HOSPICE & PALLIATIVE MEDICINE: Breaking bad news

Part of Contemporary Pediatrics’ coverage of the 2015 AAP Annual Conference. For more coverage, click here.

Delivering unsettling news to patients and families demands at least as much listening as talking, said Emma Jones, MD, and Christopher Collura, MD, during their interactive session “Breaking Bad News: A Roadmap for the Most Difficult Conversations,” which allowed attendees to role-play these skills.

Recommended: Bridging the gap

Bad news isn’t necessarily a cancer diagnosis. It can be anything a parent doesn’t want to hear about their child, from a diagnosis of head lice to a kibosh on an upcoming lacrosse season. It could even be things we might perceive as good news: “All your test results came back negative. You don’t have anything.” That may not be good news to patients or caregivers, because that means that no explanation has been found for their symptoms.

Furthermore, the physician’s job does not end with delivery of the news. Rather, the REMAP (Reframe, Expect emotion, Map what’s important, Align, Plan) mnemonic emphasizes the collaborative nature of medical communication and decision-making under difficult circumstances. At the core of REMAP lies the “ask-tell-ask” dynamic. Whether it’s good news, bad news, or news you’d rather not share for whatever reason, the presenters contend ask-tell-ask will always get you to the right place.

For example, one must discuss the possibility of a feeding tube for a child with cystic fibrosis who is not gaining adequate weight. The physician’s first question should attempt to elicit the family’s assessment of the situation, such as “How do you think things are going with nutrition?” After listening to the answer, tell the family your concerns: “Although the child is eating, I’m worried about poor weight gain. I recommend tube feeds and planning for a surgical G-tube in the next few weeks.” Then ask the parents again if they understand the recommendation; how they feel about it, and how does it compare with what they expected to hear?

In most healthcare encounters, the medical provider talks 90% of the time. The fundamental practice change is that ask-tell-ask provides opportunities to let the patient or family talk.

Emma Jones, MD, is an instructor of pediatrics, Harvard Medical School, Dana-Farber Cancer Institute, and Boston Children’s Hospital, Massachusetts.

Christopher Collura, MD, is an assistant professor of pediatrics, Mayo Clinic College of Medicine, Rochester, Minnesota.

NEXT: Commentary and the ask-tell-ask technique

Commentary

This is excellent advice for providers. Drs Jones and Collura have done an expert job of pulling together several key ideas for effective communication with patients and families. Audio recordings of doctor–patient encounters indeed show that providers do the vast majority of talking during encounters. The ask-tell-ask technique, which may need to occur in several cycles of “asking-telling-asking,” provides repeated opportunities to let the patient or family talk and for the pediatrician to listen.

Indeed, the ask-tell-ask technique can be used in many situations, not just when breaking bad news. We can use it all the time. For example, ask-tell-ask works well in instances in which the family or patient may have a concern and the pediatrician wants to provide information or reassurance.

Next: Leaning to care for mental health

Suppose a child presents with a rash that has the mother worried. A pediatrician could ask, “What is it about this rash that has you worried?” and then listen to what the mother has to say. Next, the pediatrician could respond to those worries by pointing out characteristics of the rash that are not worrisome or other information about the rash that would address her anxiety.

Finally, the pediatrician can say, “Now that we’ve talked about those things, are you still feeling as worried as you were when you came in?” As mentioned earlier, you may need to go through several rounds of the ask-tell-ask sequence before all the issues have been addressed, but parents (and older patients) report that being heard by their provider is, in itself, deeply satisfying.

Chris Feudtner, MD, PhD, MPH, is director, Department of Medical Ethics, The Children’s Hospital of Philadelphia; professor of pediatrics, medical ethics and health policy, and an associate chief, Division of General Pediatrics, University of Pennsylvania Perelman School of Medicine.