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BREAKING BAD

NEWS

IIT FITRIANINGRUM
DEPARTEMEN BIOETIKA DAN
HUMANIORA
PRODI PENDIDIKAN DOKTER FK UNTAN

BACKGROUND

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
Breaking Bad News/EBP3KH
TA.2014/2015

What is Bad News?

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 recipients 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
Breaking Bad News/EBP3KH
TA.2014/2015

Why It is Hard to explain bad news to


the patient?

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)
Breaking Bad News/EBP3KH
TA.2014/2015

How to Inform the Bad News to


Patient?

Setting up the interview


Perception of the patient
Invitation by the patient
Knowledge to the patient
Emotions of the patient
Strategy and summary

Breaking Bad News/EBP3KH


TA.2014/2015

Setting up the
interview

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

Breaking Bad News/EBP3KH


TA.2014/2015

Perception of the
Patient

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
Breaking Bad News/EBP3KH
TA.2014/2015

Invitation by the
patient

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
Breaking Bad News/EBP3KH
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Knowledge to the
patient

Give a warning shot


Unfortunately, I have some bad news to tell you....
Im 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...
Breaking Bad News/EBP3KH
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....Knowledge to the
patient

Give information in small amounts, then


periodically check the patients understanding
Ive 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
Breaking Bad News/EBP3KH
TA.2014/2015

Emotions of the
patient

Respond to the patients emotions with


emphaty
Often shock, isolation, disbelief, grief or anger
Observe for emotion on patients part
Identify emotion
Identify the reason for the emotion
Connect with patient

Breaking Bad News/EBP3KH


TA.2014/2015

...Emotions of the
patient

Doctor : Im sorry to say that the X-ray shows


that the chemotherapy is not working [pause].
Unfortunately, the tumor has grown
somewhat
Patient : Ive been afraid of this! [cries]
Doctor : [moves his chair closer, offers the
patient a tissue and pauses,] I know that this
isnt what you wanted to hear. I wish the news
were better
Breaking Bad News/EBP3KH
TA.2014/2015

...Emotions of the
patient

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
Im sorry to have to tell you this
This is very difficult for me also
I was also hoping for a better result
Breaking Bad News/EBP3KH
TA.2014/2015

...Emotions of the
patient

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?
Breaking Bad News/EBP3KH
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...Emotions of the
patient

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 patients isolation and validate the
patients feelings/thoughts as normal and to be
expected

Breaking Bad News/EBP3KH


TA.2014/2015

Strategy and
Summary

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
Breaking Bad News/EBP3KH
TA.2014/2015

Falsehood is so easy,
truth is so difficult

(George Elliot)

Breaking Bad News/EBP3KH


TA.2014/2015

Ilustrasi

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
Breaking Bad News/EBP3KH
TA.2014/2015