Finding Out the Hard Way - How Do You Share Diagnoses?

On Monday, my 25 year old sister had 2 precancerous moles and one skin cancer lesion removed.

How did my baby sister discover she had cancer? The receptionist at her docs office called to "schedule treatment for your skin cancer."

My sister had been monitoring some moles on her own. During a dermatologist visit (for another condition) she asked her doctor for an evaluation. Scrapings revealed one site on her abdomen, one on her arm, and one on her hand were precancerous.

At my sister's request, her dermatologist removed the hand lesion in the office and performed a biopsy, which neither of them expected to return positive results. Further tests will be done to determine if the abnormal growth is cause for additional examination/treatments.

It's a good thing my sister is a remarkably stable, well-adjusted gal with supportive family and friends, or the delivery of this news in such an unexpected manner may have thrown a bit of a wrench in her works.

In addition, members of a family/social support group may 'take' diagnosis-related news very differently - the most visibly affected member of a group may not always be the patient, and may not always be the person most 'profoundly' affected.

Often, implications related to a potentially adverse diagnosis flourish at a subterranean level below that immediately obvious to medical personnel in the care environment. Example: Hereditary concerns related to types of cancer (such as melanoma) may indicate offering testing options to siblings and children in a family unit.

So, does your office/hospital/clinic have training for staff (at all levels, for all positions, with mandatory completion standards) on how to deliver news related to diagnoses?

Is each staff person aware of the impact of communicating unexpected outcomes, and have they had training on how to offer support services should they be needed (counselors, support groups, a patient advocate, further time with the doc one-on-one, etc.)? I hope the answer is yes.

Needs for diagnosis-communication training go beyond the most basic "Good afternoon, my name is XXX and I'm here to talk with you about your diagnosis," and will vary significantly from facility to facility. Some sectors (LTC, CCRC, peds oncology, etc.) have ingrained cultural methods related to their unique patient populations and how often staff must deliver bad news.

Do you offer CE courses related to delivering diagnoses as new methods become available and your service line composition evolves? If you've just added oncology, cardiac, or neuro related services, perhaps communication standards could use an updated efficacy audit.

Consider customizing the following baseline steps, from Bruce Ambuel, PhD and David E. Weissman, MD, posted on the End of Life/Palliative Care Resource Center at the Medical College of Wisconsin:

Steps in Delivering Bad News

  • Determine what the patient & family knows; make no assumptions. Examples: What is your understanding of your present condition? Or What have the doctors told you?
  • Before presenting bad news, consider providing a brief overview of the patient’s course so that every one has a common source of information.
  • Speak slowly, deliberately and clearly. Provide information in small chunks. Check reception frequently
  • Give fair warning: I am afraid I have some bad news then pause for a moment.
  • Present bad news in a succinct and direct manner. Be prepared to repeat information and present additional information in response to patient and family needs.
  • Sit quietly. Allow the news to sink in. Wait for the patient to respond.
  • Listen carefully and acknowledge patient’s and family’s emotions, for example by reflecting both the meaning and emotion of their response.
  • Normalize and validate emotional responses: feeling numb, angry, sad, and fearful.
  • Give an early opportunity for questions, comments
  • Present information at the patient’s or family’s pace; do not overwhelm with detail. The discussion is like pealing an onion. Provide an initial overview. Assess understanding. Answer questions. Provide the next level of detail or repeat more general information depending upon the patient’s and family’s needs.
  • Assess thoughts of self-harm
  • Agree on a specific follow-up plan (I will return later today, write down any questions.). Make sure this plan meets the patient’s needs. Involve other team members in follow-up.

Click here for an additional resource, a case outline for med students enrolled in a Patient Centered Medicine course taught at The Ohio University, titled "To Tell the Truth: Delivering Bad News to Patients."

And here is a protocol from The Oncologist.

The good news? A plentitude of resources exist to review and renew current diagnoses communication practices.

The bad news? Delivering bad news doesn't get any easier.

No comments: