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Breaking the Bad News

Dec 09 | 1:30 PM

One of a physicians most challenging responsibilities is to deliver bad news, but medical school often provides little formal preparation for this daunting responsibility. The anxiety and uncertainty associated with giving bad news might compel physicians to emotionally disengage from their patients. Join us as we discuss this difficult task with Dr. Roma Kumar (PhD), a Clinical Psychologist with over 30 years of experience.

good evening everyone i'm dr niveda and on behalf of netflix i welcome you all to today's session on breaking the bad news um if though it's an important part of a physician's job description it's often the most neglected part in the med school curriculum so today we have with us um dr rama kumar who is a senior psychologist with over 30 years of experience um working with shri gangaram hospital in new delhi and max super specialty hospital she's also the vice president a vice chairperson at the department of psychiatry and behavioral sciences at sri gangaram hospital delhi along with that she's the founder director of suction and she's the co-founder of emotionally in we know that uh the topic for today is a tough one and we actually need to get trained on such a topic you know this topic doesn't um you know it doesn't gel with everybody we don't become in sync with while we are doing this you know delivering negative news especially when it's a negative news when it's a positive news it's very easy to handle in your communication skills are good enough to do that uh but delivering this uh you know bad news is uh it's a clinical skill you know and so what is most important it has to be a patient-centered communication you know it's rather very multifaceted task and it of course needs a lot of empathetic communication you know when i say empathetic communication it i mean that you need to be kind you need to be soft you don't need to raise your voice and you need to make good eye contact you know all those skills are needed when you are imparting this news to someone you know put yourself into those shoes and see for yourself when you are going to get some news like this what happens to you it's a simple task like if you uh if you've been a school student which most of us have been school students and we've got our parents there you know and the teacher is saying something very negative about us oh my god you know and the mom looks at you like how dare you did this okay you really did this so it's like delivering a negative news is the toughest one and to then the person who's getting it there's always the first thing that happens is um denial that no this couldn't be for me especially if it's end of life especially if it's a life-ending diagnosis or if it's a chronic illness so for children if it is maybe you know the worst diagnosis that a lot of parents think is the autism spectrum disorder coming to them you know or the child having some disability or the older people where you feel that you have to go in for a surgery or it's uh you know some blood disorder which has taken place or there's some chronic ailment you know so delivering such a news means that it requires a lot of professionalism a lot of patience and a lot of energy now that energy needs to be the softer one you just need to be very patiently listening to the person and also imparting your knowledge to that person you know or obviously you're going to share a part of your knowledge to them so you also need to see how patient and the family will react to that situation because very often i myself have seen a reaction which is like you know i was imparting a news about a child and this lady you know looks at her husband and says that i think you need to get remarried to someone else because i haven't been able to give you a child who's a normal child you know so it can be a very devastating experience for the person who's getting that news you know there's a lot of the degree of distress is very very high and that degree of distress can actually uh create problems you know and especially for the person also who's delivering that news you know also it's not just delivery of the negative news it's also meaning that you have to discuss some future plans you know it's not just the diagnostic you have to have some future plan you have to have you have to show that there is hope you know and there's realism and there's hope it's not imaginary because the first time when this diagnosis comes to the person there's denial and there's also doctor shopping then you know they have consult let's go to someone else so you start talking to everybody that this is not possible how can this be possible that it can happen to me why me because this person is going through that distress within himself or herself or as a family you are going through that distress you know so as a as a doctor as a professional your body language should be such that the person doesn't get intimidated by you you also need to minimize distraction that means you're not going to take calls at that time you're not going to be on your phone that time you're not going to have like 20 people reach out in your room and it's a very busy opening so you need to make some effort in how you impart that news you know what is your setting in which you are trying to impart that news you know is it an appropriate place i hope there's not too much noise there you know and you're able to make the person or the family comfortable in that setting you know the background is most important so there are there are a few protocols that we are trained to follow you know something known as a breaks or something known as spikes where all ah you know we we need to impart this news according to that protocol uh what is the person's perception when you're saying this you know check this out with the person what do you think is doing to you what and in our country we don't like to talk about emotions about feelings you know we need to get in there to talk about feelings you know i understand that you're feeling upset just be quiet being quiet itself will reassure the person don't argue too much when you're giving this news don't try and convince the person way too much you need to just wait for that little reaction or that response to coming from there sometimes uh you know how when you share this information and what knowledge you use to impart that medical fact is you need to explore how the person is feeling you know might be that somebody is listening very differently might just tear up you know or might just get very silent or the reaction that i said that oh this lady just said you you should go get married to somebody else you know it's like and sometimes it's anger you know there's another lady who came back and told me that oh so you know how can you give this diagnosis to my grandchild how can you do that you know so how many children do you have that you know that my child has a problem