Communicating the Bad News and Discussing Code Status: Why and How

Maria Fidelis C. Manalo, MD, MSc.

Department of Community and Family Medicine Truth-telling and breaking the bad news to patients and their families is one of a physicians most challenging jobs, yet medical education typically offers little formal training for this arduous task. This is especially so as the attitudes and practice of the physicians towards truth-telling are affected by the cultural and ethical norms, and the social milieu where the physicians and their patients live. Without proper training, the discomfort and uncertainty associated with breaking bad news may lead physicians to emotionally disengage from patients. Numerous study results show that patients generally desire frank and empathetic disclosure of a terminal diagnosis or other bad news. Focused training in communication skills and techniques to facilitate breaking bad news has been demonstrated to improve patient satisfaction and physician comfort. Physicians can use the SPIKES strategy both in breaking the bad news or discussing code status. Key words: code status, SPIKES strategy
His words poured over me. The door of his sadness opened, and I plunged into his shock and apparent betrayal. In that moment I felt ashamed of being part of the system that had betrayed him, his son, and his family. In our silence, I imagined the countless opportunities that had been abandoned by his doctors, hurriedly dismissed, as another priority conveniently emerged, and a too time-consuming, too-intimate conversation was, again, postponed. At 26, Jack was diagnosed with myelodysplastic syndrome. All the wrong cytogenetics lined up neatly, declaring the road to come. Induction chemotherapy was followed by consolidation. He was young, strong, vibrant, and beautiful. He was only 26. He fared well... for a year. Then Jack developed a bluish patchy rash that persisted for weeks. A biopsy revealed leukemia cutis. His myelodysplastic syndrome had transformed into acute leukemia, and the revolving door was re-entered. Reinduction. Consolidation. Plans for allogeneic transplantation were made. When Jack and his sister learned she was a match he, perched atop an examining table, and she, folded into a tight ball on a nearby chairthey practically leapt into each others arms, tears streaming down their faces as they held each other in a long and laughing embrace. His baby sister beamed with pride that she alone held the key to her brothers cure. The roller coaster of admissions and discharges began. The track was long and circuitous. Predictably unpredictable. Neutropenic fever. Line infection. Sepsis. Twice, Jack survived admission to the intensive care unit. He was young and strong. Quietly, his vibrancy began to recede.

Introduction
Truth-telling and breaking bad news to patients is one of the most difficult responsibilities in the practice of medicine. Although virtually all physicians in clinical practice encounter situations entailing bad news, medical school offers little formal training in how to discuss bad news with patients and their families. Although the majority of health providers believe that patients and caregivers should be told the truth about the prognosis, in practice, many either avoid discussing the topic or withhold information. However, avoiding the topic can have adverse outcomes, such as patients receiving burdensome and painful treatments and not having sufficient time to prepare for death. Unfortunately, this frequently happens as is clearly illustrated in the following account written by an oncologist (Rockwell, 2007):
Tears rolled down his cheeks as he stood motionless outside his dying sons door. He seemed to be standing vigil. We shook hands. Our eyes met. The lines of his face were etched with grief. I waited for him to speak. "No one told us..." "Im sorry?" I asked. "No one told us Jack was dying," he replied. His tears streamed.

