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Module 2:
Communicating Bad News
© EPEC Project, 2003
Permission to reproduce for educational purposes granted
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Communicating Bad News
Module=
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Objectives
•Know why communication of “bad” news <=
/span>is important
•Understand the 6-step protocol for <=
span
style=3D'position:absolute;top:32.49%;left:5.02%;width:82.01%;height:8.66%=
'>delivering bad news
•Know what to do at each step of the =
protocol
•Know how to apply the protocol to communicate with patient’s in general
•
•Mr Gonzales is a 67 year old mechanic who immigrated to the US from Mexico ten years ago
•Dr.
O’Brien has cared for his family for three years
<=
/div>
•One week ago Mr. Gonzales presented with a CC of weakness
PE: occult blood in stool; lab
– iron-deficiency anemia
Scheduled colonoscopy – =
mass
in descending colon
Biopsy - adenocarcinoma=
![](3D"slide0030_image005.jpg")
Clinical Case<=
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![](3D"slide0031_image006.gif")
How would=
you
discuss the prognosis with Mr. Gonzales?
• Recognize that you are confronting=
a
person trying to deal with
a time in his life that is filled with possible suffering and loss&=
#13;
• Create an environment that lends i=
tself
to good communication
v use dedicated time that avoids
interruptions
• Find out specifically what Mr. Gonzales knows and how much &=
#13;
wants
to know
• Share the information in a sensiti=
ve but
straightforward manner
v Utilizing a warning statement to
indicate that bad news is coming
• Anticipate and allow for emotional
reactions
Ø=
• Plan for the next step<=
/span>
![](3D"slide0033_image007.gif")
What is y=
our
ethical responsibility in giving bad news?
<=
span
style=3D'font-family:Arial;font-size:83%;color:white;mso-color-index:0;
text-shadow:auto'>• Give Mr. Gonzales the opportunity=
to
know all the facts,
but take cues from him
<=
span
style=3D'font-family:Arial;font-size:83%;color:white;mso-color-index:0;
text-shadow:auto'>• Give him the right to decline to r=
eceive
information or
to
designate someone else to communicate with on
his
behalf
of the
discussion
<=
span
style=3D'font-family:Arial;font-size:83%;color:white;mso-color-index:0;
text-shadow:auto'>• Be aware that false hopes may defl=
ect
him from hearing
important issues and goals and even cause him to accept or
reject treatment
![](3D"slide0034_image008.gif")
What would
you discuss on a practical level?
• The
modifiable elements of his experience:
o Physical symptoms
<=
/span>
o Psychological and cognitive
symptoms,
o Social relationships,
o Support, economic demands and care
needs, hopes,
and
expectations
Ø=
• Ways to utilize existing support
structures and bring in other
&=
nbsp;
services:
o Counseling for anger and depressio=
n are
key elements of
grief
often contribute to symptoms
o Social services to permit Mr. Gonz=
ales
to live to the fullest
exte=
nt
possible
![](3D"slide0035_image009.gif")
What are =
the
barriers to establishing a plan of care?
<=
span
style=3D'font-family:Arial;font-size:83%;color:white;mso-color-index:0;
text-shadow:auto'>• Patients or health care providers =
may
not recognize the
importance of doing so
<=
span
style=3D'font-family:Arial;font-size:83%;color:white;mso-color-index:0;
text-shadow:auto'>• Reluctance of patients and health =
care
providers to
confront the underlying prognosis
<=
span
style=3D'font-family:Arial;font-size:83%;color:white;mso-color-index:0;
text-shadow:auto'>• Lack of formal training, which lea=
ves
providers feeling
unprepared
<=
span
style=3D'font-family:Arial;font-size:83%;color:white;mso-color-index:0;
text-shadow:auto'>• Fear, helplessness and hopelessnes=
s
Significance…
![](3D"slide0004_image010.gif")
6-step protocol . . .
•The recommended Six-step protocol has been adapted from =
How
to Break Bad News: A Guide <=
/i>for Health Care Professionals=
by Robert Buckman M.D. Medical Oncologist
•The first 3 steps deals with preparatory activities to be competed prior to delivering the bad news=
3;
• Step 4 the news is delivered
•Last two steps allows time for the clinician to repsond to the patient’s reactions and to pr=
ovide constructive feedback for follow up<=
/div>
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Step =
1:
Getting started . . .
•P=
lan
what you will say
confirm medical facts
don’t delegate
•C=
reate
a conducive environment
![](3D"slide0019_image012.gif")
Getting started . . .
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•A=
llot
adequate time
Prevent interruptions
Turn cell phones & beepers off/silent
•D=
etermine
who else the patient would like present
![](3D"slide0006_image013.gif")
Step 2: What does the patient
know?
•E=
stablish
what the patient knows/
child’s parents
•A=
ssess
ability to comprehend new bad news
•R=
eschedule
if unprepared
![](3D"slide0007_image014.gif")
Step
3: How much does the patien=
t want
to know? . . .
•R=
ecognize,
support various patient preferences
decline voluntarily to receive information
=
;
designate someone to communicate on his
or her behalf
![](3D"slide0020_image015.gif")
. .
. Step 3: How much does the
patient want to know?
•P=
eople
handle information differently
Race
=
;
Ethnicit=
y
Culture&=
#13;
Religion=
Socioeco=
nomic
status
Age and
developmental level
![](3D"slide0009_image016.gif")
When family says
“don’t tell” . . .
“don’t tell” . . .
•Legal
obligation to obtain informed consent from the patient&#=
13;
<=
span
style=3D'font-weight:normal'>•Promote congenial fami=
ly
alliance
<=
span
style=3D'font-weight:normal'>•Honesty with a child
promotes trust
![](3D"slide0021_image017.gif")
. . . When family says
“don’t tell”
“don’t tell”
•A=
sk
the family:
Why not tell?
What are you afraid I will say?
What are your previous experiences?
Is there a personal, cultural, or religious context?
•T=
alk
to the patient together
![](3D"slide0010_image018.gif")
Step 4: Sharing the <=
span
style=3D'position:absolute;top:51.8%;left:1.31%;width:97.36%;height:49.39%=
'>information
. . .
•S=
ay
it, then stop
avoid monologue, promote dialogue
avoid jargon, euphemisms
pause frequently
check for understanding
use silence, body language
![](3D"slide0022_image019.gif")
. . . Step 4: Sharing the information
•<=
span
style=3D'color:white;mso-color-index:0'>Don’t minimize severity
=
avoid vaguenes=
s,
confusion
•<=
span
style=3D'color:white;mso-color-index:0'>Implications of “I’m
sorry”
![](3D"slide0011_image020.gif")
Step 5: Responding to =
feelings
. . .
•A=
ffective
response
tears, anger, sadness, love, anxiety, relief,
other
•C=
ognitive
response
denial, blame, guilt, disbelief, fear, loss, shame,
intellectualization
•Ba=
sic
psychophysiologic response
fight-flight
![](3D"slide0012_image021.gif")
Step 5: Responding to =
feelings
. . .
•Be
prepared for
outburst of strong emotion
broad range of reactions
•G=
ive
time to react
![](3D"slide0024_image022.gif")
. . . Step 5: Responding to =
feelings
<=
span
style=3D'font-weight:normal'>•Encourage descriptions=
of
feelings
![](3D"slide0013_image023.gif")
Step 6: Planning,
follow-up . . .
follow-up . . .
•Plan for the next steps
additional information, tests
treat symptoms, referrals as needed
•Discuss potential sources of support=
![](3D"slide0023_image024.gif")
. . . Step 6: Planning, follow-up
•G=
ive
contact information, set next appointment
•B=
efore
leaving, assess:
safety of the patient
supports at home
•R=
epeat
news at future visits
![](3D"slide0014_image025.gif")
When language is a barrier
. . .
•U=
se a
skilled interpreter
familiar with medical terminology
comfortable translating bad news
•C=
onsider
telephone translation services
![](3D"slide0025_image026.gif")
. . . When language is a barrier
•When
family members are present who do speak both languages, ask them
to supplement the primary translation and support the patient =
and
other family members
• Speak directly to the
patient
![](3D"slide0015_image027.gif")
Communicating prognosis . . .
<=
span
style=3D'font-weight:normal'>•Others are seeking
reassurance
![](3D"slide0026_image028.gif")
Communicating prognosis . . .
•I=
nquire
about reasons for asking
“What are you expecting to happen?”