you know so it's like they might just pounce on you so it depends how you also safeguard yourself and how you're able to impart that news because it's a negative news you know so um and when you announce this news just be soft just be quiet and use some strategies to summarize your self when you're giving that news summarize it very nicely because when you summarize it you're also going to talk about what is your next action plan so when people come in for therapy to me uh they will you know i will always first begin the session with an agenda and then end the session with a summary of what needs to be done right in the same way when you're delivering news which is a negative news you need to have an agenda okay this is what has happened and i'm not happy sharing this but we all are in it together and that we'll be there to support you uh it's basically to do a lot to do with emotions and maybe if the person it's an end of life situation maybe it's the only earning member of the house so there's a lot of financial difficulty that the person is facing you know and the person doesn't know how to deal with this situation and there's suddenly too many thoughts you know there's a barrage of thoughts that that person is getting so how you are actually sharing that knowledge also depends on how you are going to communicate to the person so your micro communication skills are the most important you know and when you see the person is crying you don't need to get up and go hug the person you know let the person be you can get some water you can get some tissues and say i can understand i'm hearing you i'm there you can ask me as many questions as you want so have time and not between your uh two patients that you're giving this diagnosis or between your opd's and you're in a hurry so such diagnosis should never be done when you're in a hurry because you're not allowing the person who's listening to this news enough time to even process this information you know processing this information is very important because there's distress so i think i will uh let people ask me questions so that i can you know involve the question answer session and it can be easier to do that sure uh so everyone in the uh comment section you all can either drop in your questions or y'all can use the day's hand feature uh to come up on stage and ask them questions um till then i have a few questions yes sure sure um when you're imparting such uh news to patients is it um advisable to give them the news give them the room and like give them space to understand and then you leave the room and come back in or just be with them and be silent and okay it depends it depends that if you need immediate intervention which is medical intervention if you if the person needs immediate uh you know immediately needs to be an admission into the hospital or a surgery then you need to leave the person or that family in the room and just say that you can chat with each other you can be there with each other i'll be back in about five seven ten minutes and then we'll catch up again and let's understand you know let them also come up with a strategy because you're when you summarize they will need to talk about some things you know because sometimes it's a it's a surgery which is an emergency surgery that is required and the the client has not come in with the thought that there's going to be an emergency surgery that is going to happen right or the person is going to get admitted you thought that okay it's going to be an opd protocol or opd process and things will get better or maybe you know or there's a cardiac issue and that immediately requires an angiography or an angioplasty so you need to take that call you know so allow that person to talk about it it's all delivering a negative news it's a multifaceted task so we okay so we have dr desai who's asked so when you're delivering such new should you be direct or should you work up or do the bad news slowly like ah yeah you need to work up you need to work up to the bad news uh well i would say negative news you know something that is not going to be easily acceptable and whenever there's a denial to a diagnosis you know there's a little process you know you actually get angry you start getting angry with the doctor you get angry with yourself you're angry with god there are so many other things that keep happening before you reach acceptance so as a clinician you need to prepare yourself to go slowly towards the diagnosis and not just immediately say that this is it and there's no hope and nothing can be done so never say something which is a full stop and nothing can be done we need to have hope against hope you know you need to keep that realism alive in the person [Music] uh so how do you talk about death of the patient to the family members so you need to prepare the person also you know you'll come back very often you you we know that maybe the person is sinking or there's other you know the person's gone on a ventilator or we've tried you know many methods so you will keep coming back and giving that information to the to the family you know so slowly gradually that is done and we are trying our best we are doing everything and then slowly say that um you know he or she is having an issue we may not be able to do too much or the um you know the other parts of the body are giving up or the brain is giving up you know slowly gradually build it up for them so that it's not like a shock whenever there's a shock there's always a reaction so we have uh dr dinesh thakur who's raised a hand i'm accepting your request so you can turn on your audio video when prompted and you can come up on stage uh so can you hear us you can ask your question yes yes yes yes yes yes i am so you can ask your question i just uh i can't listen to you okay i am listening all right no no questions all right all right all right so we'll just turn off your audio video you can come up when you have a question uh so we had a follow-up question to dr jacqueline itself he is asking uh so when you're when you deliver such uh bad news like about the death of the patient to the family they obviously i mean often get furious so on hearing that so how do you handle it handle that situation how would you uh well every hospital has a little strategy to that you know when there's uh there's a little strategy you might have security you might have more people around so that you're not very vulnerable in that situation and then you can see also that the person is uh or the family is getting agitated and angry so you need to involve other people of the hospital you know it has happened to people like us also who are we not doing admissions we're not doing anything of that sort we've also had similar situations so we must also be cautious and also we must be um fast enough to ask for security to be there so that you can do some self-protection also it's not just delivering the negative news and taking care of the family and the patient but it's