mood changes to thunderous 4 . I am getting ready that the figure of the surgeon-savior will fly with a swing from the pedestal. And there is. “We were looking for you all over the country, such reviews about your practice! We flew across several states to get to your clinic!” While everything is according to plan. I expect the main "forbidden" reception. Well, here he is. “What will we say to our 6-year-old daughter? She expects her mother to get better!” My husband's eyes turn red, filled with genuine tears. At such a moment, it is easy to regard the reaction of the family as direct aggression.
Calm down, we went through this and expected. Not a word of justification (that we had spoken out the most unfavorable options before the operation). Of the last forces, it is necessary to react to the mountain 5 , which is vented on the only object suitable for this - on me.
End of the day, I want to go home. Thinking about whether to go into the office, whether to answer a stack of phone messages from colleagues and patients 6 .
What's for dinner? Probably, it will be necessary to buy lamps for the path in front of the house along the way. I'm trying to look at myself from the outside. I note that now the conversation will end, I will go about my business, the family of my patient will go through one of the most difficult evenings in my life. Only I from this company can determine the outcome of the conversation. Quite a lot of insulting words, words of disappointment, have already been addressed to me. Judging by the pace of the conversation, almost everyone had the opportunity to speak. I automatically show interest and participation 7 . Now we need to look for clues to find a warm word for everyone.
“What a close-knit family! 8 It's very nice that you stand behind Ann like a mountain. She is very lucky. What do you think we need to do now? ”I say in the first pause between direct and indirect curses addressed to me. As many sincere compliments as possible, try to semantically side with the family, and not against.
"What will happen to mom now?" 9 , the daughter asks, choking on her tears. I hand her face wipes and she rubs the mascara around her eyes. We turn the conversation into a practical direction. We talk about the symptoms, methods for their elimination, quality of life. About what is important, what is not. The idea is to move away from the global problems of “survivability”, which everyone discusses, but which are difficult to “feel”. I think to myself that we should not forget to advise my husband to pay more attention to his eldest teenage daughter than to a 6-year-old daughter - the youngest will much more easily endure the death of her mother. There will be time for such a conversation.
Answer questions patiently. The patient's brother stepped in. "Do not be angry at our intemperance, I see it is difficult for you at the end of the day." (I have a hard time finding words when I'm tired, and a parched mouth doesn't contribute to correct English pronunciation.) I was not surprised by this turn of events.
If everything is done correctly, then this is a completely expected phrase. The main thing is that it should come from relatives 10 , and not be my prayer: I did everything I could, what have I got to do with it, it's a tumor, isn't it obvious?!
One by one, everyone came over to my side. It is amazing how quickly the most aggressive militant pressure collapses if you do not reflexively respond with the same aggression! We quickly sketched out an action plan 11 for the next 2-3 days, who will stay in the hospital, who will come to visit and other practical things. I leave the most important for the end. “We all understand that the findings during the operation mean a fairly quick death of the patient. Do not forget that she is still a living person and needs each of you. I stay with you to the end, no matter how this end may happen!
Slowly getting up. Everyone gets up too. Instead of a handshake, the patient's husband opens his arms for a real biker bear hug.
In the same way, I say goodbye to everyone. My daughter leaves black blots of mascara on my chest. The reason for the final smile: “It’s good that I didn’t change my operating suit for a shirt, otherwise I won’t justify myself to my wife!”. An attempt at the most flattering joke is often received with gratitude in such a setting. Everyone laughs. It's time to end 12 conversation on this one.
In the locker room I look at the clock - I missed 15 minutes 13 . I did not get the slightest pleasure from the operation, but praised myself for having completed all the planned methods of 14 communication in a conversation. Now it remains to decide whether to go to the office or home. Let's do this: if a woman comes across first, I'll go home, a man - I'll work with papers. In the elevator, I answer simple e-mails in monosyllables. Doors open. In front of me is the operating sister: “Well, how?”.
The authors declare no conflict of interest.
Credits
Maksim Andreevich Kotov N.N. Petrova, resident of the Higher School of Oncology program; e-mail: [email protected]; https://orcid.org//0000-0002-2586-1240
Gushchin Vadim Viktorovich — Director of the Department of Surgical Oncology, Mercy Clinic, Baltimore, USA
*e-mail: [email protected]; https://orcid.org//0000-0002-2586-1240
3 One of the main communication skills with a patient is active listening and pausing after each cue or question. This allows, firstly, to better understand the information that you convey to the patient, and secondly, to gain the patient's trust.
4 Surgeons often pay attention exclusively to the semantic side of the conversation, that is, to the literal meaning of what is said. Non-verbal communication, however, comes out on top in terms of informativeness. This must be remembered both as a speaker and as a listener.
5 Empathy is the key to communicating in difficult situations.
You should actively identify the emotions of the interlocutor and respond to them. The "natural" behavior to avoid is reacting to one's own emotions, which can lead to conflict.
6 For a doctor, a “hard conversation” is just one of the events and one of the duties in his professional routine. The problems that occupy the doctor at the time of the conversation are different from the problems of the patient and family. Therefore, the same words and gestures can be interpreted in different ways. This circumstance creates prerequisites for mutual misunderstanding.