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On his good days, his olive-green eyes shone like jewels. His balding head accentuated his handsome face. He didnt seem to mind his change in appearance. He was patient and kind, often serving as a reminder to all of us who cared for him of our own inadequacies. On his bad days, he was profoundly fatigued, unable to stroll down the fluorescent corridors or to come to the table and eat with family during his brief stints at home. This energyless state was foreign to Jack. He had been an "extreme" biker and mountain climber. He felt estranged from this alien self, who only knew how to lie in bed and watch mindless television. During these days, his father drew closer to his side. In a weathered, leather bag that rested beneath Jacks bed, his father kept healing oils. He would lovingly massage his sons frail body, as if to breathe life into every cell through the strength and love in his hands. Jacks father was his soul mate, his champion. His dad donned various colorful bandanas from one day to the next to match his sons. He shaved his head as a gesture of solidarity with Jack. He, too, was kind and patient, holding vigil for his son. With gentle determination, he would inquire regarding the days eventsthe scans, blood cultures, chest x-rays, and so on. He was witness to the rise and fall of fevers and blood counts. As his son rode the roller coaster that was now his life, with little or no control, his father was steadfast. It was amazing to watch. We all admired his endurance. It fed usthis loving, unhindered display of commitment. We were grateful for their strength and kindness toward one another. After the transplantation, his remission lasted 3 months. Reinduction. Not a word of death or dying was offered by the doctors caring for him, though the chance of cure was nil. No mention of hospice. As an oncology fellow, I stood more or less in the wings, disheartened by the absence of dialogue, reluctant to speak my own peripheral truth. What was I witnessing? His frailty grew. His exhaustion deepened as his body was assaulted with each round of chemotherapy. Discussion of goals grew more elusive. It was as though an unseen pilot was steering this relentless course. Was it hope? Whose hope? Who defines this hope? This time there was no remission. At what price is cure a goal? And what price does hope carry? More trips to the intensive care unit and more bouts of sepsis. His young body was now a relic. There was talk of another transplant... another chance....

therapeutic benefits of treatment, at relapse and terminal illness. This desire to shield patients from the reality of their situation usually creates even greater difficulties for patients, their relatives and friends and other members of the healthcare team. Although the motivation behind economy with the truth is often well meant, a conspiracy of silence usually results in a heightened state of fear, anxiety and confusion, rather than one of calm and equanimity. Ambiguous or deliberately misleading information may afford short-term benefits while things continue to go well, but denies patients and their family opportunities to reorganize and adapt their lives towards the attainment of more achievable goals, realistic hopes, and aspirations (Fallowfield et al, 2002), and eventually to prepare for death.

Patients Right to the Truth

Man, though not owner is steward of his life and health. To hide the truth from a patient is to underestimate his capacity and to treat him as immature. It is not licit to create illusions which lead to a false sense of security in the patient or his family, thereby, endangering his eternal salvation or impeding him from fulfilling his obligation of justice or charity. There are cases wherein the physician is obliged to talk clearly, a duty which takes priority over any other medical or humane consideration. It would be erroneous to justify such conduct or explain it by saying that the physician communicates the truth in the manner that best suits the patient. (Monge, 1994)

Health Care Professionals Must Not Lie

To lie is to say something contrary to what one thinks. A health care professional should never lie or deceive the patient. One is not always obliged to tell the whole truth if one judges that revelation could have a negative effect upon the patient. Sometimes, the physician may keep silent about the truth, evading answers to indirect questions by the patient made for other motives (to get reaffirmed, to revive hope, to overcome fear, etc.). He waits for the opportune moment to reveal the truth. Better still, he tries to reveal it gradually. (Monge, 1994)

Indeed, healthcare professionals often censor their information giving to patients in an attempt to protect them from potentially hurtful, depressing, or so called bad news. There is a commonly expressed belief that what people do not know does not harm them. Analysis of doctor and nurse/patient interactions reveals that this well-intentioned but misguided assumption about human behavior is present at all stages of cancer care. Less than honest disclosure is seen from the moment that a patient reports symptoms, to the confirmation of diagnosis, during discussions about the

Health Professionals Dilemma: What if the Truth Hurts?

The principle which is universally valid is: The patient has the right to know the truth about his illness. An exception to this norm would be patients of minor age (small children who do not have full use of their mental faculties). The physician will have to inform their parents or legal guardians. (Monge, 1994).

