Breaking Bad News to Families in

Crisis: An Interdisciplinary Training

Approach Utilizing Personal Values
 Introductions

School of Behavioral Health, Department of

Counseling and Family Sciences
• Jackie Williams-Reade, Ph.D., LMFT, Associate Professor
• Elsie Lobo, M.S., MFTI, Doctoral Student
• Abel Arvizu Whittemore, LMFT, Doctoral Student

School of Medicine, Department of Pediatric Surgery

• Joanne Baerg, M.D., Associate Professor
 Learning Objectives

At the conclusion of this session, the participant will be able to:

• Design, implement, and evaluate a training program to enhance

compassionate communication skills in breaking bad news to
patients and family members.

• Describe relevant concepts of adult learning theory, behavioral

health and medical cultures, and family systems theory as they
relate to the acquisition of communication skills.

• Identify areas where behavioral health and medical

professionals can collaborate in interdisciplinary training
interventions in integrated healthcare settings.
Background
Learning Objectives for MedFTs
»Understanding of interpersonal and cultural differences
between medicine and family therapy
»Explain the benefits of medical family therapy to medical
care stakeholders
 Learning Objectives for Surgical
Residents
»Communication skills: core competency
» Specific skills: rarely taught
»Barriers to adequate training: a lack of curricula, time, and
supervisor skill.
»Holmes: the process of making patient care routine shifts the
patient from status as an individual with suffering to
the object of the physician’s work.

Holmes CL1, Miller H2,3, Regehr G4. (Almost) forgetting to care: an

unanticipated source of empathy loss in clerkship. Med Educ. 2017
Jul;51(7):732-739. doi: 10.1111/medu.13344.
Surgical Residency Background
» Goals and Objectives: The Accreditation Council for Graduate Medical
Education requirement: competency in communication and professionalism.
» A recognized paucity in curricula
» New requirement for resident curricula in the empathic communication of
bad news.
» The APD for General Surgery contacted the MFT Director
» A collaborative training was created
 Factors Contributing to the MFT and
Medical Cultures: Professional
» Basis of Knowledge Differences
» Orientation
~ Paradigm
~ Philosophical Stance
~ Goals
» Identity and Sovereignty
» Care Provided
~ Client / Patient Focus
~ Orientation
~ Exposure to Clients / Patients while in Professional Training
~ Interventions
~ Time Frame of Action
~ View of Organizational Resources
 Different, yet complementary cultures
MFT: A culture that…
»Allows for the tentativeness, “holding lightly”
»Recognizes the client as expert
»Values being relational
»Values collaboration
»Includes other core mental health professions
»Acknowledges the systemic and complexity
»Accommodates multiple clinical training
paths / approaches
»Is process oriented
Medical: A culture that…
»Is evidence, based, values objectivity
»Recognizes well defined roles / specialties
»Values individual expertise
»Rewards solo practitioners
»Stems from a well-established and cohesive
guild
»Aims for perfect outcomes
»Extensively socializes its members into the
profession
»Is action / results oriented
Our Project
 Compassion
»Compassion – 2nd of our 7 values – JCHIEFS
»Empathy – to feel what another is feeling, walk in their shoes
»Sympathy – to feel for another’s pain, implies distance
»Compassion – to be moved to action by another’s suffering
»“Compassion… is the mandate that drives those of us in the
healing professions to seek relief from suffering... But it must be
tempered. We talk about the "wall" or "guard" that we watch
develop, and even encourage, as we help students come to
grips with pain and loss as a necessary part of becoming an
effective professional.” ~Richard Hart, Notes from the President,
March 2016
 Breaking Bad News
»BBN poorly has negative impacts on patient satisfaction,
treatment decision making, and patient–provider relationships
(Reed, Kassis, Nagel, Verbeck, Mahan, & Shell, 2015).

»The process of BBN also affects medical professionals,

producing physiologic stress responses in both novice and
experienced physicians (Meunier et al., 2013).

»Goal: Teach residents how to be aware of and regulate

their own stress response in order to live out value of
providing compassionate, competent care
 Simulation Overview

Eight 2.5 hour educational seminars

2 residents per session
Behavioral health training clinic using 2-way mirror and
audio feed system
MedFTs as family members and trainers
Pilot study of family systems-based BBN curriculum
(that we created) based on Kolb’s learning theory
May and June 2016
 Family Systems Theory:
Bowen’s Theory of Differentiation
Main goal of Bowenian therapy is to reduce anxiety by
~ Differentiate between thinking and reacting/feeling
~ Being able to live true to one’s own values
Emotional Fusion / Emotional Cutoff
 Residents’ felt like they would either get lost in the patient/family
pain (fusion) or they had to shut down and distance (cutoff)
Differentiation: A place in between - aware and able to regulate own
emotions in order to provide compassionate, competent care
 Pre-Simulation Briefing

Provide a safe learning context: Normalize BBN is difficult

Previous experiences and concerns with BBN
Common worries: saying the wrong thing, want to do it perfectly, feeling
too little or feeling too much, didn’t know how to fix the pain
Values
What values would you like to exude as a physician when breaking
bad news? (common ones were compassion/empathy and
competence)
How can you bring those values to this encounter?
SPIKES and case study
Simulation and Feedback –
Kolb’s Four Stages of Experiential Learning

