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Uh I'm on the Bonus School Committee and past year we're really pleased to have you here today. Um Our speaker tonight is Doctor Hannah Beckett, who is an S T six and clinical oncology. Uh working at University Hospital Southampton, she'll be covering the topic of breaking bad news, which is a really essential skill for speed and clinical practice. So I'm going to hand over now to Hannah and thank you very much. Great. Um Well, hi everyone. Um, welcome to this evening and thank you ever so much for having me speak. Um, so as Emma said, I'm a clinical oncology registrar. Um And I know these uh mind the bleak talks, but with bonus with a sort of um oncology theme with them. Um, and having looked at some of the other presentations that have been happening, they've been sort of slightly more concrete medical presentations. This is the, the more kind of wooly one, I suppose breaking bad news. Um, so I have tried to keep it as general as possible, um, lighthearted as possible because it's quite a heavy subject. Um, but to also give you some personal experiences in with it as well. Um which I hope will be interesting. Um I've said to Emma before, I'm really happy for people to interrupt, but I know it's a bit difficult on this platform um And won't run as well for those watching this on youtube later on. So please do feel free to put something in the chat and Emma can let me know if you really want to, to speak halfway through, but otherwise there'll be plenty of opportunities for questions and comments and experiences and whatever else you want to talk about after. Um So I will get started. I hope my slides are moving on for you. Um I've put a couple of objectives at the beginning. So, um I hope that by the end of this, I will help you to understand why the technique around breaking bad news is so important to consider. Um I know when you're in medical school and a junior doctor, it's, it's can feel a bit tedious doing the kind of calm skill stations. Um But when you actually start working, you know, you'll see how relevant it is, but also to appreciate a few different models that have been developed to help clinicians preparing to break bad news, understand the various contexts that might affect how we break bad news. And then also just at the end to consider yourself in the picture as well. Um And we'll go into why that's important. So this is the best sort of definition of what I could find for what breaking bad news is. And lots of people, if you read papers and you search on pub med for any kind of publications around how to break bad news will quote this at the beginning as well. And I quite like it. Um, it's that any news that drastically and negatively alters the patient's view of the future. Um, and I think that really nicely kind of puts into context that the patient is the key person here and it's their feelings, um and their views and they're kind of thoughts that are going to be affected. And it also just highlights how any news could in theory be bad news. It's completely down to the patient's perception and how that then changes their view of things. Um So I guess I was sort of thinking to myself or what, what might be bad news in the context of medicine in general. And I think um on the kind of far right hand end of the scale are the more obvious things that you might think of. So news that you're nearing the end of life or a relative is nearing the end of life, a life limiting diagnosis, bad scam results and then kind of moving to the to the other thinner end of the scale on the left diagnosis of a chronic illness, withdrawal of drugs due to any reason. Um So in other words, saying that you can't have a treatment anymore because it's not working or the funding is gone but also negative test results. So we might not think of a negative test result as being particularly bad news. But I think if you think about within the context of a G P surgery where a patient might be experiencing some really bad symptoms and looking for the the underlying cause of it and every test keeps coming back as negative, negative, negative and you still are no closer to knowing the answer that can also feel like really bad news. So actually, um, what is one person's bad news is not the same bad news for somebody else and there's lots and lots of context um into whether or not someone might feel that they're being given bad news or not. Having said that I think it's, it's really reasonable to, um, to be able to predict what might be bad news and they're, I'll talk in a minute about kind of more obvious bad news deliveries and when you might feel like you need to prepare advance. Um, but I think the last slide is just to highlight, actually, you quickly can sometimes be caught out and, um, the surprise when someone reacts in a certain way. So I guess because this is I'm an oncologist and this is an oncology themed webinar. What bad news that I deliver on a pretty regular basis. Well, it might not be in these words, but the probably the most common bad news that I have to break is that your cancer has grown. Um Also that your cancer is back. So recurring cancer relaxing cancer is often down to us to deliver that news news that I don't have any more treatment options for you. So that might be because a patient has had really significant toxicity or has become really poorly and we just can't safely give them treatment anymore or it might be that they're kind of third line, fourth line, fifth line uh into their treatment. And there just isn't anything else that we, that we could give that would offer them any kind of benefit. Uh We can't cure you is a really common thing that we often have to deliver. I think especially as clinical oncologists um that medical oncologists as well. Um because patient's often come to us with not all of their staging complete and it might be that they are assuming that they may be able to go down a curative pathway. But actually, we've had some extra scans that show that there's a small metastases somewhere. That means that that actually the treatment uh intent has shifted from a radical treatment to a non radical treatment. Um We can't continue your treatment anymore, sort of similar to what we've already talked about. And then I'm sorry, this is cancer. So, delivering a new diagnosis of cancer, you think maybe isn't in the remit of oncologists. But actually, we do occasionally see, patient's that have either just not had that news delivered to them for some reason or who have got what looks like a cancer of unknown primary. And we're helping to investigate it and we do end up giving them the final diagnosis and we sometimes find second cancers when we do things like pet scans as part of our staging because you can get unexpected findings that you know, whilst investigating something else. So why is it even important to think about how we break bad news and why, why are we even having this talk? Um So I guess in this day and age, we all have a duty to be honest with patient's and give them all the information. Um So there, there was a time, you know, within the last 30 or 40 years where actually it was sort of the clinicians responsibility to um to come up with the treatments and maybe hide information from patient's. Obviously, that's not what we accept is the kind of standard thing to do now. So we have to break bad news to patient's. There is no other way about it. Um And we naturally might worry about a person's ability to deal with the news and want to sort of feel like we have to protect them by downplaying the bad news. And I think it's really easy to fall into that trap um of starting to go in with the intention of telling someone some bad news and actually then sort of backtrack a little bit and try and try and be more optimistic than you need to be. So, I think part of the skills of, of learning how to break bad news well, is to be able to deliver it. Um, and to be really clear and not to give some or false hope while also trying to control your, your desire to want to protect them. Um, and not upset them. Also bad news will cause cognitive behavioral and emotional defects to the recipients. So I think that's obvious really any bad news that that person is, is being given or their family um is going to have a huge emotional impact on them in ways that we might not really be able to predict for everyone. And that kind of consultation is often a really key moment between the doctor and the patient. So um if it's something that's right near the beginning, the quality of that