Communicating the Bad News and Discussing Code Status

Truth-Telling: the Philippine Cultural Dimension A paternalistic attitude toward truth telling in medicine is dominant in the Philippines. Influenced by Asian philosophies and cultures, the tradition of Filipino values and ethics emphasizes the good behavior of the practicing physician rather than a system of principles and rules. The Filipinos feel that disclosure of bad news brings loss of hope and unwanted emotional distress which may lead to isolation, depression, and in the elderly, even a possible angina, heart attack, and earlier demise. In the Philippines, families want to hear the news first. They care for their sick at home, rather than in institutions. Family bonds are so strong in the Philippines that they would rather bear the psychological shock of the bad news of a terminal diagnosis rather than share it with their loved one. They want their dear family member to remain hopeful and optimistic. And for their part, especially among the elderly, patients prefer not to be informed of a terminal illness. They willingly relinquish their right to autonomy and let family members make health care decisions for them. As in the rest of Philippine society, there are strong authoritarian and paternalistic elements in the Philippine healthcare system. In typical Filipino tradition, a good physician is paternalistic. Accordingly, he would not disclose to a patient that he has terminal disease such as cancer; rather he would tell the spouse, the children, the siblings, or other close family member. For example, even when there is already a suspicion of a malignancy, physicians often do not fully explain to the patient the reason for a planned examination and dont disclose test results directly to them. Sometimes chemotherapeutic drugs are prescribed or administered without directly informing the patient that they are a form of cancer treatment. Preferring thus not to inform cancer patients of the nature, course, and prognosis of their condition even at stage 4, advance directive discussions are rare. However, little by little, the attitude of younger physicians towards truth telling suggests a transition from the long tradition of paternalism to a modern embrace of the principle of patient autonomy. This is so among those with training on effective communication skills during medical school or during residency training in family medicine in university hospitals especially in Metro Manila. Likewise this is prevalent among those exposed to contemporary Anglo-American concept of autonomy. US trained doctors assert the rights of patients to be informed of their diagnosis, prognosis and the risks and benefits of therapies, and to be allowed to make informed decisions about treatments and withholding resuscitation.

Many health professionals (HPs) express discomfort at having to broach the topic of prognosis, including limited life expectancy, and may withhold information or not disclose prognosis. A systematic review (Hancock et al, 2007) was conducted of 46 studies relating to truth-telling in discussing prognosis with patients with progressive, advanced life-limiting illnesses and their caregivers. Inclusion criteria were studies of any design evaluating communication of prognostic information that included adult patients with an advanced, life-limiting illness; their caregivers; and qualified HPs. Results showed that although the majority of HPs believed that patients and caregivers should be told the truth about the prognosis, in practice, many either avoid discussing the topic or withhold information. Reasons include perceived lack of training, stress, no time to attend to the patients emotional needs, fear of a negative impact on the patient, uncertainty about prognostication, requests from family members to withhold information and a feeling of inadequacy or hopelessness regarding the unavailability of further curative treatment. However, the studies reviewed suggest that patients can discuss the topic without necessarily increasing anxiety. Furthermore, avoiding the topic can have adverse outcomes, such as patients receiving burdensome and painful treatments and not having sufficient time to prepare for death. By discussing this information sensitively, and encouraging the patient to share in decision-making, the HP can help the patient reset goals and choose appropriate supportive treatments rather than those that are burdensome. May the common clinical conversation be used to explore whether or not seriously ill patients want to talk about possible limitations of life support? In a study by Lfmark and Nilstuna (2000), a clinical conversation with 20 seriously ill patients was used to identify different reaction patterns among typical DNR patients. Within 1020 minutes of conversation, most patients seemed to be ready to talk about fundamental questions of life and death. It was also quite easy to get an idea of both the patients values and his or her understanding of medical issues. For example, their knowledge about CPR was often very poor. Many patients approved. They also emphasized that it is the doctors duty to give such information to their patients. After talking about their diagnosis and prognosis, most patients said it was natural to talk about possible limitations of life support, and a substantial number immediately indicated that they did not want any life-sustaining treatment. Although their emotional reactions were different, no one seemed to be troubled or upset by talking about such issues. Many but not all patients said that they wanted a family member and possibly also a nurse to participate in the conversation.

