In this day of selivering bad news, I thought that this article that I saved from last year would be a great refresher. Food is food regardless of the source.
The Rules for Delivering Bad News to Patients
August 27, 2019
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I've talked to some colleagues recently who've been a little down about their roles as nurse practitioners. Working in family practice, they have found themselves in the position of delivering bad or upsetting news to their patients. Cancer diagnoses were fortunately made rather than missed, but letting a patient know they've got a serious, life-altering illness or condition is tough, not to mention, this is not something most of us as NPs learn to do in school.
Have you ever found yourself in the position of delivering difficult news to patients? How did you feel? Having such conversations as nurse practitioners can make us anxious or awkward. Some of us approach these discussions emotionally while others appear detached and robotic in their delivery of the news. Delivering bad news is an unavoidable part of our jobs as nurse practitioners but that doesn't mean we get used to it. Fortunately, however, conducting serious conversations is a skill that can be learned and there are many guidelines out there to help healthcare providers hone this skill set.
Rule #1: Know what constitutes bad news
Sometimes I share information with a patient that I perceive as not a big deal. Then, the patient starts to freak out. Or cry. Or to have some other sort of emotional reaction that I didn't anticipate. Bad news doesn't have to be a terminal diagnosis. It can be related to anything surrounding a diagnosis such as timing, personal or professional consequences. Breaking a metatarsal and wearing a boot, for example, may not be too bad in the grand scheme of things, but breaking your foot the day before your wedding is pretty disappointing.
Rule #2: Full disclosure is best
In the past, healthcare providers operated on a more guarded front. In the 1800's, for example, the American Medical Association even encouraged physicians to avoid sharing news that discouraged patients. Today, however, studies (not to mention ethics!) show that most patients prefer full disclosure. It's our duty as nurse practitioners to share up-front, honest information rather than sugar coat our delivery with excessive optimism, withhold details, or give false hope. Share news with the patient directly rather than directing it toward family members. Honest, trustworthy information is empowering!
Rule #3: Prepare yourself
Anticipate the conversation you're about to have with your patient. You may even wish to practice your delivery with a colleague. Prepare yourself to feely badly as you share the news. And, don't forget that silence is OK. Avoid the temptation to fill gaps in your conversation rather let the patient process and take the time to formulate questions.
Rule #4: Frame the conversation
Framing the news you're about to share is essential. Your patient may or may not be expecting to hear something difficult. And, the way you set up your conversation has an impact on the patient's reaction. Using the word "serious" (ex. "I have some serious news to share...") is better than using the word "bad". "Serious" creates a more constructive framework that inspires action and empowerment as opposed to the word "bad" which indicates the situation is helpless. Even if you're delivering a terminal diagnosis, your patient can choose how to react and what steps they wish to take in response.
Rule #5: Think SPIKES
There are a few well-known methods for delivering serious news to patients, my favorite of which is the SPIKES method. This algorithm lays out considerations for nurse practitioners and other healthcare providers in these situations. Here's the SPIKES protocol:
Setup - Think through the conversation you're about to have, anticipating questions the patient might ask beforehand. Prepare for an emotional reaction. Gather any necessary resources that might be helpful for the patient.
Perception - Gauge the patient's understanding and perspective on the news you have shared. This is best accomplished by asking questions like "What did you take away from what I just shared with you?" or "What are your expectations of treatment?". This way you know you are both on the same page as far as understanding the medical outlook, next steps and goals.
Invitation - Encourage the patient to think further about their care going forward. Find out how much information the patient wants about his or her medical condition as well as who he/she would like to be included in decision making such as family members.
Knowledge - This step has to do with how you as a provider deliver information. The best practice is to deliver the headline first, followed by the details. Communicate using language that matches the patient's level of education and medical knowledge. Be direct in your delivery, avoid skirting the main message.
Empathy - Understandably, patients get emotional about serious news. Anticipate such a reaction and display empathy. Naming the patient's emotions can help. Asking "Can you tell me more about what you mean by that?" will also help you determine how the patient feels about the situation.
Summarize and Strategize - Make a plan for the next steps in both treatment and communication with your patient. Express support and encourage the patient to tell friends and family the news to develop a personal support system. Talk about how the patient can act on this news to accomplish his or her treatment and lifestyle goals going forward.
Have you ever delivered bad news to a patient? How did it go?
Thank you for taking the time to read my post. I’m new to the PA Forum, but I desperately need some advice! I am fortunate enough to have been accepted to the dual PA/MPH (Master’s of Public Health) program at Yale and the PA program (MPH is pending) at Emory. However, I’m having a very difficult time deciding between the two so if you have any advice, have gone to either school, or have even been in this position before, I’d love to hear what you have to say!