communication can actually permanently affect the patient doctor relationship either positively if you do it really, really well. Um And you've got a really good level of empathy and trust and it may be the thing that actually determines the rest of their whole of their treatment pathway. Um but also negatively if you start off on a really bad fit with the patient as well. Um But also the quality of the communication then um which is going to affect how they react and respond, um, behave so then can affect their compliance with treatments and also how they've sort of psychologically adjusted to their diagnosis. So it's really important to get it. Right. Right. At the beginning, if you can, it's really challenging in clinic because the person receiving the bad news will expect to receive more information than just a standard clinic appointment where they're being assessed for chemotherapy or coming to have their BP checked. Um They're going to expect more information from you more time. Um and um a longer appointment times. And so you also have to be able to kind of deal with, with moving the conversation on and coming to a conclusion of making a plan. And I think we all know that some people may be more natural communicators than others and that we all have different life experiences as the doctor. So there's sort of two people in this consultation isn't there, there's the patient and the news that they are being given and then obviously the doctor us on the other side of it. Um And because you're all here, you're all attending webinar related to oncology and breaking bad news. It may be that you guys are all in that sort of section of slightly more natural communicators and that's why you're drawn to something like this, but not everyone is, lots of people will go into their, their subject um like oncology because of its medicine. And um you know, chances to do trials and things and actually no in themselves, that communication and breaking bad news is something that they just have to wear that little bit harder at um and ask for support from others. And also we all have different life experiences. So somebody who has got a relative with pancreatic cancer, who has been sat in that chair, maybe even themselves is going to have a completely different reaction response and experience. Um, if they then have to deliver that news to somebody else than someone who hasn't had that personal life experience. Um So, um I also came across this survey by Bale, who I mentioned again in a minute, which suggested that 60% of oncologists break bad news to patient's 5 to 20 times a month. Um And I guess I just like everyone just to think for a minute how often that is and what else you do kind of 5 to 20 times a month. Um You know, that's almost every day. Um And you've got weekends factored into that as well. Um And 14% of those delivered values more than 20 times per month. So it's an awful lot. It's a huge burden of our job as oncologists, but also as any doctor really. Um And this is an old survey, I think it was something like 2000 or 2010. Um But I would say based on my own personal experience that probably still rings true today if not, maybe even more. Um And I guess the other key thing is that communication can be improved through experience, interactions and training. So whether that's attending stuff like this, whether it's engaging in your rainy learning or whether it's just getting stuck in on the job, whether they're pleasant experiences or not, um your communication will improve. Um So I thought a good place to start would be just to look at some models that I came across for breaking bad news because I think they're quite a good starting point just for reflection, for discussion, but also on the job for beginning difficult discussion's as well and they're quite good for structuring reflective practice. So, um I'm not sure whether everyone here is a medical student or junior doctor, but either way, I'm sure you'll have already come across reflective practice and how important it is now in um in putting into our portfolios and getting onto paper as well. Um But I think a bad news conversation or bad news break is a really good uh reflective practice discussion point, put you onto your portfolio and actually using these sorts of pneumonic, some models is quite a good way than to reflect on it as well. Um And also I think these models might be able to inspire confidence when you're faced with new and challenging consultations. So the further into your training, the more experienced and comfortable you are with breaking bad news, the less you're going to need to refer back to one of these. But I think especially at the beginning, I thought they were quite helpful. So, um I wasn't ever talked about spikes in medical school. Um But you guys may have heard of it. It looks like it was sort of came about in 2010. Um And it's a Pneumonic for defining a structured plan and it was designed for oncology, interactions, um specifically difficult interactions, but it's very much translatable across any bad news conversation. Um And then I came across another one called Peter, which is another Pneumonic, which also is for defining a framework to communicate bad news. Um And it was originally developed apparently as a tool for school counselors. But again, I actually think I prefer it to spikes as a as a really handy kind of Pneumonic. Um And I thought I moved to slide around, so I hope it doesn't seem sort of out of sync just while I was on the topic of this before I go into those models in more detail. Um I thought I would just pop up this link at the bottom which I can, I can um send out or put on the bottom of the youtube, um which is a Liquid E learning for healthcare, which I'm sure everyone is familiar whether if you're not, when you start working, you will be because we often trust, use it for induction. But it's also got a huge range of modules on it across lots of different topics. And there is one on there for breaking bad news. It's in the kind of palliative care section. And I just really, I worked through it while I was preparing for this. And I just thought this was a really good um uh summary as to why professionals might find it difficult to answer challenging questions and during breaking bad news conversations. Um so it might be a lack of confidence on how to approach the situation and therefore avoidance of it, facing the emotional challenge of breaking bad news and dealing with its darkness and finality. Um It might spark difficult emotions by similarities between that scenario and past experiences. As I've already touched on sense of treatment, failure, not wanting to let the patient down, being unsure of the prognosis and therefore not wanting to give inaccurate information. And I'll touch on that again later. Um That questions often come out of the blue. So there isn't actually any time to prepare an effective answer. Uh time pressures which make effective communication difficult a sense that the question would be answered better by somebody else. And that's a really um significant thing that I've struggled with certainly um coming through my training um of that kind of imposter syndrome. Um and also a belief that there's a right answer, which means professionals can be terrified of getting things wrong. So, um back to these models, so spikes and Pewter that are both know Monix, as I said, um spikes uh stands for setting perception, invitation and, and information, knowledge, empathy and then strategy and summary. And so what they're getting at is that you would work through these in kind of in the order that the pneumonic is. So, um setting means you should find a physical area for the news to be delivered and that ideally would be acquired to secluded area perception. Um So that means you should try to determine the patient's understanding of their disease and the consultation they've walked into before proceeding with the consultation itself. And I guess that might be with direct questioning saying, you know, do you know why you're here today? Um or it might just be by observing their behavior. Um I stands for invitation and information. So you're trying to determine how much information would be helpful and to what extent they want to know about the bad news. And again, that might be some direct questioning. So saying to them, um do you, do you know how much information do you want me to give you? Do you want me to go through the whole scan? What would you, you know, how would you like me to tell you? And I think that is quite difficult to be honest, um knowledge which is when they actually deliver the news and the spikes models suggest that you should probably do that in small segments and speak slowly. To allow them time to process um and also to avoid medical jargon. E stands for empathy. So acknowledge the patient's emotions and their reactions. Um And you might do that by saying to them, I can see that you're, that this is really shocking news for you. Um I can see that, that you're upset and you're taking a while to process that. Shall we pause for a minute? Um And the s then is about strategy and summary. So it's going back over what's been discussed with opportunities for repetition and then discuss the ongoing management plan and treatment options at the end. And then puter um stands for prepare, evaluate warning, telling emotional response and then regrouping preparation and prepare this time means knowing what information needs to be shared, how best to explain it and then arranging the setting appropriately as well. So it's both physical preparation but also um I guess sort of knowledge, preparation yourself e for evaluate. So assess what the patient already knows or suspects as well as what kind of emotional state they're in how they're feeling, whether they're in a good position and ready to receive the news or not. W is warning. So this is kind of your classic firing a warning shot. Um Just before you're about to break the bad news, so indicate there's bad news coming and then pause for them to process that t for telling, this is kind of the equivalent to knowledge in spikes, which is actually delivering the news in a straightforward manner. And computer kind of model suggests that you give small pieces of information again at a time, but also maximum of three bits of information at a time for your pausing e for emotional response, which again is is similar to empathy. So just assessing their response, but also them reacting to it appropriately and then regrouping preparation involves an interactive conversation perhaps between a nurse and a patient afterwards and, and discusses their hopes for the future. So it's about kind of trying together with the patient to identify and work towards new goals. Um And we're really into kind of shared decision making at the moment. It's been a really big topic of conversation, particularly in South Hampton. We've had a lot of um talks on it from our kind of senior registrars and um consultants. Um And I guess that regrouping preparation includes shared decision making, so telling, giving the patient options, um and your opinion, but then taking on board, what, what is important for them. And so I was reflecting on what, how good I thought both of those were. And I think actually I my kind of the way that I would, would give bad news and deal with this and the way that I would um use those models, I think would be to do a mix of the two. Um So my pneumonic isn't great puckish. Um But I think I would want to mix a couple of them in together um and get rid of a few of them. So I'm going to go through each of these separately and give some more detail about each, each section. Um and then in the next few sides. So firstly prepare, what do we really mean by that? I think my advice would be um that knowledge is your best friend and there will be some of you out there who can kind of wing it and look confident with, with less background knowledge and be um not in a negative way, but just be able to act a little bit more sort of ad hoc. Um But I think for me, I've worked out that actually knowledge is um you know, pre knowledge is the way that I feel most confident going into consultations and bad news breaks. So I would always go through their previous letters. You might want to discuss some of the imaging if you're giving scam results with radiologists or make sure that they've been discussed at an MD tea and check what's been said there do a bit of research. If you're going to be telling someone something on a ward that you just don't know anything about, then have a read around about it. Often. Um computer systems and hospitals will have access to something like up to date and you can go on there and read a bit about it so that, you know, roughly what they might ask and what, what treatments might be available, um, or speak to a friendly oncologist or a palliative care person, nurse doctor, um, or your seniors. Um, so that you're kind of armed with what, you know, what their advice would be before you go and give someone some bad news. Um, and then try and appear confident in what you're explaining. I know that's really difficult and it's easier said than done. But I think um you know, being confident in yourself. Um and, and having that background knowledge in order to be confident is really important because if you look nervous, then it's not going to instill confidence into, into the patient or their family. And like I said, I think then you can be able to predict what questions they might ask you as well. Um Plan the consultation. Well, so I would always recommend picking a time where you can either hand over your bleep or where, you know, it's going to be a little bit quieter if it's down to you as a junior to break bad news in award, for example, but we also still have bleeps as registrars. So, um I lots of times have been midway through conversations and have just had to take the battery out of a bleep. Um Obviously not if it's a crash bleep or an emergency bleep. Um But you can often find someone else, you can just cover you whilst you just give that time to um you know, a significant consultation, definitely find a quiet space so that on all wards, there are always relatives room, relative rooms, always quiet rooms that you might be able to, to, to go to. Um, and if not, then and you're having to do it at the bedside, make sure you're pulling the curtains around, um and just giving them that privacy in that space. And then I would always invite a family member to join as well. So in our oncology clinic appointments, if we know there's going to be a bad news break or this is a new appointment, we always tell people to bring a family member or friend or someone with them both a support because people just don't know how you're gonna react. But also there's that classic thing where that we're always told where you, you tell someone something bad and then somebody just switches off and never hears anything else. You know, in the whole consultation, I can't remember anything else from it other than the fact that they have cancer. Um So it's really important to get somebody else who's going to be, then leaving with them and going home with them to also be there to make notes and to write things down and just be an extra pair of ears. Um And then we often also let them know that they might have some important information being discussed. They often already know that in oncology clinics because they've had a scan, they're anticipating what it might show and they know that they're coming for the result. Um, but if you're on a ward and you're having to arrange a meeting like this and you can call someone's family and just say we're going to give them the scan results. Do you want to come in? What kind of time, um, bring tissues, water, bring a friend if you like. So another friendly junior doctor or S H O and then also just position the room appropriately. So, um I would always take a chair with me to the bedside. Um But if you're in a relative room or something, then just, just have a little conscious, think about where you're going to put the patient and where they're going to sit. Um so that you can be kind of facing them so that you are uh somewhere where you can have sort of open um uh body posture. Um and where you've also just got space, so you're not all cramped in. Um And then as I've already said, I think just ask for help. So if you don't know, just ask other clinicians for the most up to date information and if I'm worried about something or I don't understand something in clinic, I would, I wouldn't think twice about going to check with my consultant and just talk it through. Um And then I would always take a second person with me anyway. So just try not to do bad news breaks alone if possible. So there is always award nous or an HCA someone around that can come with you because it's just, it's just that little bit of support for you as the doctor anyway. Um But also if you have to rush off for any reason, um or you know, you're, you're really struggling with being able to answer questions and you just need someone