Attention to the patient’s spiritual and religious needs Regular personalized revision of the care plan and access to services based on the changing needs of the patient and family
The final phase of life often has a spiritual and religious component, and research shows that spiritual assistance is associated with quality of care. Care must be person-centered and fit current circumstances, which may mean that not all the above components will be important or desirable in all cases.
COMMUNICATING LIFE-ALTERING NEWS
“The best way to convey meaning is to tell people what the information means to you yourself. And there are three words to do that: “I am worried.” They were such simple words, but it wasn’t hard to sense how much they communicated. I had given her the facts. But by including the fact that I was worried, I’d not only told her about the seriousness of the situation, I’d told her that I was on her side—I was pulling for her. The words also told her that, although I feared something serious, there remained uncertainties— possibilities for hope within the parameters nature had imposed.” 22 --Atul Gawande, MD Delivering bad or life-altering news to a patient is one of the most difficult tasks physicians encounter. 23 Ultimately, the determination of what is bad news lies not with the physician, but with the person receiving the news. Although classically related to cancer or a terminal diagnosis, bad or serious news may also include information related to diagnosis of a chronic disease (e.g., diabetes mellitus), a life-altering illness (e.g., multiple sclerosis), or an injury leading to a significant change (e.g., a season-ending knee injury). Most of the research into the delivery of bad news,
however, has focused on patients with cancer and subsequently applied to the delivery of bad or serious news in non-oncologic settings. Patients prefer to receive such news in person, with the physician’s full attention, and in clear, easy-to-understand language with adequate time for questions. Most patients prefer to know their diagnosis, but the amount of desired details varies among different cultures and by education level, age, and sex. The physician should respect the patient’s unique preferences for receiving bad news. Physicians may experience stress related to providing bad news that extends beyond the actual conversation. For example, physicians may be afraid of eliciting an emotional reaction, being blamed for the bad news, and expressing their emotions during the process. Physicians often withhold information or are overly optimistic regarding prognosis, but this can lead to confusion for patients regarding their condition. There are several algorithms available to help guide the physician in the delivery of bad news, including the SPIKES protocol (see Table 3). Skillful delivery of bad news can provide comfort for the patient and family.
Table 3. SPIKES protocol for delivering life-altering news 24
Step
Key Points
Example Phrases
Setting
Arrange for a private room or area. Have tissues available. Limit interruptions and silence electronics. Allow the patient to dress (if after examination). Maintain eye contact (defer charting). Include family or friends as patient desires.
“Before we review the results, is there anyone else you would like to be here?” “Would it be okay if I sat on the edge of your bed?”
Perception Use open-ended questions to determine the patient’s understanding. Correct misinformation and misunderstandings. Identify wishful thinking, unrealistic expectations, and denial. Invitation Determine how much information and detail a patient desires. Ask permission to give results so that the patient can control the conversation. If the patient declines, offer to meet him or her again in the future when he or she is ready (or when family is available).
“When you felt the lump in your breast, what was your first thought?” “What is your understanding of your test results thus far?” “Would it be okay if I give you those test results now?” “Are you someone who likes to know all of the details, or would you prefer that I focus on the most important result?”
Book Code: CA23CME
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