7 Here is a description of the technique of empathy. This technique can be performed analytically without significant emotional energy on the part of the doctor, which is one of the main practical differences from sympathy.
8 Complimenting the patient's family is an effective way to respond to patients' emotional statements. In most cases, such a reaction of the doctor allows you to reduce emotional tension and increase the level of trust in him.
9 Such questions, first of all, have an emotional connotation and not always patients or their relatives want to receive comprehensive answers to them right now. When answering such questions, the most important thing is the doctor's reaction to the patient's emotions. This helps the patient to calm down and increases the level of confidence in the doctor.
10 We advise you to pay special attention to this condition for effective conversation. It echoes Step 3 of the SPIKES protocol. The initiative to talk and change the nature of the conversation should be offered to the patient and relatives, and not tightly controlled by the surgeon. The feeling of control in a hopeless situation is highly valued by the interlocutor.
12 The end of the conversation is the second critical moment (the beginning is the first), which, more than the middle, emotionally colors the entire conversation.
13 Surgeons often feel impatient when talking to a patient and their relatives, believing that such communication is unacceptable for their busy schedule.
However, step-by-step, systematic communication with the patient in practice takes much less time than surgeons imagine.
14 Properly performed communication techniques do not guarantee a result in all cases, but increase its probability. It also gives satisfaction to the doctor that he has fully completed all the steps known to date to achieve a result.
"Kick in the gut": 7 ways to support yourself by learning bad news
It is impossible to imagine life without problems and difficulties. Illnesses, the loss of loved ones, difficulties at work, a broken heart - events have happened to each of us that overnight turn our lives upside down. As a rule, we are completely unprepared for such situations, and they can significantly affect physical and mental health. Psychotherapist Andrea Bonior is sure that there are no universal tips on how to reduce the pain of such changes and cannot be. But there are steps that we can take to gather maximum resources at a difficult time.
1. Breathe in and slow down
When we receive bad news, it feels like a hurricane. Time stops, breath catches, the heart is ready to burst out of the chest, thoughts rush in the cycle and it seems that we are about to lose consciousness. Everything that is important to us flashes before our eyes, the mind instantly builds possible and most catastrophic scenarios.
If something like this happens to you, stop first. There is no need to immediately react to what happened. Focus on your breath. If you are in a potentially unsafe situation - on a busy street, driving, or carrying a baby - focus and try to move to a safer place or position. When we slow down, we are less likely to do something we later regret.
2. Feel here and now
If everything is spinning, focus on where you are in the room. It is not without reason that people often ask others to sit down before giving them bad news: this allows not only to avoid injury during a loss of consciousness, but also to “ground themselves”.
If you have symptoms of depersonalization (you look at the situation in a detached way, as if from the outside, without feeling yourself) or derealization (everything seems surreal, happening as in a dream), try to focus on four objects that you see in the room around you. Feel your feet rest on the floor and your clothes against your skin, feel the weight of your body on the chair. Breathe. Concentrate as much as possible on how the air passes through the nose as you inhale and exits through the mouth as you exhale. This will help bring you back to the present moment.
3. Assemble your support team
Very few people can deal with bad news alone, and why should they? Having received unpleasant news, try to remember who could support you and help you find the resource to move on.
You may text a friend asking them to pick up their children from school, or call a relative who is also overwhelmed by the news and shares your feelings. If the bad news is about health, it's especially important to get a support group together.
These people are your allies in a difficult situation.
4. Make a preliminary plan
Naturally, immediately after receiving bad news, you should not and cannot plan in detail and clearly all the necessary actions. But even a rough plan of how you're going to act can help you feel more stable and predictable, which will reduce your stress levels.
Not every news needs to be followed by action. Sometimes the whole plan comes down to summing up, realizing what happened, emotionally experiencing the event. But if you need to make decisions, think through details, or organize an event (such as a funeral), participating in it can help you regain a sense of control over the situation.
5. Feel free to ask for help
Many people have difficulty asking for help or admitting they need it. However, now is the time to step over the barriers and reach out to those around you. Think about who can help and talk to these people.
The worst thing that can happen is the answer is no.
But such an outcome is unlikely: people usually want to be useful and needed, especially in a difficult moment. In addition, it helps to maintain closeness in a relationship.
6. Don't forget to take care of yourself
Tragic events deal a double blow: not only do we experience strong emotions, but we also lose the ability to take care of ourselves. In difficult times, we forget about sleep, exercise, good nutrition, the need to be in the fresh air, socialization. Most likely, for the first time after what happened, you will not be able to return to your usual daily routine, but in order to maintain physical and mental health, you need to move at least in small steps in this direction.
If you didn't have a habitual schedule that included all of the above before, it will be even more difficult after the shock. You have to force yourself to go to sleep - even if by force. Go for a walk, call a friend, have dinner, even if you don't feel like it. These are all manifestations of self-compassion: living your feelings and not forcing yourself to conform to standards or someone else's ideas about how you should behave or feel in such a situation.