to just deflect things for a moment. Um Then it's really, really helpful to have somebody else with you. And if that's someone that is experienced it, this like a specialist nurse from that cancer site, um or, you know, a palliative care specialist nurse that's coming with you. Um Then that's obviously even better if they've already got experience of doing a bit of sitting in good bad news breaks. So secondly, e I'm sorry, this is say wordy. Um I hope everyone's following um evaluate. So I guess at the beginning when they first come in, I would, I would say introductions are really important. So let them know who you are and who the others are. But also I would always give them a bit of a context over how you know, their history and their results because if you're meeting someone for the first time and you're giving them some life changing information, um I think it's, it's only fair to explain who you are um in that kind of context. So for example, I'm, you know, doctor, doctor. So and so's registrar, I've seen all your clinic letters, I'm working with him at the moment and we've been looking at your scan results. I hope it's okay for me to talk through it with you. And then I'll be able to, to tell you, uh, our management plan after that. Um, and I think you'll find often if you've got a specialist nurse with you in an oncology clinic, then they'll often have made contact with the patient in advance to introduce themselves. And that can also be quite helpful then that there's a kind of familiar voice, at least in the room that you can then, um, introduce them to. But if you're on the ward and you're having to deliver some, some new bad news, you can also explain that you're, um, one of the ward doctors, um, that you're under the care of this particular consultant who will try to see them at some point, but you're working with them and that you have had a look at their, their results and you've got the information that you and you're willing to give it to them. Um, I guess, read the room. Um, so there, there have been lots of times in the past where I've gone to try and give some bad news to someone either in clinic or on a ward and they've been loads of those of family members there or, you know, friends that have just pop down from the village next door. We're already in hospital visiting them. So I guess always check who's there and who they want to be there. But also I would always suggest that they gave you a bit of space. So I think generally having more than three or four extra people can be really overwhelming for that patient when they were receiving the bad news, but they might not realize it. They might just say, oh, it's fine, you know, all my six grandchildren, you know, whatever, whatever. I know, I'm happy for them to know as well. But actually when you, when you deliver the bad news and you really get into it, it can feel a bit overwhelming when you've got lots and lots and lots of people having their own reactions looking at the patient looking at you. Um So I think it's, it's fair enough to say we can all have a discussion afterwards, but maybe it's best if you just have one or, you know, pick one or two people with you whilst we're just actually talking through this. Um And that also leaves you in control as well because if you've got questions coming from all different angles, then it can, it's really easy for them to kind of escalate into um uh you know, an out of control consultation and you want to try and keep these as controlled as possible. Um And then assess their emotional state. So do they need time to calm down first? Just with some, some comments? Um, you know, it's, it's not uncommon for people to arrive at these sorts of consultations already really head up in anticipation of what's happening. So it's fine to, to, to read that and then to say, you know, we can appreciate this has been really overwhelming. You must be feeling really apprehensive, you must be, this must be really scary. Do you just need a moment to pop out and get some water? Can we get anything else for you? Um uh etcetera, etcetera. Um And I think also, um, you know, if they, if they come in and they're really, you know, not at all expecting bad news and they're really upbeat and joyful then giving them that bad news then might be a real huge blow and a real sort of change of, of dynamic. And so I think if someone comes in and they're not expecting their scan to have been bad or, or, you know, just have no idea, then I would maybe just move on quickly to the warning shot. Um So, you know, just explaining actually, I'm really sorry, but we do have some, some bad news today and then you might need to actually take a step back and go back through some of these steps afterwards. But I think kind of bringing them down to the level of, of the appropriate level of the consultation is also okay to do there as well. It's just reading what their emotional state is at the beginning. Um, so already having, you know, done all of that and prepared everything, what barriers might have already encounter before you even got onto the subject of, of what you're trying to tell them. So, I guess the for you guys as more junior doctors, um, uh, a noisy award setting with no support is sort of the classic heart sink when you have to deliver bad news to someone, particularly if that's sometimes out of hours and that's never a good, really good idea. But you will get um, family members desperate for scam results or who are only there at the weekend and just need to know, you know, neat. That's the only time they can be there. Um, and with lots of interruptions as well, like your bleed, going off or an arrest be going off or something else happening on the ward. Um So trying to think back as to what I used to do and what advice I could give you now as a, as someone who's been through all of that and, um, have experienced a bit more. Um, I guess just try and think about controlling what you can. So if you have to break bad news to someone in award, bring a chair, pull it up next to them, pull the curtains around, offer some empathic comments and acknowledge their frustration. So you can say I really appreciate this isn't an ideal situation. You know, it's a, it's a shame that we have to do this while we're in a hospital. But, um, and I'm sorry, I wasn't able to find any of the oncologist to come and see you, but I can tell you the scan results, I just won't be able to give you all the information. Is that okay? Um, and you can always apologize that that isn't the ideal set up. Um, but explain that you just felt it was more important they were updated and then if you do need to leave halfway through, I think, just find an appropriate time. So if you can just, you know, finish the topic that you're on and then find a point that seems appropriate for a pause, you can then say I'm really ever so sorry, I've had a really important call. Is it okay if I step out and answer it and then I will, I will come back afterwards and I've never had anyone say no. Um, and I guess just be honest as well. So lots and lots of the kind of breaking bad news studies and things that I was reading. Um, the top thing that people like is honesty. Um So if you don't know something, it's, it's obvious to say it, but just explain that you're not the expert, you know, this isn't got good news, but you will try and find someone who may know the answers as soon as possible. Um, and people will appreciate that and then also don't be afraid to organize an appropriate meeting time later on or tomorrow. If it is really 8 30 in the evening, you don't know the patient, you've never met them. They've got really bad news on this scan. Um, you've got the patient and the relatives kicking off that they haven't had the result. Just don't be afraid to say. Actually, this is not, this is not an appropriate situation for me to be giving the news if it can wait until, if it can't wait until the morning. Obviously, that's a matter. Um, but if it can wait until the morning, when you can be more prepared, there's, you have more answers and there's more of a team around, then don't be afraid to, to explain that to the patient and then to maybe just organize a meeting time the next day. Um, and then follow that up. Um What about angry relatives or preconceived faults in the system? So I think particularly the moment we're getting lots and lots of people coming to us with diagnoses of cancer having been to the GP loads that we're having called their GP lots and lots and lots and haven't been able to get, uh, appointments. Um, and