FEU-NRMF Medical Journal The Truth Need Not Hurt

In the first place, it has not been demonstrated that truth-telling harms the patient. Telling the truth is often beneficial and alleviating if done properly. Just as a physician does not hesitate to cause physical pain when he prescribes a painful or mutilating treatment, in the same way, he must not be held back for fear of causing moral suffering when he has to communicate information because the truth is often beneficial (both physically and spiritually). What influences more than the content of the information is the manner of communicating it. This depends primarily upon the patient-physician relationship. The key to the problem is good communication. (Monge, 1994) It is better to inform gradually, always leaving some hope, but never telling a lie. The purpose of the universally accepted norm of informing the patient properly is to enable him to adapt to the different therapeutic maneuvers without alarming him unnecessarily. This principle obliges the physician always to explain the gravity and prognosis of the illness. He is not bound to give percentages, mean survival, frequency of complications, etc. This can be done when one knows the personality of every patient. He must be given the dose of information that he needs at every moment without stating survival time and maintaining a prudent reserve as regards unforeseen events. (Monge, 1994)

patients themselves adequately. In difficult cases, sometimes a close relative (wife, husband, children or a friend) might be in a better position to communicate it. The suffering that results from this gesture is justified by the fulfillment of a final duty. Man needs to be forewarned of the moment of his death so that he can prepare himself with a lucid mind. He may need or want to settle matters with others, fulfill moral, familial, and personal obligations which cannot be delegated. For a seriously-ill and incurable patient but with a certain chance of survival (e.g., primary stage of cancer), the patient should be gradually informed about facts related to his illness. The physician, with the nurses assistance, will judge whether it is advisable to inform the patient immediately or to defer it until a more opportune moment. In this regard, the interest of the patient (personal, professional, familial and religious) should be taken into consideration. (Monge, 1994)

Preferences of Cancer Patients Regarding Communication of Bad News

The findings in the systematic review of 24 studies made by Fujimori and Uchitomi (2009) suggest that patient preferences with regard to the communication of bad news by physicians consist of four components: setting, manner of communicating bad news, what and how much information is provided and emotional support, and that patients preferences are associated with demographic factors. Younger patients, female patients and more highly educated patients consistently expressed a desire to receive as much detailed information as possible and to receive emotional support. Asian patients were shown to prefer that relatives be present when receiving bad news more than Westerners do and to prefer to discuss their life expectancy less than Westerners.

Practical Guidelines on Telling the Truth to Different Patients

Terminally-ill patients usually suspect that their condition is grave and that they are in the final phase of life because of their poor general condition, kind of therapy, etc. Thus, it is enough to confirm gradually their impression. Nevertheless, one must always give hope. The knowledge of their illness need not cause despair. Terminally-ill patients fall into despair only when the truth is revealed to them in a brutal way and they are thereafter abandoned. The medical team must support them by not only giving them the impression that it will never cease to take care of them; it must really do so. For example, patients can be given symptomatic relief for fever, appetite stimulants, analgesics and help them receive their families, etc. For terminally-ill patients who really or apparently ignore their actual state, it is an urgent obligation on the part of the physician to inform the

Breaking Bad News: The ABCDE Mnemonic

Physicians can build on the following simple mnemonic, ABCDE, to provide hope and healing to patients receiving bad news: Advance preparation arrange adequate time and privacy, confirm medical facts, review relevant clinical data, and emotionally prepare for the encounter. Building a therapeutic relationshipidentify patient preferences regarding the disclosure of bad news. Communicating well determine the patients knowledge and understanding of the situation, proceed at the patients pace, avoid medical jargon or euphemisms, allow for silence and tears, and answer questions. Dealing with patient and family reactionsassess and respond to emotional

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Communicating the Bad News and Discussing Code Status

Are you the kind of person who prefers to know all the details about what is going on? How much information would you like me to give you about your diagnosis and treatment? Would you like me to give you details of what is going on or would you prefer that I just tell you about treatments I am proposing?

reactions and empathize with the patient. Encouraging/validating emotionsoffer realistic hope based on the patients goals and deal with your own needs. (Vandekieft, 2001)

Breaking Bad News: The S-P-I-K-E-S Strategy

The S-P-I-K-E-S protocol described by Buckham (2005) provides a simple, easily learned strategy for communicating bad news and suggests ways to assess the situation as it evolves and respond constructively to patients.

