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breaking bad news
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BREAKING BAD NEWS
IIT FITRIANINGRUMDEPARTEMEN BIOETIKA DAN
HUMANIORA PRODI PENDIDIKAN DOKTER FK UNTAN
Breaking Bad News/EBP3KH TA.2014/2015
Tidak seorangpun menyukai mendengarkan
berita buruk, walaupun dokter dan professional lainnya selalu memiliki berita buruk :
Penyakit kronik meningkat Mempertinggi pentingnya mengerti
bagaimana menyampaikan berita buruk mempengaruhi pasien, keluarganya, dan dokter/tenaga medis lainnya
BACKGROUND
Breaking Bad News/EBP3KH TA.2014/2015
Berita buruk dapat berarti different things to different
people Berita buruk adalah “setiap informasi, yang mana
adversely dan dampak serius bagi masa depan individu”
The impact cannot estimate until one has first determined the recipient’s expectations or understanding
Ex: pasien dengan kanker payudara who is told that her back pain is caused by recurrence of her breast cancer will be most likely to be shocked due to her expectation to be told it was muscle strain
What is Bad News?
Breaking Bad News/EBP3KH TA.2014/2015
Cemas for causing and adverse event (stress, marah, anxiety) Anxiety from the patient increase when patient were given the
bad news (Lienard et al, 2006) Other studies showed that when reported about bad news, 54%
will shock, 46% will frigth, 24% akan sedih, 40% akan menerima dan hanya 15% that wont worry (Whippen and Cannelos, 1991)
Worry that will be difficult to handle the reaction of patient & their family
Barnett (2002) found that when patient given the doctor about bad news, 49% will neutral, 20% will have positive perception, 20% will negative perception, 6% will have a very negative perception on doctor
People will most likely not remember about the information (Eden, 1994)
Why It is Hard to explain bad news to the patient?
Breaking Bad News/EBP3KH TA.2014/2015
Setting up the interview Perception of the patient Invitation by the patient Knowledge to the patient Emotions of the patient Strategy and summary
How to Inform the Bad News to Patient?
Breaking Bad News/EBP3KH TA.2014/2015
Arrange for privacy Involve significant others“ is there anyone you would want to have present when we talk” Duduk Make connection with the patient Manage time constraints and interruption
Setting up the interview
Breaking Bad News/EBP3KH TA.2014/2015
Sebelum diberitahu, ask (ask about his/her view of the
situation)
“what have you been told about your condition so far?”“How much do you understand about what is going on medically?”“what is your understanding of why we did the MRI?” Can determine if patient is in denial Can determine unrealistic expectations of
treatment
Perception of the Patient
Breaking Bad News/EBP3KH TA.2014/2015
Majority of patients express a desire for full
information Discuss Information disclosure while ordering test“ How would you like me to give the information about the test results”“Are you the kind person who likes lots of detail, or would you prefer big picture? If patient does not want to know details, offer to
answer any questions they may have or involve a relative or friend
Invitation by the patient
Breaking Bad News/EBP3KH TA.2014/2015
Give a warning shot“Unfortunately, I have some bad news to tell you....”“I’m sorry to tell you that...” Start at level of compherension of the patient Use nontechincal words “spread” instead of
“metastasized” Avoid being blunt as it may make the patient
isolated and angry “You have such bad cancer that you will nots surveive without treatment...”
Knowledge to the patient
Breaking Bad News/EBP3KH TA.2014/2015
Give information in small amounts, then
periodically check the patient’s understanding“ I’ve given you a lot of information. What are your reaction and concerns at this point?” When the prognosis is poor, avoid using
phrases that inconsistent with other important theraupetic goals
“ There is nothing more we can do for you” The fact is that we have another goals such as good pain control and symptom relief
....Knowledge to the patient
Breaking Bad News/EBP3KH TA.2014/2015
Respond to the patients emotions with
emphaty Often shock, isolation, disbelief, grief or anger Observe for emotion on patient’s part Identify emotion Identify the reason for the emotion Connect with patient
Emotions of the patient
Breaking Bad News/EBP3KH TA.2014/2015
Doctor : “I’m sorry to say that the X-ray shows
that the chemotherapy is not working [pause]. Unfortunately, the tumor has grown somewhat”
Patient : “I’ve been afraid of this!” [cries] Doctor : [moves his chair closer, offers the
patient a tissue and pauses,] “I know that this isn’t what you wanted to hear. I wish the news were better”
...Emotions of the patient
Breaking Bad News/EBP3KH TA.2014/2015
Continue to make emphatic responses until
the patient becomes calm Emphatic statements I can see how upsetting this is to you I can tell you were not expecting to hear this I know this is not good news for you I’m sorry to have to tell you this This is very difficult for me also I was also hoping for a better result
...Emotions of the patient
Breaking Bad News/EBP3KH TA.2014/2015
When emotions are not clearly expressed, the
physician should ask question before makes an emphatic response
Exploratory questions How do you mean? Tell me more about it You said it frightens you You said you were concerned about your
children, tell me more Could you tell me what you are worried about?
...Emotions of the patient
Breaking Bad News/EBP3KH TA.2014/2015
Validating responses I can understand how you felt that way I guess anyone might have the same reaction You are perfectly correct to think that way Your understanding of the reason for the tests is
very good Many other patients have had similar experience It will reduce patient’s isolation and validate the patient’s feelings/thoughts as normal and to be expected
...Emotions of the patient
Breaking Bad News/EBP3KH TA.2014/2015
Patients who have a clear plan for the future are
less likely to feel anxious and uncertain Ask if patients are ready to discuss this Clinicians are often uncomfortable doing this
especially in unfavorable prognosis Explore patients’ ICE (ideas, concerns and
expectations) Understand specific goals patient may have like
symptom control and pain relief Give hope in terms of what is possible to
accomplish
Strategy and Summary
Breaking Bad News/EBP3KH TA.2014/2015
Falsehood is so easy, truth is so difficult
(George Elliot)
Breaking Bad News/EBP3KH TA.2014/2015
Dua pasien dibawa ke UGD dengan mobil polisi. Mereka berdua
adaah suami istri yang mengalami kecelakaan lalu lintas. Karena trauma yang parah, sang suami setelah diupayakan tindakan penyelamatan jiwa tidak dapat terselamatkan
Sang istri dalam keadaan sadar dan tengah dirawat di ruangan yang lain yang berbeda. Karena terjadi perdarahan dan trauma pada beberapa organ vital di dallam rongga thorax dan abdomen, dokter Sp.B memutuskan untuk segera melakukan operasi
Ketika saudara mempersiapkan pasien tersebut untuk dioperasi, pasien tersebut bertanya kepada saudara mengenai keadaan suaminya, “Bagaimana keadaan suami saya dok? Apakah dia juga harus dioperasi? Saya ingin bertem dengan dia sebelum saya dioperasi!’
Jika saudara adalah dokter yang merawat pasien ini, apa yang akan saudara katakan kepada pasien tersebut
Ilustrasi
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