so they're already perhaps coming to you with frustrations in the system with, you know, uh, true or false impression that their cancer might have been picked up earlier if X Y and Zed. Um and I guess I would say just allow them to vent their frustrations first. It might be that you just have to spend the first five or 10 minutes sitting listening, nodding, giving them the space and the time to tell their story. Um And you will then end up just getting a bit of a bit of a feel for, for them as well. Um And a bit about their journey and how they've got to where they are. If you feel that the consultation is getting out of hand, um then I often just try to reel it back in and regain control. I think it's okay to just calmly interrupt someone, then explain why you're interrupting. And just to say, actually, um you know, I, I completely appreciate that, that, you know, your frustrations that we're going, you know, we're getting down a little um uh side road here and is it okay if we just go back to, you know, we can absolutely discuss that again in the future, but shall we just get back to the news today? Um And so try and just turn the conversation around to moving forwards and then you can also offer, offer patient's or where it is a choice. So if they'd like a bit of time to regroup, if even after they've had a bit of a warning shot, things have just spiraled and escalated with frustrations. Um It's fine just to say, actually, should we just all just calm down for a minute, take five minutes, go out and get a cup of tea and then meet back again in half an hour. Um And then often people, I think in my experience just want some acknowledgement over what's happened and then other things that maybe aren't in your control. So language barriers, cultural differences, I would say, always try your best to arrange translators even on the ward. So we always have a phone service that you can use. And the wards will normally have a portable phone that you can take to the bedside. Um It's not always ideal to use family members to translate. Um But if you have to, then you can often get a bit of a sense as to whether they are translating or not. Um And it might mean that you just have a conversation with, with the relative beforehand just to say I'd really appreciate if you try to say a word for word. Um And I think if in some cultures still, it may be expected that the family or the people that are informed about bad news and it's then down to them as to whether they will not, they inform their relatives for the patient. There'll be circumstances where that's entirely appropriate. For example, on, uh you know, elderly care wards where someone maybe has got the severe dementia. Um But I think otherwise I would say just try and stick to your own practice. And we know that, you know, in, in our UK hospitals, that it is our duty to inform the patient and to check with the patient, whether they want their family to be informed or want them to be there. Um, and I think you just have to stick to your guns and if it's, if you're being put in a situation that makes you feel uncomfortable, then I would discuss it with someone senior. And then the other thing that I come across quite commonly is that some, I will have done all of those steps. So um doing my preparation, um inviting them in introducing myself and then some people will just come out with questions immediately, um just asking for the results and then a period to kind of take over and lead the conversation. And I think for most people that's probably just a combination of nerves may be a bit of personality as well. Um What I try to do is just to acknowledge, acknowledge that. Um and then just not prolong the first part of the consultation. There have been times when I've tried to say I got on the back foot and sort of said, hang on a minute. Um Let me just introduce myself first. Um And that that can be okay if I think you handle it in the right way. Um But I think also you just risk annoying people. Um And particularly sort of further on down the line. Um, you know, when people have had lots of different bad news breaks, they, sometimes they do just want to come in and know the results and that might just be the way that they're dealing with it is to just, you know, straight away and then you can backtrack afterwards. So, um, I think it's fine just not to prolong it, move on straight onto a warning shot and say, well, actually, really sorry, I'm afraid it isn't good news and it is possible then to backtrack so you can then go do it backwards instead and, and find out afterwards after you've given it to them, is that what you were expecting? Um, and, and work backwards and I think that's also fine. Um So next in the demonic then I invitation and information. Um I think this is probably, um, the, you know, one of the most difficult bits. Um, and I'm not sure that I always do this um, in every circumstance. So I think it's fine to try to gauge how much information would be helpful for them. Um, but I think that is difficult to ask that and to know where to fit that in. And it can sometimes I think confuse people, um, when, you know, they, they, there's more sort of answer, but I just want to know what the results are. Um So I think unless it's offered to you and they specifically say, you know, don't, don't tell me, uh you know, all the details I just want to know has it, has it spread, you know, they might offer that up to you anyway or for example, say we just want to know how long we've got. Um uh uh but I think it might be helpful in knowing what they might actually here. So, um if, you know, if, if they've hinted to you that actually they just want to know a prognosis, um then actually, it might be irrelevant as to what you, what else you say that might be the only bit that there sort of gonna clutch onto. Um And then I think in invitation and information might be more relevant in a hospital setting or when results have come back unexpectedly. So for example, do you know, do you want to know your scam results um today might be more relevant because they've not come in specifically to see you if they're already in hospital. And I think your facial expressions can tell them a lot at that point as well. If you ask them that question and look sort of really, really glum, then actually if they don't say no, I don't want to know the scan results yet, you've kind of already hinted to them what the result is. So I guess just be careful and try and be a bit matter of fact. And then w warning shot, I think for me, this is probably the most impactful part of the consultation. And I think that's probably one you would have been taught at medical school to give a warning shot, but it's really, really, really powerful part of a consultation just saying, actually I'm afraid it's not good news and people often then know what the result is anyway. Um, and I think pausing afterwards and allowing them to process it first is really important as well And to some extent that will depend on what the news is. If it's actually just that, you know, they've got a liver metastasis that we didn't know about. And you're planning to treat them radically and it's something like an anal cancer or colorectal cancer or actually, you might still be able to treat them radically, but it just means that they've got metastatic cancer and their prognosis is less um or it's gonna be more difficult, then you may want to then give them the news, but move on a little bit more quickly because you're going to be talking about something a bit more hopeful. Um And then give them the knowledge. So give them the bad news. I think it's fine to try and plan what you would want to say in advance. Um And just to practice it, especially early on, um you might want to start with the headline or you might want to explain the context first. So, um if you're just saying, I'm afraid it does show cancer, you might just want to lead with that. Um But if you want to say something like, well, we were looking to see if your cancer has spread and if there were any other areas before starting the treatment. Um, so that we knew what treatment to offer you. And actually, it has confirmed that unfortunately, it has spread to bit in the liver, then it's also fine to give it in the context of, of, of the news. And as I said, I think three pieces of information at a time sounds like plenty. Um use simple language. So you can always add in something medical if they request it later. But times that I've had consultations with medical people or doctors or nurses, I think