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Right. Hi there, everyone. Um, we'll give it just another minute. I see some folks slowly trickling in. Sometimes it can be hard to navigate all the clicky buttons. Um, and we'll get started in just a minute. All right. So why don't we get started then? So, hi, everybody. Welcome. Uh, good morning. Good evening. Good afternoon. Depending what time zone you're in. Um, it's a pleasure today to have the next two hours or so, depending how things go, uh, to talk about breaking bad news. So, uh, my name is Beatrice. I'm a pretty new medical oncologist. Um, I'm based in North America. I have affiliations with Emory University, which is in Atlanta, Georgia, in the USA and Western University, which is in London, Ontario, in Canada. And I'm joined today by Lena. Lena. You want to introduce yourself? Yeah, for sure. Hi, everybody. My name is Lena Abuja. Um, I'm a first year medical student at Emory University. All right. So, over the course of the next two hours or so, we're going to start by discussing two frameworks. Um, that can be used when you're trying to learn or you're trying to break bad news for the first time. Now, the thing with frameworks is they're just guidelines. So it kind of gives you a structured way. Um how you could consider it to approach breaking bad news. Now, once you do this over time, you'll become more comfortable with it and you may develop your own approach, you may find things that work for you and things that don't work for you and that's fine, that's very normal. But we're gonna put me um starting uh more on the basic side for folks who aren't too familiar or too comfortable with breaking bad news to kind of explain some of the different ways that you could approach this. Additionally, we're going to be discussing some potential pitfalls or um maybe mistakes or things to think about when breaking bad news. Uh So you don't have to learn these through experience like a lot of us do. So first things first just thinking about breaking bad news in general before we jump into the nitty gritty of it. Um Even if we haven't been exposed to breaking bad news much in medicine, a lot of us often have a picture in our mind of what that looks like, whether from personal experience. Um or maybe something that we've seen on TV or something we've read in a book or something we've heard that happens to other people. When we think about breaking bad news specifically, there may be certain diagnoses or certain conditions, things like death or maybe, um, something like cancer or terminal illness that come to mind. However, I think one of the biggest pitfalls and one of the biggest things as um medical practitioners to keep in mind is that bad news can mean different things to different people in different contexts. I remember I was a very early resident. So, uh a junior postgraduate learner, uh telling a patient with knee pain and, and uh foot pain that uh we had good news. She uh just had osteoarthritis. Now in the rheumatology clinic for me, at least there seemed to be good news because it wasn't any connective tissue disorder. It wasn't rheumatoid arthritis. Um But for the patient, she became very upset and said, you know, you're saying this so casually when this is something that's not going to get better, this is something that will affect my life for the rest of my life. Um And I think that was really eye opening that um, you have to be sensitive and we have to bear in mind that what's bad news for us may not be the same thing as what's bad news for a patient. So now on that note, um and uh folks can either write in the chart on the side of the screen or if you want, you can uh unmute your mic and uh chime in as well when you hear the term breaking bad news in your experience or uh from what you've seen before what comes to mind and we'll give folks just a few minutes to think about that and chime in if they wish quiet crowd this morning. That's all right. You know, like I said, breaking bad news can mean different things to different people. And, um, some, sometimes it can be challenging as well because if you have seen different context or you've seen different things, kind of like the word cloud here, sometimes it can be hard to characterize as well and just a couple of words or a phrase exactly what breaking bad news is. So, along that lines, we're going to give you an example. Um Lina and I are of an example of undesirable ways to break bad news. So in this context, I'm gonna be the clinician who is breaking bad news. And Lina here is going to um represent our standardized patient. Um who for the purposes of this presentation is going to be Sarah and we'll see Sarah quite a few times over the course of this talk. Um But let's get started. I don't think, I don't think I can swap unfortunately, the slides and our videos to make it bigger that way. What will make this work? OK. All right. So, um OK, so I have your scan results here. Um I know you called in saying you were worried about them. Uh But you know, that wasn't really necessary because we already got you a follow up appointment. As soon as we could. Um, well, I was just wondering because it's been three weeks and I hadn't heard back. So I figured everything was all right, but I just wanted to. Right. Ok. So, unfortunately the biopsy looks like it came back positive for cancer. Um, yeah. So, uh, we're, we're gonna refer you to a surgeon and an oncologist. Um, probably they need to get you some chemo or something. Um, and then they're gonna do some more tests and, um, you know, we'll see what they have to say but, um, they, uh, yeah, um, sorry about that. Um, so yeah, more tests and get something sorted out for you and uh that'll be following you. So you don't have to come back here again. Um, does that sound uh good to you? Wait but, but I have cancer. Um, yeah, yeah, that's what I