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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
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  • 16. Social and Psychological
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    Back to Module 2: Communicating Bad News
    A Six Step Protocol

    Using the Six Step Protocol in Other Situations

    Using the Six Step Protocol in Other Situations

    When Language is a Barrier

    • Use a skilled translator who is:
      • Familiar with medical terminology
      • Comfortable translating bad news
    • Meet with the translator before the interview to:
      • Brief them on what will be said
      • Reassure them their role is only to translate
      • Verify that they will be comfortable translating the news you are about to give
    • Avoid family as primary translators
      • Confuses roles in family unit
      • May raise issues of confidentiality
      • Family members may not know how to translate medical concepts
      • Family members may modify news to protect patient
      • Instead, encourage family to:

        • Supplement the primary translation
        • Support patient and other family members
    • During the interview:
      • Sit in a triangular arrangement so that you can:

        • Face and speak directly to the patient
        • Yet still turn to look at the translator

      • Speak in short segments, then give the translator time to convey the information
      • Verify the patient’s and family’s understanding and check for an emotional response
    • There are several services in North America that offer translation by telephone if there is no one directly available.

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    Communicating Prognosis

    Why Do Patients Ask about Prognosis?

    • Patients frequently ask about prognosis
    • There are many motivations for this request
    • Some want to have a sense of their future so they can plan their lives
    • Others are terrified and hope that you will reassure them

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    What to Do Before Responding to Patient Inquiries

    • Before directly answering their questions about prognosis, inquire about their reasons for asking. Questions might include:
      • What are you expecting to happen?"

      • "How specific do you want me to be?"

      • What experiences have you had with others with a similar illness?"

      • "What experiences have you had with others who have died?"

      • "What do you hope/dream will happen?"

      • "What is your nightmare about what will happen?"
    • Consider the implications of the prognostic information you provide
      • Patients who wish to plan their lives want information that is more detailed.

      • Those who are terrified may do better with answers that are more general

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    Responding to Inquiries about Prognosis

    • Definitive answers, e.g., "You have 6 months to live," run the risk of producing...
      • Disappointment, if the time proves to be less
      • Anger or frustration, if you have underestimated the patient’s lifespan
    • Consider responding by giving a range of time that encompasses an average life expectancy, such as:
      • "Hours to days"
      • "Days to weeks"
      • "Weeks to months"
      • "Months to years"
    • Alternatively, indicate averages such as:
        "One third of people will do well a year from now, half will live about 6 months; exactly what will happen for you, I don’t know."
    • After giving a range, it may help to emphasize the limits of prediction by saying something like:
        "What this will mean for you I can’t tell. We need to hope for the best, while we plan for the worst. We can’t predict surprises and should plan in case something happens. Over time we’ll have a better sense over time how things will evolve for you."
    • Always caution patients and families that unexpected surprises can happen
      • Suggest that they get their affairs in order so they won’t be so vulnerable if something unexpected does occur

      • Reassure them that you will be available to them to deal with issues and support them throughout their illness, whatever happens

      • Help clarify what can be realistically expected and distinguish this from what might be wished for, or what is most feared

      • Identify the miraculous for what it is—something outside of usual experience that happens exceedingly rarely

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    Caregiver Communication

    • The sharing of information among caregivers is critical
    • Maintain a chart or log book close to the patient that can be shared by all who provide care, including physicians
    • Pooled information can help:
      • Facilitate a continuous plan of care
      • Avoid constant repetition of questions
      • Avoid unwanted activities
    • It will be most effective if the chart or log book includes:
      • Goals for care
      • Treatment choices
      • What to do in an emergency
      • Likes and dislikes
      • Things to do and or not to do
      • Contact information for family, physicians, and other members of the interdisciplinary team
    • Ensure that data is recorded accurately and accessible to everyone
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