they still appreciate you just assuming that they're not medical and just telling them um you know, uh normal language and then also try not to shy away from words like cancer. Um try and be clear about what it means. So, um we spend a lot of time saying that we do have treatments but it's not curable and trying to actually be clear about whether it's a palliative treatment or it's a, it's a, you know, a curable cancer and a curative treatment because people often will not understand the difference between that unless you really spell it out. Um And then as I said, I think pauses can be really, really powerful. So it often feels like something that's really, really awkward to do. Um And you might need to actually consciously make yourself stop talking to do it. Um But it's really important just to give the patient permission to have an emotional response and then to ask questions. And often that's the time that I've had the most from a patient is when you just stop talking and listen, I thought I put a quick slide in um about talking about prognosis because we're often asked about prognosis. And I think that's really often a feature of a bad news conversation. Um So, um and people will often say, I know you can't really tell me and I know that you can't really, you don't really know but and then ask you about prognosis anyway. So um people still want to know their prognosis even if they know that you can't really tell them. I think it's a very, very difficult thing to, to predict. Um And I personally would never give a solid number. Um I think sometimes even estimating in broad strokes can also be a challenge. Um So it's fine to use phrases like short, long weeks, long months, maybe short years. Uh Most patient's, most people with this may get this. Um someone live much longer, some may have less time. So there's a real, there's a real scale. Um And I often try and say phrases like I am asked this a lot actually. And the honest answer is that it's really difficult to predict just because it, then it then um sort of reminds the patient that um this is what you tell everyone and their not unique. We're not withholding information about them specifically. Um And I think things that can help in, in trying to talk about prognosis is knowledge of that illness again. So you might be able to use numbers from trials, but you'll need to then go into detail about explaining it's a median overall survival that the type of patient in the trial might be completely different. Um And you really get things like that from trials that are looking at adding in treatments or their effectiveness. So if we can use this treatment, we may get an improvement of two or three months. But I think nowadays we have to be really, really careful with using overall survival um from trials because especially things like immunotherapy, you either respond to it really or you don't. So it's not really a case of the individual person getting an extra six months or whatever, you know, as an individual, you might not respond and not get any benefit from it or you might respond and get a really long benefit from it. So I think it's even looking at trials is actually really difficult to then interpret in the patient in front of you. Um I think knowledge of the patient's current condition is really helpful. So if someone is really poorly, if they're in hospital if their performance status is, is poor, then, you know, automatically that actually the chance of them getting onto treatment is less and they're prognosis, maybe less their personal rate of decline. So we can often see if the cancer is behaving in a really rapid way. Um, and you may, you may get an inkling for that. For example, if you have a chat with prostate cancer, which is normally a much more indolent cancer, but actually the PS PSA is going up really dramatically and really quickly, that might help you to say, well, actually, normally and prostate cancer people have many years, but your cancer seems to be behaving much more rapidly than that. Um, no, a little bit maybe about opportunities for what disease modifying treatments they may have. Um, and then also, I think it's important to ask them why they want to know. So, um, it might be that actually they want to know whether to write it will, it might be that they want to know whether to cancel the holiday they've booked in a year's time. Um, and so actually, you may be able to give them some really important and helpful information if you think it's unlikely that they're going to make that, but you still can't give them an exact time. I'm going to speed up a bit because I'm aware I'm over talking. But moving on then to empathy and emotional response. So I think obvious things watching and listening are really important, um allows you to acknowledge their feelings and I'd say try not to share um in their distress. And I mentioned that a little bit later because that can actually be quite negative to the consultation. I think you have to be professional and lots of sort of observational studies have shown that actually share ing in their distress and getting upset or welling up can actually be negative to, to the relationship with them. Um So saying things like I appreciate this is a lot of very shocking information. Um And you might find that actually they're not able to take on any more information that day at that point. And if that's the case and they are just really heightened and upset, it's fine to then defer it to another appointment strategy and summary, then at the end. So I guess, be prepared to summarize lots of times you might need to keep repeating information as a consultation goes on, you might need to summarize and use different language. If it doesn't, the information just doesn't seem to have been absorbed or understood. Um And it's often a good time later on for nurses, if they're in the room, particularly specialist nurses with a lot of experience to interject and offer their observations as well because they might just have picked up on something that, you know, that the patient's not understood that you haven't picked up on. Um And then I guess for oncologists, particularly the strategy of it is often the meatiest kind of part of the consultation. Um It might be that we're having to change treatment strategies or we're coming up with, you know, some, some potential solutions or treatments and a plan going forward. And so we might then take up a lot of time discussing treatment options. Um And often, I think that's often perceived as the most important bit of the consultation as well. So it's nice to have a bit of a summary pause and then say right now, you might need to take some notes and we'll talk about, we'll talk about the treatment and of course, it will depend completely on the bad news that you're breaking. And then I wanted to add another point at the end that I thought was important and that is handover. So I think you should always let someone know what's happened at the end of breaking bad news to someone. And if you're on the ward, I would let someone know who's responsible for the patient. So the nurse looking after them, the sister in charge of the ward, don't just write it in the notes and then move on. I think it's really important for them to know the context of what a patient or a relative has just heard and why they might be looking upsetting at the bed type at the bedside. Um particularly if you've got to rush off. And I think in an outpatient clinic, you always write a detailed letter to the G P to talk about what you've discussed. Um, and then if I haven't got a specialist nurse with me, then I would always email them and let them know as well because they probably will need some sort of follow up support. Um, and some people, you know, will, will not want that and it's not appropriate for everyone. Um, but I think, you know, the majority of people will appreciate a phone call in the next few days from the specialist nurse or another visit the next day. And I think the reality is it's a clinician. You're almost never going to have enough time to offer them the support that they need. So those kind of oxylone re people are really, really important um and always try and offer some sort of ongoing support even if you're unable to offer treatment as a result of the bad news break. So another clinic appointment just to answer any more questions and checking on them or referral, almost a palliative care. And then I'll just really quickly go through a couple of examples. So um this is a 75 year old man who I saw recently on the