Knowledge (K)
Before you break bad news, give your patient a warning that bad news is coming so he/she can prepare psychologically for it. Examples of warning statements include: Unfortunately, Ive got some bad news to tell you. Im so sorry to have to tell you. When giving your patient bad news, use the same language the patient uses. For example, if your patient uses the words growth and spread, try to use these words. Avoid medical jargon or technical terms as they are hard to comprehend and remember during enormous emotional turmoil. Give the information in small chunks and clarify that the patient understands what you have said at the end of each chunk (and you may need to repeat this several times, particularly when the patient looks nonplussed even if they say they understand): For example: Do you see what I mean? or Is this making sense so far? Ask often. Tailor the rate at which you provide information to your patient. If the indication is that your patient understands perfectly so far, move on to the next piece of information. If he or she isnt clear, go over the information again. As emotions and reactions arise during this discussion, acknowledge them and respond to them.

Setting (S)
Ensure privacy. Involve significant others. Sit down. Look attentive and calm. Adopt a listening mode through the communication skills of silence and repetition. Be fully available to this important discussion, making arrangements for the phones to be answered by other staff members, putting mobile phones into silent or meeting mode, and making sure that staff members do not interrupt the meeting.

Perception (P)
Follow the before you tell, ask principle. Before you break bad news to your patients, you should glean a fairly accurate picture of their perception of the medical situationin particular, how they view the seriousness of the condition. The exact words you decide to use depend on your own style. Here are a few examples: What did you think was going on with you when you felt the lump? What have you been told about all this so far? Are you worried that this might be something serious? As your patient responds to your question, take note of the language and vocabulary that he or she is using and be sure you use the same vocabulary in your responses. This alignment is so important because it will help you assess the gap (often unexpectedly wide) between the patients expectations and the actual medical situation. If a patient is in denial, it is often helpful not to confront the denial at the first interview.

Empathy (E)
It is much more usefuland more therapeutic to acknowledge patients emotions as they arise and to address them. The technique that is most useful for this task is called the empathic response, and it comprises three straightforward steps: Step 1: Listen for and identify the emotion (or mixture of emotions). If one is not sure what emotion the patient is experiencing, an exploratory response can be used, such as How does that make you feel? or What do you make of what Ive just told you?

Invitation (I)
Obtain overt permission from the patient if and how much he/she wants to know. This respects the patients right to know (or not to know). Some examples of ways to address this follow:

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Step 2: Identify the cause or source of the emotion, which is most likely to be the bad news that the patient has just heard. Step 3: Show the patient that you have made the connection between the above two stepsthat is, that you have identified the emotion and its origin. Examples might include: Hearing the result of the bone scan is clearly a major shock to you. Obviously, this piece of news is very upsetting. Clearly, this is very distressing. Once you have shown empathy and identified and acknowledged the patients emotion, be ready to validate or normalize his or her feelings. You might use a phrase such as I can understand how you can feel that way. To minimize feelings of embarrassment and isolation, let your patient know that showing emotion is perfectly normal..

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status to patients and families is a simple, easily learned strategy.

Setting (S)
Ensure comfort and privacy; sit down next to the patient. Ask if family members or others should be present. Introduce the subject with a phrase such as: Id like to talk with you about possible health care decisions in the future.

Perception (P)
An informed decision about code status is only possible if the patient has a clear understanding of their illness and prognosis. Ask an open-ended question to elicit patient understanding about their current health situation. It is important to get the patient talking if the doctor is doing all the talking, it is unlikely that the rest of the conversation will go well. Start with phrases such as: What do you understand about your current health situation? What have the doctors told you about your condition? If the patient does not know/appreciate their current status this is time to review that information.