said but um, we'll get you some scans to make sure it hasn't spread too far and like I said, we're gonna set you up with everything that you need. Will I be ok? Um, yeah, so the, yeah, um, sorry, um, the oncologists are gonna discuss all of that with you. Ok. So why don't I just walk you up to scheduling now? So, um, uh you can figure out when you're going to see them? Oh, yeah. Ok. Ok. And see, um, so that was an example of what we might consider uh undesirable way to break bad news. Now, the question for the group is when you were watching, that was there anything that you could pick out uh that made this uh less desirable or a bad way to break bad news? Was there anything that you noticed? Tanvia says lack of empathy? Yes, definitely. So me as the healthcare provider, I was providing a life altering diagnosis and um really, really no show compas no compassion um or no consideration um that our patient might be shocked, might be scared. Some of the things that they might be going through, the patient wasn't allowed to express their feelings. Yes, I kept talking. I didn't really leave any space for questions or for the patient to say much of anything, not having answers to questions that could have been anticipated in advance. That's a very good thought. Yes. Um When you come into these situations, you want to be prepared, you may not always have all the answers, but you want to make sure that you have a good follow up plan for how the patient is going to get those answers rather than oh yeah, we'll just send you to see someone and they'll discuss some things with you. The conversation was very technical. Yes. That's a big one that when you're discussing serious things or anything really with a patient, you want to make sure that you're speaking at their level. So for some patients, they don't have a knowledge of the technical terms and even same thing like a biopsy. Um Maybe a patient doesn't quite understand what a biopsy means or why it was done. Excellent. Yes, some very good thoughts that folks are sharing. So, um that's wonderful. And on that note, we can start with going through, there we go. Uh First of the two frameworks that we're going to cover. So the first one is the spikes framework. Um And as you can see here, this has six different components. It's probably the most widely used one, at least in North America from what I've seen. And we'll go through each of these steps, one by one. Then what we'll do is we're going to uh role play another scenario using the spikes framework and then we'll have the opportunity for you to practice as well. So first up is setting, so even before you start breaking the power news, you want to think about where you are. Sometimes it can be challenging, especially in a busy hospital environment, uh especially emergency departments or crowded wards. However, as much as you're able, getting somewhere quiet, getting somewhere private, uh maybe if you're able to sit down, of course, this is all ideal and not always practical in the environments we work in. But as much as you're able to even just pulling a curtain, um even just turning off a beeping monitor or turning off a beeping page or giving you a page to someone else to try and make sure that you're in a situation that minimizes destruction. So you, the patient, their family can focus on the conversation. Next step is perception. So it's always good in these situations to understand the patient's understanding of what's going on, what you're here to discuss why the tests were done. Um Some people will come into breaking bad news conversations with very, very good insight. You know, I had a biopsy to look for cancer. Other people will have less um clear understanding, you know, they put a needle into my belly, but I'm not really sure why or what they were looking for and this will help you as well to pitch your conversation and figure out, you know, how technical you should be or where you need to stop from. Even then you have the invitation, which is really just another way to build rapport where you ask the patient for permission. You know, I know you had this test done. Can we speak about the results? But this also lets you do. And what lets the patient do is let you know if there's something that they don't want to hear, it's not too common, at least in North America. But I certainly have been in situations where patients will say to me, you know, I don't want to know if this is cancer or I really don't want to know if this is something that can't be cured. Maybe you can speak to my family member instead. Um maybe uh you know, you could just give me broadly instead of the details. So it's always good as well to figure out what the patient wants to know. And then the knowledge part, this is the part where you sit down and you drop the news and you say, ok, this is what it is, this is what we're dealing with. Um and this can reach anything from, you know, I'm sorry, your loved one didn't make it to. Um you know, I'm I'm sorry. Uh depending on the context, uh you know, your kidneys aren't working. Uh you need dialysis, um your baby uh didn't make it um lots of different ways this could go. Um But it's important to in your mind when you're having this conversation to very deliberately say, ok, now this is when I am going to convey the information in the most sensitive. So, empathy, compassion, respect, um and clear way possible. A lot of times when folks are breaking bad news or are not comfortable with it, there can be a tendency to ramble or to use technical terms or to use euphemisms. Um So to use fancy nice sounding phrasing rather than being very clear because you don't want to hurt the other person, you don't um want to make them feel bad. But unfortunately, as healthcare providers, this is our job where sometimes we do have to convey very difficult information. Next step is empathy. So part of breaking