elderly care ward. He was admitted, drawn distant, confused. He had an oropharyngeal cancer which was localized and had been treated with radical radiotherapy treatment six months before. And he had a difficult time of getting off N G feeding, which is not uncommon, having had treatment to your head and neck area, but it had fallen out at home recently. And it was, he therefore had, had a lot of weight loss because he's not been able to eat as well. And I think they thought his family thought that a lot of his sort of deterioration was down to that. So I saw him and examined him. He had a palpable mass in his tummy. He was confused and then reviewed his CT scan and he had diffuse metastatic liver disease. Um So this was, this was that he hadn't been informed of it. We have been called because we, we've been looking after him and there was no one else really around that could go and break that news to him, but we've been asked to review him. So, um I think thinking back on it and reflective on everything that I did, which will go through. Now, I did most of those steps actually without thinking about it. So I called his wife and arranged time to meet. I phoned our head and neck specialist nurse to come and join us as well as the war doctor who actually couldn't. Um So the two of us then regrouped, went through his scans and went to see him together when his wife had arrived later on. Um We arranged chairs around the bed, we introduced ourselves, um explained the context of things I was on call Oncology Registrar. Um But that I worked closely with his consultants. Um I summarized his symptoms and then re summarized why the CT had been booked. And that our concern was that this could be a recurrent cancer, then gave them the results. We offered them lots of empathy. We explained that actually, there was unlikely to be any treatment options for him because of his liver function, um and general um status and that we'd ask palliative care to come and help with his symptoms. We gave him a bit of hope at the end and his wife and that we were going to get the images reviewed with HPB to see if there were any interventions and R M D T um and then gave them time questions. I definitely missed a couple of bleeps during that which I think was okay in the context. And then just got back to the later I offered the specialist nurse to stay with them, handed over to the nurse looking after him and the ward doctor and then organized follow up by handing it over to my colleague who was on call the next day um to then go and review him with the results of what we discussed with HPB. And that was quite a good outcome, I think not for him, but for, for, in terms of it was a good bad news break and they were appreciative of it. And then the other example that she, I think was completely different was a 38 year old lady who I saw in Portsmouth actually last year who was originally from Ghana, she'd been admitted under oncology um with a known cancer, but she had gastric outflow obstruction and drawn dis. She had a background of colorectal cancer. She had recently had some really radical treatment to some brain metastases, which would therefore, you'd assume that her prognosis at that point had been quite good. Um And I saw her CT result on Sunday afternoon on an on call and it also showed widespread liver metastases causing had jaundice. So um this time, I called the on call interventional radiology and gastro team. He said that they didn't think there was an option for drainage, they were unlikely to be able to decompress it. So in other words, this is probably not going to, we're probably not going to be able to get her onto any chemotherapy. I went to see her. She was quite well. I asked if she wanted to know the scam results that evening. And she did, I asked if she wanted to call her mom in who she lived with, but she declined and didn't think that she'd want to come in at that point and that she'd rather find out the news without her. So I asked one of the nurses on the ward to join us in the quiet room on the ward and then had quite a lot of pushback actually from some of the nurses about whether I should be telling her about the weekend. Um, but I think it's ultimately, it's your responsibility with the patient to make that decision. Um I gave her some appropriate warning shots, explained why we've done the scan, what we were worried about and then explain the results and that unfortunately, we, we're probably not going to be able to give her any more chemotherapy. She was cleanly devastated and she did find it difficult to display emotions because of the brain metastases. Um And it we wasn't ideal because we didn't have any specialist nursing, support her relatives. But I think actually she was really grateful for being told the news because sometimes waiting around is, is harder. Um And she was appreciative, appreciative of the fact that actually we'd need to get a bit more information the next day before we could, we could get her seen by her own consultant. Yeah, I thought I'd mention really quickly about different attachment types of patient's, but I think it's probably outside of the remit of this talk. But there is a lot of research into how different kind of personalities and attachment types of patient's can influence consultations. I think the bottom point I've made is the important one. So as an oncologist particularly, you're likely to break bad news multiple times the same patient as their disease that stops responding, you move on to the next line, you get bad news again, etcetera, etcetera. So actually that will allow you time to build up a rapport with the patient. And that is the ideal situation is that you, you can then adapt to them knowing previously how they've responded and how they like to, to be given news. Um I wanted to do a quick mindfulness exercise at that point, but I think we've probably run out of time but I think um some good techniques just fit in clinic. If you then giving a bad news break and acknowledging that actually, you're in, you're finding it difficult yourself. Um So a really good one is just a 478 technique. So that's breathing in for four through your nose, holding your breath for seven seconds and then breathing out for eight seconds. And you can do that during a pause just to sort of uh take a bit of time and get a control over your own emotions. If you're finding it difficult, you can also use the time when you may examine the patient, go and wash your hands just to look at the wall, look at the mirror and then breathe in a rectangular manner. So breathe in across the long rectangular side, out across the short rectangle in across the long wrecked long rectangular side and just focus on that. And there are lots of other mindfulness exercises. But things you can also do in a clinic room, for example, or if you just step out of the room for a minute is five senses exercise. And I think, you know, preparing yourself for these as well, make sure that you're well fed and you've had a drink, make sure you've had a break before. I've already talked about preparing a position in the room, asked for other people's help and then try and use those mindfulness techniques if you do feel you're struggling. Um And I'm really interested in compassion, fatigue and self awareness, but I think it's just really important just to raise it at the end of a talk like this. Um And that actually, I really like that quote, that we only have a finite reserve of empathy and like a candle, we can run low and burn out. I think, you know, you need to learn how to find just the right amount of empathy. Try not to over share your emotions with, with a patient. As I said, personal distress can sometimes be negative. Um and also developing compassion fatigue can result in avoidance of similar experiences in the future. So if you find something like this really, really tough, then it's okay to take some time. Um try and reflect, as I said, either with friends, colleagues or even better writing it down in your portfolio. And that might help you to process why you're affected that way, how you can manage it in the future, particularly if something went wrong, which will happen. Lots and lots of times um or if you just something hit you and you just find it really difficult and there are lots of groups now around in hospitals that will help with that like balance groups or shorts rounds. So I think in summary, um breaking bad news will be a factor in all our jobs. There are models you can use to help give you a bit of confidence in what you're doing. Um