Strategy and summary (S)

Before the discussion ends, summarize the information in your discussion and give your patient an opportunity to voice any major concerns or questions. If you do not have time to answer them right at that moment, you can tell your patient that these issues can be discussed in detail during your next interview. You and your patient should go away from the interview with a clear plan of the next steps that need to be taken and the roles you both will play in taking those steps. Discussing Code Status: The S-P-I-K-E-S Strategy Conversations about cardiopulmonary resuscitation (CPR) preferences vary greatly depending on the age, health and health literacy of the patient. With all patients it is important to avoid vague or overly technical terminology and to use vocabulary they understand. The question Would you want us to do everything? is not helpful for eliciting preferences; it confuses patients and implies that less than optimal care may be offered if the patient answers no to the question. CPR should not always be the standard of care, so it is crucial that patients understand the difference between withholding CPR and withholding treatment of their underlying illness and its associated symptoms. (Stone and Tulsky, 2006) Steps in discussing prognosis and end-of-life issues have been proposed by Von Gunten and Weissman (2005). Adapting the S-P-I-K-E-S protocol as previously described to this process of discussing code

Invitation (I)
Find out what the patient expects. Ask the patient to consider the future. For example: What do you expect in the future? What goals do you have for the time you have leftwhat is important to you? This step allows you to listen while the patient describes a real or imagined future. Many patients with advanced disease use this opening to voice their thoughts about dyingtypically mentioning comfort, family, and home, as their goals of care. If there is a sharp discontinuity between what you expect and what the patient expects, this is the time to clarify. Listen carefully to the patients responses; most patients have thought a lot about dying, and only need permission to talk about what they have been thinking. Respond with clarifying and confirming comments such as: So what youre saying is you want to be as comfortable as possible when the time comes? What youve said is you want us to do everything we can to fight, but when the time comes, you want to die peacefully? Whenever possible, ask patients to explain the values that underlie their decisions: Can you explain why you feel that way?

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Communicating the Bad News and Discussing Code Status

If you are asked to explain heroic measures, then describe the purpose, risks and benefits of CPR in greater detail. The clinical pearl here is to start general and become specific later in the conversation.

Share the Information. Discuss a Do not Resuscitate (DNR) order. Use language that the patient will understand. Give information in small pieces. Dont introduce cardiopulmonary (CPR) in mechanistic terms (e.g. starting the heart or putting on a breathing machine). Never say: Do you want us to do everything? Everything is euphemistic and easily misinterpreted. Using the word die helps to clarify that CPR is a treatment that tries to reverse death. To most lay-people, when the heart and/or lungs stop, the patient dies. If the patient and doctor mutually recognize that death is approaching and the goals of care are comfort, then CPR is not an appropriate medical intervention and a clear recommendation against CPR should be made. You can say: We have agreed that the goals of care are to keep you comfortable and get you home. With this in mind, I do not recommend the use of artificial or heroic means to keep you alive. If you agree with this, I will write an order in the chart that if you suffer a cardiopulmonary arrest, no attempt to resuscitate you will be made. If the clinical situation is more ambiguous in terms of prognosis and goals of care, and you have no clear recommendation, the issue of DNR can be raised by asking: If you should suffer a cardiopulmonary arrest in spite of all of our efforts, do you want us to use heroic measures to attempt to bring you back? How do you want things to be when you suffer a cardiopulmonary arrest?

Empathize (E)
Respond to emotions. Strong emotions are common when discussing death. Typically the emotional response is brief. The most profound initial response a physician can make may be silence, providing a reassuring touch, and offering facial tissues

Strategy and summary (S)

Establish a plan. Clarify the orders and plans that will accomplish the overall goals you have discussed, not just the DNR order. A DNR order does not address any aspect of care other than preventing the use of CPR. It is unwise and poor practice to use DNR status as a proxy for other life-sustaining therapies. Consider using words: We will continue maximal medical therapy to meet your goals. However, if you suffer from a cardiorespiratory arrest, we wont use CPR to bring you back. It sounds like we should move to a plan that maximizes your comfort. Therefore, in addition to a DNR order, Id like to talk further with you how we can best do that. The S-P-I-K-E-S protocol applied to disclosure and advance directives discussions provides a simple, easily learned strategy for physicians to effectively and meaningfully communicate with their patients. (Table 1)