bad news is we know that this is going to affect the patients um and their families and whoever else is involved and giving the time and space for emotion. Um and allowing that to play out. However, the patient and the family need to is also important and part of our jobs finally summarizing and strategizing. So you've had this conversation, you've given this bad news, what comes next, what's the plan? What's the next step? And again, this will really depend on the context and the kind of news that you're breaking. But it's important to always leave these conversations with some kind of a plan and the plan may be as simple. You know, if you're um in a really difficult situation of, you can wait here for a few minutes, you know, take the time that you need. We'll send a social worker, a nurse to come in and talk to you about funeral homes. For example, if, if you're dealing with death or um we'll set up a follow up appointment, right? If this is some kind of terminal illness or illness, um that isn't going to get better, right? You always want to make sure that the patient and the family are leaving that conversation with some kind of direction because when you are in that high motion state, it can be hard for you as the patient, as the family to form a plan yourself. And sometimes the guidance is really really important. So now we're going to do our example using the spikes framework. And I think what I'm going to do here is actually to go back to the framework itself so you can follow along with the steps that we're using. All right. Uh Let me go here. OK. Ready. Yup. OK. So Sarah, um before we talk about your scan results, uh is there anyone that you'd like here in the room with you? Uh, we can also bring in some more chairs and make sure that you're comfortable. Uh, no, that's ok. I came alone today because I figured I was feeling well and there wasn't anything to worry about. Ok, that's ok. Now, I want to start by asking you to share with me what your understanding is about why we did these scans. Well, I thought it was just to check after the surgery to make sure everything was, um, healing up. Ok. Well, that's certainly one reason, but we also do the scans to check on the cancer and see how everything looks after the surgery is done. Are you ok if we chat some more about what the scan showed? Yeah, for sure. Ok. Well, unfortunately, Sarah, um, it looks like the scan showed that your cancer has spread to the liver despite the surgery going well at the time, it seemed that even at the time of the surgery, the cancer had already started to spread, but we're only able to see it now that it's big enough. Wow. I can't believe it. I still have cancer. Like, what does this mean? Like, am I gonna have another surgery? It still can be cured though. Right. Unfortunately, with the way the cancer has spread, we are no longer able to cure it. And that means another surgery is not going to be helpful. However, we do have drug treatments to try to control the cancer. And one of our next steps will be to send you to an oncologist who specializes in drug treatments for this particular kind of cancer. Ok. Wow. I still can't believe it. II feel so good. How can there still be cancer inside of me? Yeah, I know this can come as quite a shock, but we're going to set you up with the right team who can answer all of your questions and help you form a plan and we'll still be here for you as well. So if you have any questions or anything that we can help with along the way, you can definitely reach out. Ok. Thank you. OK. Unseen. Um So, uh one thing I'll say before we open it up to the floor is that as you can see in this example too, um The summarized strategies and empathy were a bit mixed. I'm just realizing that now that's the thing with frameworks too, as I said in the beginning, it's not a hard, you know, this is definitely how you have to do it in this order all the time. It's just kind of a guide to remind you of the different components that might be helpful to include in a conversation. All right. So based on that example, why don't we say, what did you see that was done in that example? That was done? Well, do you think may have been missing in the first example that we give, we gave of the the bad example and I'll give folks a few minutes to think about that jargon was avoided. Yes. So we were speaking about scans. You'll notice very specifically. I didn't say what kind of scans because it wasn't really relevant, right? The key message was cancer has spread to the liver. It's not curable. Let's talk about treatment and you can certainly make that much more complicated. Um But in this situation, especially because you know that you'll be dealing with a high motion state. Clear, straightforward communication is usually best other thoughts. It's a slow crowd out there this morning. Maybe I can jump in from just a patient's perspective or simulated perspective. Um Maybe some other folks have been thinking the same way, but it felt like that this simulated doctor gave me time to um to speak and to think about how to respond to certain things that they were saying versus be either interrupted in my thought process or be completely distracted. Yeah, definitely. So it's important to, to remember when you're having these conversations to allow for silence. So, if you've ever gotten bad news yourself or been in a, uh, uh, a shocking or surprising situation, something maybe like a car accident. Um, you might notice or you might remember that time seems to slow for you and, uh, a lot of things happen at once and it can be hard to process. And as a healthcare provider who's doing this routinely, you know, over the course of a regular work day, sometimes we can forget how much this can impact people and allowing for that silence, allowing for that space can be very, very helpful for patients to process. I also see a comment