We can probably acknowledge what challenges might pop up in advance and make a plan on how to deal with them. But always, and then really, really importantly, just consider your own mental health and how you're going to deal with, with having to deliver bad news during your career. Um And that's, that's all. Thank you very much. Thank you very much, Doctor Beckett. That's really brilliant overview. I think it's a really difficult topic that we don't necessarily get much teaching on either at university or as a foundation doctrine beyond. So I've definitely learned a great deal. I'm sure lots of other people have as well. Um If anyone has any questions or comments at all, um please post them in the chat. There is one. Um I don't know if you can see it essentially share. Uh You're, you're okay, I can read it out. So the question is if someone does not want to know the result, what do you do? Um Do you just not tell them and that are there any times when not telling them will create other problems. That's a really, really good question. Um And I did have another example in mind of something similar um that I was going to mention and forgot actually. So thanks for reminding me, I guess recently I had a lady in her forties who had been diagnosed with cervical cancer and came to clinic with, with her husband. Um and she specifically said she didn't want to be told anything about it. She just wanted her husband to, to know she was happy to sign the forms, but she just wanted to get on with treatment. And she was, she was a really anxious person, I would say. But also she had a really young daughter who was only four or five. And I think, um you know, the, the thought of having, you know, an advanced cancer was just too much for her to have process because these sorts of diagnoses happen really quickly. Um And you're seen in clinic really quickly. So there's often not much time between them having the initial news and they're seeing you. Um But she needed to be consented for, for, you know, radical treatment which involved radiotherapy, chemotherapy, um breaky therapy, which is a really invasive form of radiotherapy. Um And so we've got to, we've got to talk through all of that with them and we've got to explain why we're doing it and consent them properly. So, in that kind of circumstance, I guess that could cause problems if they didn't want, specifically, didn't want to know because you, it's down to us to get informed consent. Um, and, you know, not having that just would mean that we wouldn't be able to do the treatment. So I had to spend quite a lot of time with her and with our specialist nurses exploring that a little bit more and then trying to give her information enough information, but um not lots and lots of information in the way that some people might want to. But I think in terms of other circumstances, if there's um you know, a patient on the ward who's really, really poorly and just doesn't want to know the results of the scan. It is always their prerogative not to know. Um And that's okay. Um And I think if, if a relative wants to know then and if they're particularly there isn't anything you're gonna be able to do for them other than keeping them comfortable, um then people might not want to know all the details or what exactly is wrong with them. But I think if a relative wants to know, then you have to, you have to make sure with the patient that they're happy for you to share that information, I hate that answers the question. Sort of, that's great. Thank you. Um I, if you haven't done so already, please, could you fill out the feedback form which the link floor is in the chat. Um, just quickly, our next session will be on the fourth of July on hemato oncology malignancies. Um, and appears to link in the chat. We do have a couple more questions, but I am gorgeous of time. Um, you happy to take a few more or we can. Absolutely. Yeah, absolutely. If everyone else is okay. So one of them is how would you manage if a crash Cool, essentially occurs whilst you're having essentially breaking bad news, how would you manage that? I think the ideal thing would be that if you're on call that day, you're not, you're not necessarily the person that has to do the bad news break. But also I think if you, if you do then, um, I think that's one of the reasons why it would be important to take someone with you. So, if you can then leave a specialist nurse or award nurse with the patient while you just, um, run off and run back, at least they're left with someone who will have some medical knowledge and would have been there to hear what was being said. Um, so I guess that's one reason why that's, that's always a good idea as well. Um, but otherwise, you know, you have to go, you have to go to the arrest. Cool. Um, so I think most people would hear that emergency bleak going off and, and, you know, you would just have to say I'm I'm so sorry I will come back. Um This is an emergency but also definitely just tell, tell the patient and their relative before um you start the talk with them as well. Um And just explain at the beginning, I'm I just tell, you know, I, I am on call today and I've got an emergency bleep. So if it goes off, I will have to run off. I hope that's okay. And you understand, that's probably what I would do. Perfect. Thank you. And just one final question, if we can, do you have any suggestions for counseling, patient's who may become upset or, and graph you've delivered the news. Um I think, I think there's probably some general things that you could do. Um But apart, I think it's, I think in a way it would be maybe unusual or rare to get people who react completely unexpectedly. I think that's maybe why a lot of the kind of lead up to actually giving the information is important because um the time that you're kind of buying by, you know, flicking around the subject, it might seem at the beginning, introducing yourself, talking about what they already know is partly for you to get a general feel for what kind of person they are and how they are um reacting to you speaking anyway. Um So I think probably you can try and avoid those unexpected um extreme reactions by the kind of preparation beforehand. Um but absolutely, there will be circumstances where you are faced with that all of a sudden. Um, and I think, um, I think a sort of anger is, is just often a person's way of, of, um not being able to, to control the extreme kind of anguish that they're feeling. Um, so probably just giving that, you know, standing back, giving them a bit of space and time agreeing with them. Um, and, and, you know, looking to your, to your colleague who's in the room, hopefully with you as well. Um And just kind of taking their lead, I think if it gets into a kind of really confrontational situation, that's, that's obviously different and you can, you can definitely just step away for a while and say I'm just going to leave and give you a bit of a bit of space. Um But I think there's been lots of times where people have burst into tears have been uncontrollable. I've also had, I think lots of my colleagues would have had the same experience of the patient who is fine, it seems okay but seems really upset and then comes over all white and suddenly sick or faints and you have to get them onto the couch and they just have an extreme kind of anxiety or um autonomic reaction. Um And that's, that's just that you just have to be understanding, I think and give them the time afterwards and just accept that you're gonna overrun your clinic. Um And it might be that actually your specialist nurse or a nursing clinic takes them off for a while into a different room. Um, and then just talks through and explores a lot of their feelings and emotions or as a junior doctor, you might be tasked with doing that as well. Um, while you just move on with something else and then come back to it later. And there have been lots of times when actually you said they're just not in a good enough emotional state to process treatment, discussion's and things now or consent for anything. So you just book them in again for a week's time. Um And that's okay to do as well. Thank you so much, I think. Um I think that probably closes our session quite nicely. Um Thank you everyone for all of your questions and for attending and thank you again, Doctor Beckett for your brilliant webinar. Um As I say, the next session will be in a few weeks time. Um And I'm supposed to the link for registration, but thank you all very much and I hope you enjoy your last year evening. Thank you. Bye. Ok.