Breaking Bad News to Patients - Essay Example

Breaking Bad News to Patients: A Critical Look Breaking bad news to patients is difficult especially on people who are younger and those who want to live longer. Medical professionals try to give this information in a lighter stance, but that does not really happen in life. Somehow, strong emotions may contribute an unexpected reaction and direction towards a much difficult situation. Conversely, bad news with efficient nursing communicative skills to older people is undeniably lacking. There is what they call ageism insisting a principle of ignoring older people because they are not productive and will eventually face death. However, older people exhibit diseases and shorter life span because of bad treatment. In other words, the society and its communication to these people play a large part in health care services. Introduction A health care professional always thinks of a way on how to break bad news to patients. For these people, it is essential, difficult and often the most critical part of healthcare communication. For some, breaking bad news to patients is an innate skill. Patients have a hard time disclosing their feelings or find it necessary to establish a relationship of trust to be able to more easily accept the disclosure of such news. Presenting bad news to patients may give a negative result that may in turn lead to serious harm. All of these beliefs are made with a strong sense of suspicion; breaking bad news to patients is a skill learned rather than a talent. Medical doctors, for example, have in their education an area of learning good communication skills that entails a long period of learning (Back, 1999). The Role of Healthcare Professionals in Breaking Bad News According to Buckman (2007), a healthcare professional should follow a six part protocol on breaking news to patients: Preparations – in ethical terms, the atmosphere provided should be private on both the part of the patient and the medical professional. In general, patients have varying needs; hence, it is appropriate to discuss with the patient who he/she wants to be the recipients of the information and major decisions like how much should be the information. Statements such as “How are you feeling right now?” would help the patient prepare himself for a two-way affair. Finding out how much the patient knows – in such aspect asking a question such as “What have already been told about your illness?” may be essential. This approach would likely measure the patient’s knowledge about his/her illness. It is also appropriate to ask patients how much they have understood on the information given, the patient’s level of technical comprehension and most of all is his/her emotional status. Finding out how much the patient’s capacity of accepting information – patients should have a say in the capacity or content given by the medical professional. In other words, bringing up bad news has no right answer and a way to establish the right of the patient to choose, give him/her the chance to establish the information content. Sharing the information – before talking with the patient, prepare the agendas to discuss like the diagnosis, treatment, prognosis, and coping. However, a right agenda only covers two of the aforementioned areas. It is not useful to discuss in a long medically termed context. It must be simple and comprehensible; hence, medical terms are translated in simple, understandable English. Responding to the patient’s feelings – understanding the patient’s reaction is important. However, this skill improves through experience, as with the enhancement of acknowledgement and identification. Planning and follow-through – all gathered information ought to have apt documentation for further planning of the patient’s situation. A step-by-step plan given to the patient will be in his/her system of healthcare (Buckman, 2007, as quoted from Back, 1999). The nurse’s decision of family care mostly depends on the NHS Plan and the Code of Professional Conduct. Communicative skills of a nurse are an important interpersonal skill in building trust in families of patients and the patient himself. To develop good skills in communication to patients in breaking bad news, one reliable tool is the Leske’s Inventory. This inventory will assess the family’s needs, which the nurse needs to prioritize in time of stressful events happening in unfamiliar environments. Leske’s inventory will work on critical intimidating care and other fields of healthcare. However, many critical care nurses lack the skill and training for better communicative skills in delivering bad news. To give a holistic care, nurses should be able to plan, implement, and evaluate the individualized family needs effectively. Hence, the care will result in autonomy when managing both the family and the patient’s empowerment occurs (Back, 1999). Sensitivity in Delivering Bad News to Patients with Life-Limiting Illnesses Breaking bad news should be sensitive in many ways, with ample consideration of the patient’s ethnic background, gender, and social class. Patient