How to tell the bad news

Communication with cancer patients (II) The significance of bad news and its impact on patients and their families With the extension of life expectancy of cancer patients and the decline of mortality after the emergence of new treatment methods, the situation of bad news has become very complicated and diverse. So what bad news will appear in the process of tumor treatment? 1 cancer diagnosis; ② Poor prognosis; ③ Recurrence of the disease; ④ The treatment was unsuccessful; ⑤ Irreversible side effects; ⑥ Anti-cancer treatment is terminated; ⑦ CPR first aid; 8. Sudden accidental death or complications. These are all bad news to inform patients or their families. In addition, we need to find out what bad news means in the eyes of insiders. Some patients never think that bad news will happen to them, and it is especially difficult to tell them bad news. Others know something about what will happen to them, and they will be more prepared for bad news. In other words, bad news means that the person who will face it has changed his view of future life, and what kind of emotional reaction he has depends on what the patient expects to hear from the person who told the news. For those patients who really can't bear the bad news (those who never thought of accepting the bad news, those who were diagnosed with poor prognosis, young patients and those who had expected good treatment results), we should be especially prepared and give support to help them through the dangerous period. The emotional reaction of patients and their families when they hear the bad news may lead to a stronger emotional reaction of doctors (condemning their powerlessness, anxiety, etc. In order to help patients, doctors should step out of their emotions (separate the news from the person who told it), remind themselves that we will not be blamed for the patient's illness and shift our focus to providing the best support measures for patients. These strategies can help us avoid non-constructive communication with patients, such as giving patients some immature guarantees, false hopes or hindering the expression of patients' emotions. Steps to tell patients bad news: spike model In clinical practice, it has become the duty of oncologists to tell patients bad news. Therefore, it will be of great help to doctors (more importantly to patients) to establish a set of methods that can tell bad news truly, sympathetically and hopefully. The SPIKES model mentioned here was also put forward by Dr. WalterBaile of M.D. Anderson Hospital in Texas, USA. It divides the bad news for patients and their families into six steps (the initial combination of each step is a peak). This model has been applied in many doctor-patient communication training practices, and its positive significance to clinical work has attracted more and more attention from medical workers all over the world. S stands for setting, similar to the meaning of the situation represented by C in C-L-A-S-S, which refers to setting this dialogue. The specific skills are as follows: 1. Predicting the patient's reaction Before telling the bad news, the doctor should predict the patient's possible emotional reaction and ask the following questions: Does the patient want to mute his mobile phone at an undisturbed time? If the TV in the ward is on, please turn it off. 4. Prepare paper towels If the patient's mood is unstable, please prepare a box of paper towels at hand. It is also a sign of empathy to hand the paper towels to the patient with tears. Sit down and keep eye contact. Eyes are the windows of the soul, and horizontal eye contact is conducive to emotional communication. Get the patient ready. This step should strive to achieve the following results: the doctor should be prepared before the conversation, promote the whole conversation process with a positive attitude, and the patient should relax before the conversation and establish emotional communication with the doctor. Of course, it is also important to judge whether the patient is ready to accept bad news. Some patients want to wait until their families are present to hear the bad news. In some cases (for example, the patient has just returned from treatment), the patient's physical condition may not allow him to be hit by bad news. In China, in many cases, the patient's illness is first told to his family members, so it is necessary to discuss with the patient and his family members in advance (before establishing personal relationship with the patient) how to deal with the illness information to avoid the embarrassing situation after blindly telling the patient about his illness. P stands for perception of disease. As mentioned in C-L-A-S-S, it is very helpful to know the patient's understanding of the disease, which can alleviate the gap between what the patient knows and what we will talk about. For example, if you think the patient's cancer has recurred, and you give him a CT scan, but the patient thinks it's just a routine examination, then the bad news will hit them hard. Therefore, if the patient's cognition is different from the facts, we need to explain it again before telling them the bad news, so that they can understand the facts. I stands for invitation. Most patients want to know their condition completely, but as time goes on and their condition develops, patients may not want to know so much. In western countries, many patients want to see their own fluoroscopic results when they are diagnosed, but they don't think so after their illness is serious. In addition, some patients (of course, such patients are rare) may prefer to let their families know first. Next, it is important to know how patients want to deal with their disease information, whether they want to know more or less, whether they want their families to share this information and which one of them wants to know, so as to determine how to tell patients about the treatment of the disease. In order to achieve this goal, doctors can meet patients and ask some open-ended questions, such as do you want to know more information, or, or who else do you want to know about your disease? Ask the patient how to deal with the bad news in advance, so that there will be no embarrassing situation in which we blindly tell the patient the bad news and the family members ask not to tell the patient. K stands for knowledge. If the patient is psychologically prepared, then the bad news will be easily accepted. This step also emphasizes the patient's cognition (P), because what is told to the patient depends on what the patient has learned before. It is best to predict the patient's reaction after learning the bad news, so that the patient can be prepared before conveying the news. Don't tell the patient more than one or two concepts at a time, and then evaluate the patient's understanding. What patients complain most is that doctors use some words and concepts that they can't understand when explaining disease information. So pay attention to your explanation and remember that you are talking to patients, not medical students. E stands for empathy and exploration. Patients are often very excited when they learn bad news. A in C-L-A-S-S has the same meaning as E in S-P-E-K-E-S. It is important to identify all the emotions of patients at this time, because these emotions may hinder the understanding of patients. Sometimes the sender of bad news will feel sad and helpless, and will also have an empathetic reaction. For example, he will tell the patient that it is really difficult for me to tell you the news. The specific empathy methods have been mentioned before, so I won't go into details here. S stands for summary. At the end of the conversation with patients, it is necessary to summarize the conversation to help patients better understand and master the information that doctors want to convey. Studies have shown that having patients take notes on the spot or having another person take notes on the spot can improve patients' understanding ability. We can recommend good treatment to patients, not in a commanding tone. It is much better to say that I suggest it than that we have to do it, because the former considers the patient's wishes when making treatment decisions and can bear the responsibility of treatment with the patient. Most patients will follow the doctor's advice. Although it may be difficult for patients to make a choice, it is also a requirement of medical ethics and law for doctors to tell patients different treatment schemes (such as the surgical method of breast cancer, mastectomy or local lesion resection). Doctors should know what patients are worried about a certain treatment method in order to judge the obstacles faced by completing the treatment. Finally, tell the patients when they can come to see you, how often you follow up the patients and how to contact you. This completes the final summary. Telling patients bad news is a very complicated conversation. In clinical practice, it is best to break it down into a series of steps. Every step has a very important task for doctors, and the most challenging task is to face the patient's emotions. The six-step plan (SPIKES) mentioned above requires us to convey information to patients emotionally and sympathetically, and at the same time, to guide patients to explore further treatment potential by establishing close doctor-patient relationship, which is also a way to support patients in the face of disease crisis. In China, the cultivation of doctor-patient communication skills for medical students and medical workers is still in its infancy, or it has not received enough attention; At the same time, the training also lacks the corresponding theoretical and specific forms of guidance. In view of this, Tang Lili, director of the Department of Rehabilitation of Peking University Cancer Hospital, cooperated with the Department of Psychosomatic Medicine of the University of Freiburg, and since 2009, medical workers in cancer clinics have been trained in doctor-patient communication skills, especially how to tell cancer patients and their families bad news. The training is based on Professor Bai Le's spikes theory and adopts workshop mode. Workshop is a popular and flexible teaching method, which is different from the traditional cramming teaching. Not only can students master the theoretical knowledge, but the most important thing is to use the theoretical knowledge in the on-site simulation exercise to find the existing problems in time and correct them in the on-site discussion. On the one hand, this teaching mode can avoid students' hearing and visual fatigue under the conventional mode, on the other hand, it can also open up students' thinking and provide a platform for demonstrating their abilities. At present, three workshops have been successfully held, and the training targets are also from many cancer hospitals across the country, so the concept of this training has been continuously spread. We also expect more people to join us, pay attention to the communication between doctors and patients, and further improve the quality of humanistic care!