Brief summary: My goal is to be a PA, but my interests are currently in infectious disease and the prevention of such, education of underserved populations, the effects of a booming population on healthcare, and global health. I am extremely interested in working for the CDC or WHO and love international medicine. Eventually, I may get into health policy. I love travel, have lived in a sunny, dry state with lots of things to do outdoors, and enjoy smart, successful, but REAL people.
Here are my impressions of the schools (please correct me if I'm mistaken!)
Yale (New Haven, CT):
• The prestigious name – it’s not everything, but it certainly gives me a sense of pride, make my family proud, and it could unlock a lot of doors for me in my future.
• Yale has a “Master’s of Public Health: Epidemiology of Microbial Diseases” program that has a large laboratory component – this is exactly what I want. I love being in the lab and this is my exact interest in public health.
• Medical Spanish – Yale offers its students this class as a supplemental learning experience for PAs. Awesome, as I used to be fluent in Spanish and would love to travel internationally.
• Global Health Concentration – this is a great bonus and would help me expand my global experience/education.
• Amenities – Yale boasts great museums and coffee shops that are sprinkled through New Haven, it’s also a plus that you can walk around the entire town in a matter of hours.
• Downs Fellowship – this funds a 6 week international work/research experience over the summer. If I play my cards right, this could count for my thesis and summer practicum.
• Networking – it’s Yale, correct me if I’m mistaken by assuming that I would meet some of the best and brightest people in their fields.
• Clinical rotations seem limited – I don’t believe you have a say in anywhere you go and I didn’t get the impression that the school affiliations were too wide-spread. I don’t want to do all of my rotations at the same hospital. They do, however, offer an international rotation, which is super cool.
THE NOT SO GOOD
• Safety – I’ve heard that the area has a decent amount of crime and, being a petite female, this is a big concern on mine.
• Campus – while the undergraduate campus is beautiful, the medical campus seems removed and a bit undesirable. To be fair, it was snowing the day that I went for my interview, so I probably didn’t get to see as much as I could’ve.
• The atmosphere – the few people I met there (like less than 10) didn’t seem very happy to be there. In fact, I got the feeling that many of them where there for the name. That’s fine and all, but I like to have a supportive community of REAL people who are smart but also care about things other than school.
• Cost – It’s about $15,000 more expensive than Emory.
• Weather – I hear it’s gloomy and cold up there. I’m not sure how humid it gets though. I have lived my entire life in a sunny, dry place and NEED sunshine.
• There aren’t a lot of volunteer/student involvement opportunities there (besides the Free Clinic).
Emory (Atlanta, Georgia):
• Close proximity to the CDC – As someone who would really love to work for the CDC, the fact that the CDC Headquarters is on Emory campus is HUGE. Not only would it allow me internship and networking opportunities, but many of my public health classes would be taught by CDC employees.
• Farm Worker’s Project – A two week medical trip where students and faculty bring medical care to Southern farm workers. I did a trip to Ecuador like this a few years back and loved it. So rewarding.
• The enclosed campus – while the campus itself is open to the public, when you are on campus, you are ON CAMPUS. The buildings are beautiful and the area feel clean and welcoming.
• The people – the people I met seemed genuinely happy to be there and were more easy-going.
• Opportunities – While Emory is not in downtown Atlanta (another plus), the area boasts great clinical rotations, restaurants, and social activities.
• Great hospital affiliations – this makes for great rotation opportunities.
THE NOT SO GOOD:
• Humidity – I’m not a fan. But it might be just as humid in Connecticut?
• It’s not as widely known – Again, the name isn’t the biggest deal, but it certainly makes things easier!
• No concentration in infectious disease – I would be going for Global Epidemiology, but would have to use electives (I would probably only have time for 3 or so?) that are based on infectious diseases to make my “concentration”. This is a huge negative for me.
Technically, they still haven’t accepted me (although, I’m not too concerned). Yale was willing to expedite review of the public health portion of my application so that I knew whether or not I was accepted to both programs within ONE WEEK. I submitted my public health application to Emory nearly 3 months ago now (and have also known that I was accepted to the PA program for 3 months as well). The Emory lag just makes me feel a bit like they don’t care.
**These are just a few of the things that I have considered. I actually looked at 77 total characteristics of each, but the schools ended up being very similar in the end. If I am wrong about ANYTHING I have said above, PLEASE let me know! These are just the impressions I have gotten and would love to hear the opinions of real students or teachers!
Thank you so much for reading this all!
This blog was recently promoted on our intranet and I've spent the last two days reading everything on it, alternately disgusted and amazed. Really well-written and understandable with great content from both the author, Dr. Bobbi Pritt, and knowledgeable readers. It's mostly case-based. Some of the cases have more background information than others.
I am currently in my clinical year of PA school and would love to be able to complete an Infectious Disease elective rotation in the Central Ohio area which is closer to my family. If anyone has any contacts in Ohio for preceptors who have taken students in the past or may be willing to take a student I would greatly appreciate it.