Table 1. S-P-I-K-E-S Strategy in Breaking the Bad News and Discussing Code Status
S Setting o o o o o o DISCLOSURE (BREAKING THE BAD NEWS) Privacy Involve significant others Sit down Look attentive and calm Listening mode: silence and repetition Availability ADVANCE DIRECTIVES (DISCUSSING CODE STATUS) o Privacy o Involve significant others o Sit down o Look attentive and calm o Listening mode: silence and repetition o Availability o Introduce the subject: Id like to talk with you about possible health care decisions in the future. Find out how much the patient knows. o What do you understand about your current health situation? o What have the doctors told you about your condition?

P Perception

Find out how much the patient knows. o What did you think was going on with you when you felt the lump? o What have you been told about all this so far? o Are you worried that this might be something serious?

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I Invitation Find out how much the patient wants to know. o Are you the kind of person who prefers to know all the details about what is going on? o How much information would you like me to give you about your diagnosis and treatment? o Would you like me to give you details of what is going on or would you prefer that I just tell you about treatments I am proposing? Share the information. Give warning statements: o Unfortunately, Ive got some bad news to tell you. o Im so sorry to have to tell you. Check perception: o Do you see what I mean? o Is this making sense so far?

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K Knowledge

E Empathy

Ask probing questions: o How does that make you feel? o What do you make of what Ive just told you? Respond to emotions. Identify the emotion and its origin. o Hearing the result of the bone scan is clearly a major shock to you. o Obviously, this piece of news is very upsetting. o Clearly, this is very distressing. Validate or normalize feelings: o I can understand how you can feel that way. Summarize the information. Give the patient an opportunity to voice any major concerns or questions. Plan the next steps that need to be taken and the roles the doctor and the patient will play in taking those steps.

Find out what the patient expects o What do you expect in the future? o What goals do you have for the time you have leftwhat is important to you? o So what youre saying is you want to be as comfortable as possible when the time comes? o What youve said is you want us to do everything we can to fight, but when the time comes, you want to die peacefully? o Can you explain why you feel that way? Share the information. Discuss a CPR or DNR order. Give warning statements: o We have agreed that the goals of care are to keep you comfortable and get you home. However, if you should suffer a cardiorespiratory arrest in spite of all of our efforts, do you want us to use heroic measures to attempt to bring you back? o How do you want things to be when you suffer a cardio-respiratory arrest? If you are asked to explain heroic measures, then describe the purpose, risks and benefits of CPR or DNR in greater detail. Check perception. o With this in mind, I do not recommend the use of artificial or heroic means to keep you alive. If you agree with this, I will write an order in the chart that if you suffer from cardio-respiratory arrest, no attempt to resuscitate you will be made. Respond to emotions. Identify the emotion and its origin. The most profound initial response a physician can make may be silence, providing a reassuring touch, and offering facial tissues

S Strategy & summary

Summarize the information. Give the patient an opportunity to voice any major concerns or questions. Clarify the orders and plans that will accomplish the overall goals discussed, not just the CPR or DNR order: o We will continue maximal medical therapy to meet your goals. However, if you suffer a cardio-respiratory arrest, we wont use CPR to bring you back. o It sounds like we should move to a plan that maximizes your comfort. Therefore, in addition to a DNR order, Id like to talk further with you how we can best do that.