that there was a clear treatment plan, post diagnosis and absolutely, you know, coming in with the next steps, coming up with a clear plan of this is what's going to happen, even sometimes writing it down if it's multiple steps can be helpful for somebody in that height and emotional state who may not be thinking as clearly as they normally would be. So at this point, we do have the opportunity for somebody to practice with our wonderful sp Now I've seen people coming in and out of the talk. So I don't know if there's a brave soul out there who would like to give this a try. Um But you know, this is a safe space, no judgment. I can put the um the framework up for you if you'd like, I'll give it a couple of seconds if somebody is interested to identify themselves, I think we actually lost somebody. So I'm gonna take that as a no, then, um, we'll go through the other framework and then at the end to see if anybody wants to give it a try. Otherwise we will give you another um, uh, a sample scenario with the next framework. All right. So here's the next framework. It's ABCD E and you'll see here that there's some similarities and some differences compared to the spikes framework, which was the other one that we looked at. So this one is only five steps, we'll go through them one at a time. But you'll see again some things that overlap and that's because in this process, there are some core things that um I usually acknowledge to be desirable or good to do. So the first one I think somebody mentioned earlier in the talk about advanced preparation. So you want to make sure that you're coming into this conversation with as much knowledge as you can have. So you want to make sure and say something that we all do uh or have done or seen somebody do. Uh you have the right patient, you have the right scans, you have the right diagnosis, you have the right results, you're matching what you're saying to the correct person. There's nothing worse than giving somebody bad news and then realizing that you had the wrong patient or the wrong bad news that you're breaking to that person. We also want to make sure that you're coming into this conversation with a plan, um a plan that you can give the patient. And even if the plan is, we need more tests, we need more answers. I need to consult with some of my colleagues um have that right. Sometimes if you write it down, it can be helpful for you to remember because as healthcare providers having these conversations can be stressful for us as well. And depending on how this conversation goes, we may forget some of what we came in to say. Second one is building relationship. Now again, this is hard, especially if someone is in expecting bad news or expecting um to hear something uh in my own practice. Um A lot of patients who have been with me for a while will know that when there is good news um on a scan on a biopsy or a test, I will walk through the door and say the results are good. Everything is good. If I walk through the door and say so, how's your day going? How are you feeling? Uh they know that they're about to get bad news. However, in patients who I don't have that report with, um sometimes uh finding out a bit about them, you know, who's here with you. Uh is anybody here with you? How are you feeling can be helpful? It can also be helpful in knowing how to interpret results. So, in the world of cancer, which is the world I work in uh and drug it along sometimes. Um the uh uh sometimes what we can do next, it actually does depend on how a patient is feeling. And if they're in terrible pain, if they're not able to walk, that's going to be a different plan that they leave the room with, than if they feel perfectly fine and healthy. Communicating. Well, so as we've said multiple times over this talk, making sure we have clear concise communication, we get our message across, we get it across no one certain times remembering that this is gonna co come as a shock or it may come as a shock, it may cause heightened emotions um that make it hard for someone to concentrate on a longwinded spiel and then dealing with the reaction. So everyone will react. Acceptance is a reaction. Anger is a reaction, fear, sadness, surprise disbelief. Um We've probably all heard about the five stages of grief and we also know that those stages do not come in any predictable order. So being prepared to manage and deal with whatever the reaction is. And that's something that comes over time as well. And then finally encouraging and validating emotion. So no matter what the response, too bad news, that is a valid response, right? That is how that patient in that moment is taking the news, there are some lines, of course, uh we can't allow people to be physically violent. Um suicidal ideation also has to be taken seriously. But between those extremes, um you know, some people will be angry, some people will start crying, some people will not believe you. Some people may even storm out. Um And this is not to you, that's just their response to the situation in the moment and trying to have as much compassion uh as we can muster is very, very important and part of the job. So along those lines, we are going to give you an example. Now, using the ABCD E framework, I'm gonna go back to the actual framework so you can follow along. All right, let me find it. Mhm. Ok. Ok, sir. Um I know you're here to talk about your scan results today. I've taken a look through everything and I've printed out copies of the report here for us to go through. We go before we go through this though. Is there anyone you'd like in the room here with you? We can bring in some more chairs and make sure you're comfortable. Um No, no one was able to come with me today, but maybe you can call my sister afterwards. She's definitely worried about the results, of course, of course. Um And we can talk about the results. Now, did you