Giving Bad News
告知坏消息

·Learning objectives
学习目标
·List the 6 steps in giving bad news
列举告知坏消息的六个步骤
·Adapt the bad news protocol to your work setting
调整工作中告知坏消息的方式
·Explain how the manner in which bad news is given can impact patient outcome and patient care
解释告知坏消息的方式对患者结果和照顾的影响
·Explain how culture impacts patient information needs and decision-making
解释患者信息需求和决策的文化影响
·Consider a case
讨论案例
24-year-old F; HIV+ for 3 years; current IVDU
24岁女性，HIV三年，静脉吸毒
Unstable living situation
Estranged from family
家庭疏远
On HAART, but questionable adherence
高效抗逆转录病毒治疗，但依从性可疑
Recent abnormal LFTs
近来肝功能异常
You are meeting with her to give her a Hep C diagnosis
你将接诊并给予丙肝诊断
·Do physicians give bad news?
医生告知坏消息吗？
·1961 Oken in JAMA
Survey of 219 physicians
调查219名医生
88% generally DID NOT inform patients of a cancer diagnosis  
88％不会告知癌症诊断
·1979 Novak in JAMA
Survey of 264 physicians
调查264名医生
98% generally DID inform patients of a cancer diagnosis
98％会告知癌症诊断
·Giving bad news告知坏消息
Reviewing the evidence
审查证据
Recommendations for clinicians
对医生的建议
Cultural considerations
文化考虑

·Reviewing the evidence审查证据 
What do patients want to know?
什么是患者想知道的？
How do patients experience bad news?
患者对坏消息的体验是怎样的？
How competent are physicians in giving bad news?
医生如何胜任告知坏消息？
How should physicians give bad news?
医生如何告知坏消息？
Does how bad news is given make a difference?
如何告知坏消息会有不同吗？
Do cultural differences matter?
文化差异会怎样？
·What do patients want to know?
什么是患者想知道的？
2,331 patients at UK cancer centers:
英国癌症中心的2331名患者
 –98% wanted to know if the illness was cancer
98％想知道是否罹患癌症
 –87% patients preferred “as much information as possible”
87％患者希望得到尽可能多的信息
Need to individualize delivery to patient needs
需要个性化考虑患者的需求
·How do patients experience bad news?
患者对坏消息的体验是怎样的？
Bad news results in a cognitive, behavioral, or emotional deficit in the person receiving the news that persists
坏消息导致一个认知上的、行为上的或者情感上的缺陷并持续存在
Clinicians can’t change the news
医生不能改变这个消息
Clinicians can make the news worse, or they can help give realistic hopes
医生可以使消息变坏，或是能够帮助给予现实的希望
·A variety of responses to bad news
对坏消息的反应
100 patients diagnosed with cancer:
100名诊断为癌症的患者
Shock 震惊          54%
Fright  惊恐          46%
Accept 接受         40%
Sadness  悲伤     24%
Not worried  不担心 15%
·Responses to bad news
对坏消息的反应
4,527 patients tested for Huntington disease
4527名患者被检出Huntington病
<1% experienced “catastrophic event”
<1%体验到“灾难事件”
Including suicide, attempted suicide, psychiatric hospitalization
包括自杀、试图自杀、精神病发作
Increased risk associated with
增高的风险涉及
those with manifestations of Huntington’s
Huntington病行为
those with previous psychiatric illness
此前的精神疾病
those who were unemployed
失业者
·People receiving bad news may not remember much
接受坏消息的人容易遗忘
Three months after parents received bad news
三个月后父母收到坏消息
12 of 23 sets  took in “little or none of the information given”
12/23中理解一点或者不理解被告知的信息
4 of 23 sets denied that a separate information session had occurred
4/23否认存在部分信息
10 of 19 sets remembered the information session, but didn’t understand the content
10/19记住了信息，但是不理解内容
·Medical jargon can make bad news worse
医学术语会让坏消息更糟糕
Technical language frequently unclear
技术语言通常不清晰
100 women with breast cancer:
100名乳腺癌妇女
73% misunderstood “median survival”
73％不理解“中位生存期”
No agreement on what a “good” chance of survival meant numerically
不接受在数字意义上的生存机会
·Physicians are inaccurate in detecting distress
医生在发现精神痛苦方面的错误
5 oncologists studied intensively
对5名癌症专家的细致研究
None predicted patient distress better than chance
没有更好地预见患者精神痛苦
One had negative predictive behavior
一名否定预见行为
All very satisfied with their performance
全部对自己行为满意
Little probing about patient emotional state
很少探察患者情绪状态
·Patient and clinician stress related to bad news
医患对于坏消息的反应
Gaps in what patients want and what they receive
患者想知道和已知道之间的差距
Most patients are highly ‘satisfied’ yet:
大多数患者比较满意，但是
57% wanted to discuss life expectancy, but only 27% actually did
57％想讨论期望生存期，但仅27％实际得到
63% wanted to discuss the effects of cancer on other aspects of life, but only 35% actually did
63％想讨论癌症对生活其它方面的影响，但仅35％实际得到
·Pitfalls in giving bad news
告知坏消息的缺陷
79 patients, 68 family said bad news encounter was suboptimal because:
79名患者、68名家属述及认为告知的不理想，因为
Physician was too blunt
医生太生硬
Place or time was inappropriate
地点或时间不合适
Patient got the sense that there was no hope, they wanted physicians to balance sensitivity and honesty
患者感觉到无望，他们希望医生对敏感和诚实之间作出平衡
·How bad news is given makes a difference
如何告知坏消息会有不同吗？
100 patients with breast cancer, adjustment to illness correlated with:
100名乳腺癌患者在疾病适应调整方面涉及
Physician behavior during cancer diagnostic interview
癌症诊断会谈时的医生行为
History of psychiatric issues
精神病史
Premorbid life stressors
病前生活紧张因素
Patients dissatisfied with how physicians provided information were 2x more likely to be depressed or anxious
患者不满意医生提供信息时抑郁或焦虑增加两倍
·A recommended protocol for giving bad news
告知坏消息的建议
Prepare info, location, setting
准备信息、地点和摆设
2. Find out what they already know
了解已经知道的信息
3. Ask how much they want to know
询问想知道的信息
4. Share the information
分享信息
5. Respond to the patient’s emotion
对患者情绪作出反应
6. Negotiate a concrete follow-up step
商量具体的下一步
·Bad news protocol
Prepare
准备
Know the facts
了解事实
Find time
明确时间
A quiet space
安静的场所
The right people
合适的人