also taking care of yourself it is most important to take care of yourself and not put yourself into a situation that you get you know affected and so when we are delivering such new so who all should be in the news so on one hand we have the recipient of the negative news who needs all possible support but at the same time it may be too personal uh for him or her so is it better to let the person be alone in the room absorb and then with their permission have family come in or so if there's a psychiatric illness we usually do not uh say it in front of the client right so we'll always get the client to step out and maybe give the diagnostic or whatever we want to talk about to the family and say okay this is what is there this is what we're seeing and maybe the person needs to now get some psychiatric help also that's most important needs to be on medication so we usually do not talk about the mental illness in front of the patient okay we always get the patient to step out or speak to the person in a different you know the caretaker at a different space so if i have uh you know somebody who's coming in there and this uh client is not allowing the mother or the father to talk to me alone then i will always leave a message with the parent please connect with i'm also keeping this option open that this person has created a rapper with me the patient is happy coming to me i don't want to break that trust but i have to have help for that patient and i will use all the strategies because there's a risk area involved i will get some help for them yeah i can see some people just uh um you know saying good evening good evening everybody it's nice connecting over here on this platform yeah so we have there we have a lot of interaction through the comment section so you can open that up as well so we have um another question that just came in is it advisable to include the hospital psychologist and going to be there or the team who is going to take care of course you will be involving them but if you are doing your own practice then you do it differently right so uh you do it either which ways you need to do it uh we have dr amit kumar oh my this one okay uh so how much do we need to tell the patient party like uh like do we go all in tell them everything or you just give them uh bite size portions of how much they can handle so i would always say that you know depends on the the condition or depends on what diagnosis is there and since you have to keep the hope alive you should just say that okay it's going to take some while and you're going to be better you're going to be just you know the medicine takes about 2-3 weeks to kick in and you're going to feel much better and then we are also doing sessions together so you will feel better let's connect and let's do you don't need to give the entire diagnosis and especially if there's a report which is generated usually i would suggest not to let the patient read that report because if the patient's mental health is affected do not allow the patient to read that report because that affects the patient uh directly very very negatively okay i hope that's answered your question dr fatima yeah so you said that it is not okay like don't go and hug the patient immediately like after giving news or if the patient breaks down uh is there some kind of uh body language that can be used by because like non-verbal skills basically or non-verbal communication by the doctor yeah yeah so you can say would you want to have some water would you want to have some chai or something you can arrange for that just take a while to absorb this and i'm there to answer all your questions you know that's also a form of connecting and letting the person know that you there's empathy and that you are listening to them there's empathy so that's what is most important so i i can see a few questions where you know you're asking that how do you convince a patient for undergoing a surgery i wish it was that simple you just have to build it up you have to build it up that this surgery is going to be good in how many ways it's like knowledge imparting you know the medicine the medical facts need to be stated very clearly and you know it's it's world over it's not essential that you are able to convince the patient you know the patient might get convinced in front of you but not come back and get admitted you know happening in admission last minute refused i've had so many such clients where since we work in a team um for uh you know a liver transplant everything was done all of it was arranged money was done everything was done and at the last minute the person who had to donate say i'm not willing to do it so you just can't do anything there has to be there must be so many things that the person is going through you know let that be because ultimately the decision is in the hands of the patient or his or her caretakers or families so you had uh mentioned earlier about uh so breaking the negative news should be patient-centered so uh could you elaborate on that approach it depends on what news you're going to give you know what what is it that you're going to give about the diagnosis or are you going to talk about what needs to be done and something which is also going to involve a lot of finance or a lot of admission surgery or some some procedures depends on what is going to happen you know what is it that you're going to do you know very often the patient is not in a mental state of mind to even listen to you you know so it's important to impart that knowledge to the family it's not necessary that you can only involve the patient um [Music] the models in doctor patient relationship what all models in are there in a doctor-patient relationship please do well i just said there are two protocols that we usually follow is one is the known as the breaks which is background rapport exploring announcing kindling and summarizing there's another one by the name of spikes that we use those protocols you know whereas the setting up the perception the invitation that is how much information to be shared knowledge and emotions or something emotions with empathy and how you strategize and how you summarize the entire problem you know that's what is important to understand so we have dr ncr who asked at times when we break the hard news patients tend to talk a lot uh so wisely might attend a quite um quite a lot of other patients as well how do we handle uh this situation right so you have either extremes like if the patient may shut down completely or may start talking a lot like the process so how do you handle the other extreme of the situation yeah so when the patient starts talking a lot you need to let the patient know that you know where we are exceeding our time you know i i am busy somewhere else also i think i've answered most of your queries and if there's anything other than those queries then i'm willing to answer that and but again you have to use the same tone you know don't raise your voice don't