have any questions before we jump into things? Um No, I'm ready to talk about the scans. Ok. Absolutely. Well, Sarah, unfortunately, the scans show that your cancer is growing despite the treatment, which means that unfortunately the treatment isn't working. That's impossible. Um, I told you that I wanted the best treatment for my cancer. You lied to me. The treatment that you're on often works well for cancer, but unfortunately not everyone's cancer responds to it. I know this can be very disappointing news to hear. Wow. Yeah, I mean, II can't believe it. I can't believe it. Am I gonna die from this since the treatments are working? Yes, we would expect this cancer to take your life. But there are other treatment options that we can use to try to control the cancer for a while. Um, why should I believe that these treatments didn't work? I know it can be very frustrating when treatments don't work and it can be scary as well. Yeah, like really, really scary. Yeah. Would you like us to call your sister now? Um, we can go through things and come up with a plan. Yeah. Ok. Ok. Cine. So, um, that was a situation again where we use the ABCD E framework again with a little variation as the situation calls for it. Um I think the question I'll pose to the Peanut Gallery now is when you saw that example, what were some things that you felt were done? Well, especially again, compared to the very first example that we gave, I have. Ok. Yes, absolutely. So, in this case, as part of the advanced preparation, uh as the healthcare provider had actually printed out results and depending on where you are um at em right now, patients can actually get the results on their phone if their phone savvy at the same time I received them, which has its own implications. Um But definitely, yeah, sometimes bringing something in that a patient can look at can also be helpful in grounding the situation and giving them something to focus on. Definitely again, making sure we're giving enough space to digest and deal with the information at hand. In this particular example, um the patient Sarah uh was angry, which is something that we hadn't seen before. It's a very, very common emotional too. Um uh Bad news. Um Patients will often ask you questions like am I going to die or your treatment didn't work? Why should I trust you anymore? And this can be very challenging to navigate. But um it is part of the process, it's part of the reaction. Um And it's important to be able to validate these and deal with them appropriately in the moment without becoming angry or defensive ourselves. Ok. So at this point again, there is a practice scenario that we can do if there is a brave soul who would like to give it a try. Now give her a few seconds in case somebody wants to volunteer, it may also be late in certain time zones and this may be positive as well, which is OK, not to worry. So we'll skip towards the takeaway. All right. So that said we've gone through our two frameworks spikes, ABCD. E. Um, we've given you examples of both of them. We've also spoken about some pitfalls or um, some little tidbits to keep in mind when you're, um, looking at breaking bad news in your own context. So at this point, we can open up the floor if there's any questions or anyone has anything that they'd like to say or ask. Um, otherwise we can call it a day, right? OK. So it looks like no questions. Um OK, I'm glad that was useful. Oh, here's a question. Yes, absolutely. So that's a great question. So the question is if the patient asks about prognosis or how long they would live. So if someone is as asking this question, there's two kinds of people, um, ones who want specific information and ones who want general information. It's important to know that if someone is asking that question, it indicates that they're in a state of mind where they do want an answer. So it's best not to skirt around the issue. Now, depending on the situation that you're in. So for example, in oncology or things like uh renal failure, liver failure, internal medicine, like issues, um, it can be hard to know exactly how long someone has to live. So I always recommend that you do not give specifics. When we look at J 10 studies, sometimes we'll be able to see like the average life expectancy is 10.1 months. However, if you tell someone that they have 10 months to live, often, they'll take you at their w at your ward, even though that's just an average. So I always give ranges to start with. Um, my favorite way to do this is to estimate whether someone has short days to weeks, weeks to months, months or years. So for example, somebody who's newly diagnosed um may have months or years versus somebody who's in the hospital, very sick may have only hours to short days. Um And giving that range is more to help with planning. So, you know, for example, if somebody only has hours to short days, family members should come and visit, if they want to visit versus if we think you may have months or years, maybe there's a bit more flexibility with folks who want to visit. Um Sometimes if people are more numbers minded, I'll say, you know, we can discuss the data, but we need to remember these are averages. So, you know, the average is 6 to 8 months, which means half the people is less and half the people are more. I usually, I will also say, I hope that you are in the more uh than the average. If somebody is particularly sick. I may say you know, because you're so sick, I'm worried you may be less than average, but emphasizing what average means and the average is just a number that does not apply to any one particular person. That's a good question. Any other questions? You're welcome. All right. So with that, then thank you so much to everyone for coming. I hope it was useful. There will be a recording, I think as well. Um And feel free to reach out if you have any other questions. Ok. All right.