Stage I: Concrete Experience = Simulation

Stage II: Reflective Observation = “What did you do well?” “What
was challenging?”
Stage III: Abstract conceptualization = Discussed values and
emotional response; asked them to identify emotional responses and
work to exude their value more clearly
Stage IV: Active experimentation = 2nd role play, reflection and
encouragement
 What do MFTs have to offer?
SPIKES Framework Behavioral Health Clinicians Skills
S – Setting the Stage Warm Introduction; Providing context; Physical
positioning
P – Perception Listening Skills; Attending to Diversity (context-
gathering)
I – Inform Bad News is Coming Provide a warning to prepare for bad news
K- Knowledge Cadence and Tone of Voice; Being
Straightforward
Managing own anxiety
Balance of providing information details
Responding to family response
E- Empathy Key phrases / Non-verbal / Silent Presence
Managing emotions (self and other)
Conveying empathy while maintaining self
S- Summary and Strategy Closing conversation appropriately
Maintain connection
(Sternlieb,
2014)
The Results
Simulation Outcomes
 Self-Reported Outcomes
Post- 6-month
Pre-Sim. Hedges’ Hedge’s
Sim. post
Mean P g P g
Item Mean Mean
(SD) value (effect value (effect
(SD) (SD)
(N=15) size) size)
(N=15) (N=14)
How would you rate your 2.73 3.43 .006* -.80 3.36 .026* -1.27
skill at delivering bad (.80) (.82) * (large) (.50) (large)
news to patients/families?
How prepared do you feel 3.40 3.87 .014* -.55 3.36 .435 --
to deliver bad news to (.83) (.83) (med) (.75)
patients and families?
How confident do you 3.13 3.73 .023* -.65 3.79 .040* -1.18
feel in delivering bad (.83) (.96) (med) (.58) (large)
news to patients and
families?
Resident Evaluation of Simulation
% responding
“4-quite a bit”
Item Mean
or “5-very
much”
The simulation provided a positive learning 4.6 93.3%
environment
The simulation has increased my confidence in 4.1 80.1%
breaking bad news
The simulation has increased my knowledge in 4.4 86.7%
breaking bad news
The scenarios were similar to situations that I have or 4.3 93.3%
most likely will encounter clinically
The scenarios were at an appropriate level of difficulty 4.5 93.3%
The simulation has increased my ability in breaking 4.4 93.3%
bad news
The simulation should continue to be a part of the 4.5 86.7%
pediatric surgery residency
 What Residents Learned
Skills
•“how much tone of voice & touch play in conveying empathy and kindness
•“Learned how to approach family members and how to keep calm when things don’t go as expected”
•“I am trying to listen more and explain less”
•“Varying your approach by reading the patient’s family”
Self-Awareness
•“I’m aware of how your own anxieties change the way you come across”
•It was good to hear feedback about how my own reaction was perceived: what I intended was not always
what was perceived.
Outcomes
•“...families respond much better to direct conversation and thank me for it”
•“I am much more confident in my ability to be compassionate as well as direct and not ‘sugar coat things…”
Questions?
 Bibliography / References
Baile, W. F., Buckman, R., Lenzi, R., Glober, G., Beale, E. A., & Kudelka, A. P. (2000). SPIKES—a six-step protocol for
delivering bad news: Application to the patient with cancer. The Oncologist, 5, 302–311.
http://dx.doi.org/10.1634/theoncologist. 5-4-302
Bowen, M. (1978). Family treatment in clinical practice. New York, NY: Jason Aronson. Kolb, D. A. (1984). Experiential
learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice Hall.
Lamba, S., Offin, M., & Nagurka, R. (2013). Casebased simulation: Crucial conversations around resuscitation of the critically-
ill or injured patient. MedEdPORTAL, 9, 9367.
Lamba, S., Tyrie, L. S., Bryczkowski, S., & Nagurka, R. (2016). Teaching surgery residents the skills to communicate difficult
news to patient and family members: A literature review. Journal of Palliative Medicine, 19, 101–107.
http://dx.doi.org/10 .1089/jpm.2015.0292
Meunier, J., Merckaert, I., Libert, Y., Delvaux, N., Etienne, A. M., Liénard, A., . . . Razavi, D. (2013). The effect of
communication skills training on residents’ physiological arousal in a breaking bad news simulated task. Patient Education
and Counseling, 93, 40–47. http://dx.doi.org/10.1016/j.pec .2013.04.020
Meyer, E. C., Sellers, D. E., Browning, D. M., McGuffie, K., Solomon, M. Z., & Truog, R. D. (2009). Difficult conversations:
Improving communication skills and relational abilities in health care. Pediatric Critical Care Medicine, 10, 352– 359.
http://dx.doi.org/10.1097/PCC.0b013e 3181a3183a
Peterson, E. B., Porter, M. B., & Calhoun, A. W. (2012). A simulation-based curriculum to address relational crises in
medicine. Journal of Graduate Medical Education, 4, 351–356. http://dx.doi.org/ 10.4300/JGME-D-11-00204
Reed, S., Kassis, K., Nagel, R., Verbeck, N., Mahan, J. D., & Shell, R. (2015). Breaking bad news is a teachable skill in
pediatric residents: A feasibility study of an educational intervention. Patient Education and Counseling, 98, 748–752.
http://dx.doi .org/10.1016/j.pec.2015.02.015
White, S. J., Stubbe, M. H., Dew, K. P., Macdonald, L. M., Dowell, A. C., & Gardner, R. (2013). Understanding
communication between surgeon and patient in outpatient consultations. ANZ Journal of Surgery, 83, 307–311.
http://dx.doi.org/10.1111/ ans.12126
 Post-session evaluation
» - What expertise do professionals in your discipline have that can help to
enhance another profession?

- What are important components of Kolb's learning theory that should be

included in designing a curriculum that reflects your response to the first
question above.