information and the common errors for breaking bad news are presented in the following discussion. One life limiting illness where breaking bad news happens is caring for people with cancer (Moody, 2003). One case study presented on breaking bad news to cancer patients covers the role of nurses in holistic caring, that is, physically, emotionally, and spiritually. The case study consisted of 15 nurses working at the Peter MacCullum Cancer Institute interviewed based on the Colaizzi Method (Colaizzi, 1978) where breaking bad news to patients is common. The approach in this study mainly aims to describe the “total structures of the lived experience, including the meaning of these experiences have for the participants” (Omery, 1982, p. 50). All interviews are tape-recorded and transcriptions of the data analyzed. Nurses who participated in this study concluded that their part does not stop in just breaking out the news to patients but also in looking after the aftermath of the delivered information. Though the delivery of information does not concern mainly the nurses’ role in the general practice, still these healthcare professionals experience delivering bad news when the patient died or after reading the pathology results. In this case study, nurses somehow broke into the realm of medical professionals in breaking bad news because they are much concerned of the nurse-client relationship. In this event, nurses mean to interrupt when the doctor is not available to deliver the information and the doctor needs some time to deliver the information. As a whole, the nurse’s concern is caring for the patient. The findings and analysis of the nurses had made to evoke caring after breaking the bad news are: Nurses’ Caring Role – this is an essential role of nurses in health care concerning breaking bad news to patients. Care should be in a number of levels, which are physical/practical, emotional and the spiritual level. As seen in Table 1, nursing care does not end with telling the news rather the continuation. Practical/Physical caring – nurses saw the importance of how to break the bad news to patients. In other words, facts in the form of accuracy and honesty are important not only to patients but also to nurses as well. Processes involved in this area are: preparation of nurses in finding out the facts, preparation of the patient and aftermath of telling the news. Nurse Patient Relationship – this area is important in knowing how to break the bad news and what to do after telling that information. The reason for this response is that the nurses wanted to establish a strong relationship with their patients. First in achieving this is the Centrality of the Relationship, which speaks of the volition concerning the nurse with the patient. Second is knowledge of the patient, which involved the importance of determining the method in breaking the news. Last is the Reciprocity in Caring, which involved personal, emotional, and spiritual aspects of both the patient and the nurse. Nurse Personal Aspects – this will determine the nurse’s concern over her patient after the patient hears of the news. The nurse in turn will provide the appropriate care and attention to this patient. In addition, nurses feel positive and negative emotions about the situation. When nurses feel a positive emotion after breaking the news, they respond with deep caring and reciprocity of caring. While on the negative part, nurses felt they were unprepared or inadequate in informing patients about the situation. Patient’s Personal Aspects – in this field, patient’s background will generally affect how they receive the bad news. Nurses in turn will only respond to what their patient indicates about the bad news. As such, care for the patient may vary according to the response. Surrounding Circumstances – these are the indirect factors, which also affect the situation of accepting or preparing the patient for the bad news such as the medical and nursing roles, which are part of the social and cultural expectations in the hospital. In addition, time allotted for medical care gives the nurse the availability to apply that nursing intervention. Finally, the nurse should also have that team compatibility in order to work with others who can assist in breaking news to patients (Tylee, McKeown & Tylee, 2007). The importance of nurses in caring for patients before breaking bad news establishes sensitivity and trust on both sides. To break bad news is to have enough courage and understanding of the patient and that the ideal environment for the patient to hear about the bad news is when a strong relationship exists between them. For the nurse to provide positive care to the patient the outcome involves the emotions of both the nurse and the patient as interaction and needed care happens. While these suggestions may sound positive, these do not always happen in reality. Most of the negative aspects outnumber the positive outcomes and according to nurses interviewed, stress evidently occurs. Going to the spiritual aspect of caring for patients, the skills needed to give care in this