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Communicating the Bad News and Discussing Code Status

4. Hancock K, Clayton JM, Parker SM et al. (2007) Truth-telling in discussing prognosis in advanced life-limiting illnesses: a systematic review. Palliative Medicine 21: 507517 Lfmark R, Nilstun T (2000). Not if, but how: one way to talk with patients about forgoing life support. Postgrad Med J ;76:2628 Schmit K. (2005). Nursing Implications for Treating "Kanser" in Filipino Patients. Journal of Hospice and Palliative Nursing. 7(6):345-353 Searight HR, Gafford J. (2005). Cultural Diversity at the End of Life: Issues and Guidelines for Family Physicians. Am Fam Physician. 71(3):515-22. Kwak J., Haley WE. (2005). Current Research Findings on End-of-Life Decision Making Among Racially or Ethnically Diverse Groups, The Gerontologist, 45 (5): 634-641. Cress CJ. (2007). Ethnic and Cultural Considerations in Geriatric Care Management. In Handbook of Geriatric Care Management, 2nd ed. (pp. 103). Jones and Bartlett Publishers, Inc. McBride, M. (2002). Health and Health Care of Filipino American Elders. Stanford Geriatric Education Center. Stanford University School of Medicine., from http://www.stanford.edu/group/ethnoger/filipino.html. Giger JN, Davidhizar RE. (2003) Transcultural Nursing: Assessment and Intervention. 4th ed. St. Louis: Mosby; Purnell LD, Paulanka BJ. (2005) Guide to Culturally Competent Health Care. Philadelphia: F.A. Davis. Rodell P. (2002) Culture and Customs of the Philippines. Westport, CT: Greenwood Press Yun YH, Chang GL, Kim S, et al. (2004) The attitudes of cancer patients and their families toward the disclosure of terminal illness. J Clin Oncol. 22(2):307-314. Fujimori M, Uchitomi Y (2009). Preferences of Cancer Patients Regarding Communication of Bad News: A Systematic Literature Review. Jpn J Clin Oncol; 39(4)201216 Vandekieft G (2001). Breaking Bad News. Am Fam Physician, 64(12):1975-1978. Buckman R (2005). Breaking bad news: the S-P-I-KE-S strategy. Community Oncology: 138-142 Stone and Tulsky (2006). Code Status. Virtual Mentor, Vol 8, 559-562. von Gunten CF, Weissman DE (2005). Fast Fact and Concept #023: DNR Orders in the HospitalPart 1. Available at: http://www.eperc.mcw.edu/fastFact/ff_023.htm. Accessed May 17, 2011.

Medical Team as a Support to the Patient at the end-of-Life

The presence of the physician is especially needed during the terminal phase, e.g., twice-a-day visits to the dying patient. The physician ought to accompany the patient, comfort the relatives, help them confront the illness and understand the meaning of suffering. This is not the exclusive task of the chaplain, the spiritual counselor or the palliative care practitioner. If the patient is a Christian, the physician may teach his patients that illness is not something accidental. It is foreseen by God for each individual. He should emphasize the need for spiritual help (pastoral visit, sacraments of penance and Holy Communion, anointing of the sick) in order to confront the situation. (Monge 1994).

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Conclusion
10.

Despite the challenges involved in communicating bad news and discussing code status, physicians can find tremendous gratification in providing a therapeutic presence during a patients time of greatest need. A growing body of evidence demonstrates that physicians attitude and communication skills play a crucial role in how well patients cope with bad news and that patients and physicians will benefit if physicians are better trained for this arduous task. Patients cannot always be cured and the goals of care would shift towards palliation and comfort measures only. These are precisely the times that professionalism and compassion most acutely call the physician to provide hope, and to accompany the patient, to comfort the relatives, and to help them face the illness until the terminal phase, with empathy and real concern for them.

11.

12. 13. 14.

15.

References
1. Rockwell L. (2007) Truth Telling. The Art of Oncology: When The Tumor Is Not The Target. Journal of Clinical Oncology, Vol 25, No 4: pp. 454455 L J Fallowfield L, V A Jenkins V, Beveridge H (2002). Truth may hurt but deceit hurts more: communication in palliative care. Palliat Med vol. 16 no. 4 297-303 Monge M (1994). Telling the Truth to the Patient. In Ethical Practices in Health and Disease. Manila: Sinag-tala Publishing Inc. (pp. 169-180).

16. 17. 18. 19.

2.

3.