get agitated don't get angry don't let the person feel that you're not there for that person but just go a little slow you know okay thank you uh i hope that answers your question yeah we have dr iris chaudhary who's asked so in india we do not have the practice of dnr and we do till the last minute so in such cases when the patient keeps deteriorating despite the best of medical efforts and activities how do you gradually make the beloved ones ready for the ultimate faith i think we just just need to keep on talking that how every day or how every few hours the patient is deteriorating there's not much progress happening we're trying um against everything you know where the hope is still alive but after a while you need to say that um i think we need to take a call on this because this is not happening and you know very often the the patients or the the family might just come back and say okay we're spending a lot of money on this and how do we take it forward or there are times that they will go away from the hospital you know without proper medical advice so that is also there you can only do this much you can't do much you can explain but don't get agitated and don't get angry because the the family picks on that anger agitation overwhelm they pick it up and then that goes against you okay you just have to go very very patient you know and empathetic communication is the key over here you know just be soft and let them know that you are there with them so usually i would say that we should have teams where you must have a mental health specialist there with your team while imparting this or a counselor who can also help you announce this you know yeah yeah i know i can read this question iris that um that you know how does the spouse is not ready to on kids question how the spouse is not ready to accept this loss yes because it's the biggest loss for the spouse it's a loss of companionship it's the loss of you know warmth affection that that you know that desire for friendship you know you've lost that person so that person is going to go through a lot of emotional turmoil allow that to happen let the persons feel that yes he or she is no more at this point but do not argue let that person go on he or she will understand after a while you don't need to force it down thank you it's the biggest loss actually for a spouse true um so yeah i would uh so since so it's ideally supposed to be covered in um in medical school how you deal with breaking the negative news to the family uh but unfortunately in india we do not follow that so what is the best way to learn it when you you're in practice like you cannot practice such things with a patient so how do you how would you go about uh i think you can be connected with the senior the senior doctor with whom you're working or you're interning you can always be present when the diagnosis is being shared or every hospital has a psychiatric setup or a mental health special setup you can speak to the psychologist or the end of life care people or the palliative care people you know they will explain you all these things but you must uh make an effort to understand it doesn't come in very easily because this is the toughest job actually and you might get a lot of brick bats if you if we don't impart this in the right manner sure we do see the negative effect like if it's not delivered properly there's too much of anger in the patient family and it leads to all sort of mismanagement later when the family gets angry and the doctors are not treated properly true true yeah um also you know i see this question how to deal with mistakes made by us during surgical procedures you know never hesitate in asking or getting for getting help for you yourself as a medical practitioner you know it's it's well known that we as medical practitioners do not like to visit the therapist or speak to the therapist you know went it out please do not hesitate go and speak to the therapist and went out all your fears or all that you're feeling because that way you'll get the skill also and you'll you know the therapist will impart some tools to you how to deal with the with the things that have gone wrong and something that you were unable to do or you overlooked you know and we all are human beings we will make mistakes you know and we are in a profession where we are um you know a lot of uh you know time goes in it and there's this a lot of work around in the hospitals also so we do make mistakes you know never hesitate in asking for help uh could you re-type that question for us or you can come up on stage and ask ma'am uh the question so how do you handle the medical legal aspect of the violence that happens like after delivering such news uh so how not to let it affect you uh when you're going through that emotional turmoil yeah so that's why you must need a team to impart this news you know especially a surgical thing or an end of life situation or a chronic illness you must have a team when you are trying to impart this or giving away this news you know and every hospital also has a legal department so you must go back and ask what are the protocols that are there and what you need to take care of and and yes i just i agree that we all need to have an ability to be more calm unfortunately you know our country was well known for being patient and calm but no longer we are not there you know uh we've forgotten a few things but kovid has taught us once again on how to deal with this calm and composure and being compassionate but we all need to learn that you know yeah because we are all dealing with human beings you know and uh yes termination of a precious life i completely agree with you iris thank you for sharing that uh mama just go through if you have any more questions uh if you have any more or if you have anything else to add uh we can uh you can add that i think i've covered up most of it i've covered up most of it so we need to be more professional when we are doing this we need to have patience it is a clinical skill we learn clinical skills you know we learn clinical skills you know and we keep learning through our life you know so yeah we must have a team effort to do this it's always a key network which is good and thank you for getting me here thank you thank you so much ma'am for coming and for talking about the most difficult part of a physician's uh practice i'm sure everybody who is present here has learned a lot and will apply it the next time they are in practice thank you thank you so much ma'am for coming thank you thank you thank you so much thank you thank you

BEING ATTENDED BY

Dr. Darius Justus & 275 others

SPEAKERS

dr. Roma Kumar

Dr. Roma Kumar

Senior Consultant, Max Super Specialty Hospital Gurgaon & Institute of Child Health at Sir Ganga Ram Hospital, New Delhi

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dr. Roma Kumar

Dr. Roma Kumar

Senior Consultant, Max Super Specialty Hospit...

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