area is rather scarce. Ideally, the nurse should provide holistic care to patients but with the growing advancements in medicine, this chapter of healthcare is commonly overlooked. On these participants, care established minimizes the number of negative situations with utmost deep care for patients. These concerns not only cover the spiritual relationship but also of the whole nurse-client relationship (Tylee, McKeown & Tylee, 2007). Communication as a Core Competence of the Health Care Professional Consequently, communication skills in nursing are very crucial in verbal and non-verbal aspects. This is difficult and in most situations where nurses prove to be inefficient in this field, the nurse patient relationship declines. Of course, the principle of nursing is to provide quality care to patients. Nurses have to be sensitive and at most are to have high threshold tolerance so that he/she will be able to communicate effectively concerning the needs of the patients and the doctor’s requirements. Hence, the communication between nurses and patients should be mutual, given that the nurse should not only receive and give information but to understand the patient. To address properly the needs of the patient, the nurse patient relationship should convey communicative interaction (How is Communication in Nursing a Nursing Essential, 2007). The nurses should follow strict guidelines when communicating with patients. First, exclude the personal feelings of one’s self unto the patient’s boundaries. Nurses should explicate themselves in a friendly manner but not too sociable with patients and doctors. Second, the communicative skills of nurses is structural, meaning, it can include interviewing or teaching. When interviewing, the needed information should be asked so that the job is carried out effectively. On the hand of teaching, nurses should inform the patient and those involved with the patient, which in turn would regulate the health needs of the client. Finally, the nurse should have a concentration on the given time constraints. Meaning, the relationship of the nurse to the client should be in the act of purposefulness. In effect, the relationship provides care to the patient as well as to the nurse. Information sharing can identify, resolve, or help the patient adapt to the health situation. In addition, communicative skills of nurses are in non-verbal and verbal forms. To use one of the two should declare a clear, simple, point, and time appropriate so that there is an aversion for misinterpretations. Significantly, touch between the communicative skills of patients and nurses are important. Such as hard or rough touches that may conclude harsh communication on the part of the client. Hence, nurses’ touch can affect greatly the patient’s condition. On the other hand, a nurse who does not listen exemplifies the worst lack in communication skills. Nurses who do not listen to their patients express a negative and harmful behavior. The nurse should always listen even though the meaning may indicate insignificant information on the nurse’s part. The patient’s reliability to the nurse’s credibility is very high, so effective communication means effective health care (How is Communication in Nursing a Nursing Essential, 2007). Health of Older People and the Role of Effective Communication Older people’s health and its proper maintenance offer not only a decreased event of chronic illnesses but also of a society made up of economic and social benefits available to the society. Many older people have survived in over the age of 65. Hence, promotion of health among older people has made a difference. Other positive changes that occurred for elderly care is the increasing population of older people aged over 65, where 41 percent of NHS budget is allocated. In addition, more and more older people have increasing demands of health care because of change in family structures with older people living alone (Health Education Authority, 1997). The informal care experienced by older people in the recent years is a result of media, and social and health provision in the labor market concerning the culture of ageism. This commonly happens with patients over the age of 65. Observing these insufficient health care services, older people expect less of the services offered and lower awareness of health care. In addition, there is a debate about the meaning of longer life, which subsides in the contexts of worsening health or ‘compression of morbidity.’ U.S. data on older people with disabilities and fewer chronic conditions are clearer and evident compared to UK data (Manton, 1995; Bone, Bebbington, Jagger, Morgan & Nicolaas, 1995). This information proves of older people’s chance in maintaining a quality life with activities that will give independency and productivity throughout life (Health Education Authority, 1997, p. 4). Disease in old age can decline. According to the Health Education Authority (1997), much of the older people can remain active and independent even though there are threats of chronic conditions and disorders. Health promotion gives much benefit to older people such as prevention of smoking and hypertension through consistent modification of risk factors. Coronary heart disease decreases because of subsequent advice on engagement to physical activities. In addition, these preventive measures prove to be cost-effective and prevent later deterioration and lower independence. Communicative factors of nurses towards older people prove to have more engagement with the society, one of the risk factors. There are several evidences that prove of social inequalities as a factor for older people’s sickness. For instance are men and women who consistently experience unlikely social, economic, and environmental influences. The result is a shorter life span and often more persistent disabilities. Personal and collective actions contribute to the outcomes of health benefits (Health Education Authority, 1997). A Multi-Perspective Framework for Promoting the Health of Older People Tackling Diseases primarily through primary and secondary preventive measures, which address lifestyle and other risk factors. The areas to be addressed are cardiovascular disease and stroke, osteoporosis, osteoarthritis, breast cancer, dementia, depression and iatrogenic disease. Ensuring Personal Independence and Autonomy through maintaining and restoring physical and mental functioning capability. Measures focus on personal mobility and effective rehabilitation. This covers both prevention of further loss of functional ability in individuals who are already disabled, as well as primary prevention of disability. Conditions to be addressed include lack of mobility, incontinence and hearing and sight impairment. Active Participation of older people in the Community, and their active use of services. This is dependent on social networks and provision of accessible and responsive services that enable older people to help themselves. Interventions aim to develop personal resources for health and encourage active participation in the community. Supportive Public policies and social climate, which recognize the rights and values of older people society. This requires changes in structures and attitudes in the society. Ageism, socioeconomic marginalization, and lack of informal social supports are important social issues with consequences for people’s health. Health Education Authority, 1997. Factors Affecting Nursing Communication towards Older People Apathy Younger people understand why they should perform preventive measures in order to decrease the occurrence of a disease. Moreover, people who spoke of healthy behavior meant that it would increase their life span and lower independence; hence, the continuing lifestyle would be more active until retirement. However, this does not happen on older people. They much say that health promotion is not anymore necessary because they believe that death is soon to come. In addition, they could not see themselves restricting foods that are pleasurable, particularly those elderly that are isolated. Another is that older people feel weak or have no sufficient energy to perform such healthy behaviors and thinks that it would be much proper to eat foods that will add enjoyment to life (Fee, Cronin, Simmons & Choudry, 1999, p. 66). Ageism in the Health Services Research has shown that not only young people see older people as burdens but also the medical professionals. These studies participated by some members of the elderly have concluded that they experience absence of care when it comes to seeking medical advice. This may be due to the ‘internalized ageism’ and perceived ageism in many health professionals. For instance are doctors working in the North of England, where they perceive older people as ‘nuisance’ (Fee, Cronin, Simmons & Choudry, 1999, p. 68). Some cited events of obvious ageism in some parts of the medical field are: Longer waiting lists for degenerative replacements. Lack of knowledge among health professionals on diseases. Preferential treatment for older people Lack of screening for old age groups, such as mammograms The withholding of certain treatments. Refusal to treat conditions A general reluctance to waste money on older people. (Fee, Cronin, Simmons & Choudry, 1999, p. 70) Accurate Information on Health Matters and Food Safety Yes, as health professionals, providing information concerning health promotion is important. However, there has to be a sufficient consideration on older people’s capacity to acquire such information. Older people want more than information, credibility. A more credible health professional would help an older person to accommodate the chance of healthier living and some how will not feel isolated anymore (Fee, Corin, Simmons & Choudry, 1999, p. 71). Recommendations The difficulty of relaying bad news to patients with life-limiting illnesses is not a confined, parochial phenomenon, but something that adversely affects nursing practice globally. In fact a study by (Liu, Mok, Wong, Xue & Xu, 2007) assert that there is a significant lack of training on oncology-specific training on some countries such as Mainland China. To