Nonverbal cues: distance, posture, eye level
非语言交流：距离、姿势、眼光水平
Bad news protocol
Find out what the patient already knows:
了解已经知道的信息
“I want to make sure we’re on the same page; what have other doctors told you?”
我要确认一下我们是同步的，其他医生告诉你了些什么？
“When you first had (symptom), what did you think it might be?”
当你第一次有症状的时候，你以为可能是什么？

·Bad news protocol
3. Ask how much the patient wants to know:
询问想知道的信息
“Would you like me to tell you the full details of your condition or is there someone else you would like me to talk to?”
你希望我告诉你全部状况的细节还是你想让我告诉什么别的人？
Bad news protocol
4. Share the information:
分享信息
Warning shot
预先警告
  “I have some bad news about the results of your blood test.”
我有些坏消息是关于你的血液检查结果的

·Bad news protocol
4. Share the information:
分享信息
Use language at the same level as the patient’s:
在患者同水平上使用语言
“Did you get that? Did that make sense to you?”
你了解吗？你可以理解吗？

·Bad news protocol: Final steps
5. Respond to the patient’s emotions:
对患者情绪作出反应
–Acknowledge, name, empathize
承认、命名、同情
“I can see that this wasn’t something you expected to hear.”
我可以理解这不是你希望听到的
–You don’t have to agree with the emotion or share it.
你并非必须认可这种情绪或者参与其间
·Bad news protocol: Final steps
6. Negotiate a concrete follow-up step:
商量具体的下一步
“Let’s talk next week after you see the GI specialist.”
让我们谈论下周你见过胃肠专家之后的事情吧

·Dealing with the fallout
Walk through the bad news encounter
全程经历遭遇坏消息
Use case-specific knowledge
使用个案知识
Know usual clinician pitfalls:
了解常见医生缺陷
Failure to assess understanding
达成理解失败
Failure to acknowledge emotion
应对情绪失败
·Survey of 800 patients in LA: Assessing cultural differences
调查LA800名患者：评价文化差异
Should a patient:
   Be told of a         Decide
   diagnosis       about
   of cancer           life-support  
African-American 88%      60%
European-American 87%      65%
Mexican-American 43%      41%
Korean-American         35%      28%
·Can discussing death cause harm?
讨论死亡会导致伤害吗？
Studies have shown that people from many different cultures are more likely to believe discussing death can bring death closer:
研究显示来自许多不同文化人群更相信讨论死亡会带来死亡
African-Americans非裔美国人
Some Native-Americans某些土著美国人
Immigrants from China, Korea, Mexico
来自中国、韩国和墨西哥移民
·Exploring cultural beliefs
探索文化信仰
What do you think might be going on?
你认为接下来会怎样？
If we needed to discuss a serious medical issue, how would you and your family want to handle it?
如果我们需要讨论严重医学问题，你和你的家属希望如何处理？
Would you want to handle the information and decision-making, or should that be done by someone else in the family?
你希望处理信息和决策或是交由家庭中其他人来做？
·Summary
概要
Giving bad news is a fundamental communication skill
告知坏消息是一个基本的沟通技巧
How bad news is delivered can affect how patients adjust to the illness
如何传递坏消息能够影响患者对疾病的心理适应
Exploring cultural beliefs is important in adapting the bad news communication to each patient
探索文化信仰对适应与每个患者进行坏消息沟通是重要的