You are in the Palliative Care Unit. You are asked to see the daughter of Mr Williamson. Mr Williamson is a 73-year-old man with metastatic mesothelioma. He is currently an in-patient for pain control following a pathological vertebral fracture. This is his 7th hospital day. He has widespread metastatic disease, and this morning your consultant has suggested putting him on a care of the dying pathway. He is currently on a fentanyl patch with prn Oramorph. A DNAR form has already been completed. He is conscious but intermittently agitated and drowsy.
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To start this scenario, it is important that the candidate acknowledges they have the appropriate consent. The candidate should introduce themselves and start by exploring the relative’s current understanding of the situation. The candidate should then elicit any concerns and expectations of the relatives. During this discussion, they should demonstrate empathy. Concerns should be addressed. The candidate should leave time for the relative to ask questions.
The ICE and SPIKES models are well-recognised frameworks that can be used by candidates in Communication Skills, and it can help you frame your discussion for breaking bad news.
Step 1: Setting Make sure that you’re in a private setting and invite the daughter to bring along someone for support. Before meeting with the relative, you will have already confirmed that you have the patient’s consent to discuss their case with the relative.
Step 2: Perception Use the ‘before you tell, ask’ strategy of starting with an open-ended question, such as: ‘Thank you for meeting with me today. My name is Dr X. So, we are meeting today to discuss how to best manage your father’s condition and in particular his pain control relating to his cancer, but I just want to start by establishing what you understand about his condition presently?’ The response to this open-ended question will allow you to determine how much the relative understands and, at the same time, offer the relative the opportunity to pose questions to you.
Step 3: Invite the relative to express how much they wish to know Examples of questions asked to the patient would be: ‘Sometimes patients and relatives want to go into detail about the management of their care, and other people would prefer to focus on the specific points. Before I start, I just wanted to establish what you wanted to discuss and how much detail you would like me to go into.’
Step 4: Giving Knowledge ‘Unfortunately, I've got some bad news to tell you’ or ‘I'm sorry to tell you that…’. (i) Pitch the discussion at the level of comprehension for the daughter (ii) Make sure that you use non-technical information (iii) Give the information in bite-sized chunks rather than all at once (iv) Periodically check the person’s understanding
At this point, it would be appropriate to discuss specific end of life issues. Introduce this by saying something along the lines of: ‘When patients have terminal cancer, and are nearing the end of life, there are specific targets for treatment that we try to address pre-emptively. To counteract pain, we prescribe medications that sometimes contain morphine. If the patient is unable to take this by mouth, then we can give this by injection, or sometimes via a pump to keep on top of pain. One of the sideeffects of morphine-based painkillers is constipation, and so to avoid this we usually prescribe laxatives to keep the bowels regular. Agitation is also common, and we will prescribe medication that can be given in case this occurs.’
Regarding the daughter’s concerns about the father suffering and speeding things up, you need to explain that although there is nothing that can be done to speed things up, one of the sideeffects of the morphine-based medications is something called ‘secondary effect’, which is that some of the medication that helps with pain control can in turn slow the breathing.
Step 5: Address the Emotions/offer an empathetic response In this case, the daughter is concerned about the prospects of her father’s suffering, and certainly for a long period of time. Although you cannot offer precise details, explain that when patients are less rousable and as poorly as her father, we are probably talking in terms of days to short weeks at the most.