address, the problem on this area, a learning session with an appropriate atmosphere supporting such learning will enhance the nurse’s skills on their workplace and have the support of their senior nurses. A study consisted of 129 nurses on a quasi-experimental design with a non-equivalent group as control. Measures, including basic communication skills, self-efficacy in oncology-specific communication skills, communication outcome expectancies, and self-perceived support for communication, were administered at pretraining evaluation, formative evaluation (1 month after training), and summative evaluation (6 months after training) in the training group (Liu, Mok, Wong, Xue & Xu, 2007). The results on the nurses’ integrated study gave a positive outlook in overall basic communicative skills, self-efficacy, outcome expectancy beliefs, and aid from the support group. Hence, the overall enhancement of nursing communication skills were improved on the integrated communication skills training model. However, negative outcomes were not included in such study. According to another study involving 34 nursing and medical students, simulated events were contributing greatly on their improvement on instant feedback from their patients. These aided greatly on the strategies of imparting bad news to patients and pairs of student doctors and nurses enabled them not to feel isolated and to feel strongly prepared. It has been suggested that this form of teaching to students will result in better communication skills, specifically in delivering bad news to patients with life limiting illness. The simulated approach enhanced the patient-practitioner and the practitioner-practitioner interaction (Wakefield, Cooke & Boggis, 2003, p. 32). Communication among minority ethnic groups in UK are not given on a quality basis, rather different problems arise because of language differences. In a study funded by the Luton Health Action Zone, the role of communication is not satisfactory; rather effective palliative care services are incorrect or not readily recognized. Hence, a problem on cultural competency apparently exists (Randhawa, Owens, Fitches, & Khan, 2003, p. 24). Conclusion Palliative care administered by nursing concerning communication skills is a critical issue that remains to be effectively addressed through both policy and practice. It covers the utmost promise of clear but comprehensible outreach to people who want clear manifestations on effectively breaking bad news to patients with life limiting illnesses. Several problems such as cultural competence and sensitivity and the adoption of a holistic approach may possibly increase effectiveness of health care delivery among these groups. Conversely, nursing communication in elderly people seems lax. They see older people as unproductive citizens who only anticipate death. Hence, more of the elderly population look at health behavior and promotion as unnecessary and perhaps bad news to medical professionals and other young people may indicate good news. References Back, T. (1999). Breaking Bad News. Retrieved December 25, 2007 from http://depts.washington.edu/bioethx/topics/badnws.html. Bone, M.R., Bebbington, A.C., Jagger, C., Morgan, K., & Nicolaas, G. (1995). Health Expectancy and its uses. London: HMSO. How is Communication in Nursing a Nursing Essential. (2007) Retrieved December 25, 2007 from http://www.yourcommunicationskills.com/communicationinnursing.html. Fee, L., Corin, A., Simmons, R. & Choudry, S. (1999). Assessing older people’s health and social needs: Qualitative Research investigating health beliefs and social factors relevant to older people’s health. 77 pages. Health Education Authority. Health Education Authority. (1997). Promoting the Health of Older People: A Compendium. 125 pages. Liu, J., Mok, E., Wong, T., Xue, L. & Xu, B. (2007). Evaluation of an Integrated communication skills training program for nurses in cancer care in Beijing, China. Nursing Research, 56(3). Manton, K.G. et al. (1995). Changes in morbidity and chronic disability in the U.S. elderly population: evidence from the 1982, 1984 and 1989 national long-term survey. Journal of Gerontology. 50B. Omery, A. (1983). Phenomenology: A method for nursing research. Advances in Nursing Science,5: 49-63. Randhawa, G., Owens, A., Fitches, R. & Khan, Z. (2003). Communication in the development of culturally competent palliative care services in the UK: a case study. International Journal of Palliative Nursing, 9(1): 24-30 Tylee, J. McKeown, P. & Tylee, P. (2007). Registered nurses’ experiences of breaking bad news: a phenomenological study. Retrieved December 20, 2007 from http://www.education4skills.com/jtylee/breaking_bad_news.html. Wakefield, A., Cooke, S. & Boggis, C. (2003). Learning together: use of simulated patients with nursing and medical students for breaking bad news. International Journal of Palliative Nursing, 9(1): 32-38. Wilkinson, S., Roberts, A. & Aldridge, J. (1998). Nurse–patient communication in palliative Care: an evaluation of a communication skills programme, Palliative Nursing, 12(1): 13-22. Read More