“How specific do you want me to be?”
“What experiences have you had with:
others with same illness?
others who have died?”
![](3D"slide0016_image029.gif")
Communicating prognosis . . .
•P=
atients
vary
“planners” want more details
those seeking reassurance want less
•A=
void
precise answers
hours to days … months to years
average
![](3D"slide0027_image030.gif")
. . . Communicating prognosis<=
/span>
•L=
imits
of prediction
hope for the best, plan for the worst
better sense over time
can’t predict surprises, get affairs in order
•R=
eassure
availability, whatever happens
![](3D"slide0017_image031.gif")
Caregiver communication
•M=
aintain
common chart or log book
goals for care
treatment choices
what to do in an emergency
likes, dislikes
things to do / not to do
contact information
![](3D"slide0036_image032.gif")
=
; &n=
bsp;
BREAKING BAD NEWS
S etting, list=
ening Skills
P atient’=
;s Perception
I <=
/b>nvite patient=
to
share Information
K <=
/b>nowledge
transmission
E <=
/b>xplore Emotions and Empathize
=
Summarize & Strategize
=
;
E
P
E
C
P
E
C
End of Module 2: Communicating Bad News
=
;
Review Fast Facts
Then Complete
=
; &n=
bsp;
Module 2 Post Quiz
The Education in Pallia=
tive
and End of Life Care program at UTMB and the Department of Surgery wo=
uld
like to acknowledge and offer our appreciation to the EPEC Project(1999).<=
span
style=3D'mso-spacerun:yes'> The core Project ma=
terials
were created with support of the American Medical Association and the Robe=
rt
Wood Johnson Foundation and the partnership of t=
he
Northwestern University's Feinberg School of Me=
dicine
( Emanuel LL, von Guten CF, Ferris FD. The Education for Physicians on
End-of-Life Care (EPEC) curriculum, 1999).
&nbs= p;
Additional materials and resources have been added to the UTMB EPEC Program. For any qu= estions, please contact Co-Directors Kristene K. Gugliuzza, MD or Gary Kesling, PhD= .
&nbs= p;
Additional materials and resources have been added to the UTMB EPEC Program. For any qu= estions, please contact Co-Directors Kristene K. Gugliuzza, MD or Gary Kesling, PhD= .
‹header›
‹date/time›=
Click to edit Master text styles
Second level
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Fifth level
‹footer›
‹#›
The vast majority of Americans wa=
nt to
know if they have a life-threatening illness. Although legitimate cultural
variations are important, braking bad news in a professional, direct and
compassionate manner can improve the patient’s and family’s ab=
ility
to plan and cope. This discussion may encourage realistic goals and autono=
my, support
the patient emotionally, strengthen the physician-patient relationship, an=
d foster
collaboration among the patient, the family, the physician and other profe=
ssionals.
The 6-step model has been adapted=
from
How to Break Bad News: A Guide for Health Care Professional (1992), by Rob=
ert
Buckman. The first three steps deal with preparatory activities that could=
be
completed before actually meeting with the patient/family. Before starting=
to
communicate any information, plan what will be discussed. Confirm the medi=
cal
facts of case. Ensure that all of the needed information is available to y=
ou.
Don’t assume, guess or delegate.
Create an environment conductive =
to
effective communication. For pediatric patients, have staff available to be
with the child while information is conveyed to the parents first. Ensure
privacy and adequate seating. Allot adequate time for discussion. Do not s=
lip
this into a short interval between other tasks. Prevent interruptions. Arr=
ange
to hold all calls and pages.
Others might include family, sig=
nificant
others, surrogate decision makers and /or key members of the interdiscipli=
nary
team (nurses, social workers, chaplain, etc.)
Start the discussion by establis=
hing
what the patient and family know about the patient’s health status. =
With
this information, evaluate to what degree the patient and the family will =
be
able to comprehend the bad news at this time.
Possible questions might include:
What do you understand about your illness?
How would you describe your medical situation?
Have you been worried about your illness or symptoms?
What did other doctors tell you about your condition or procedures th=
at
you have had?
When you first had symptom X, what did you think about it or what did=
it
mean?
Did you think something serious was going on when…?
Occasionally a patient or a parent if it is a child will become silent and
seem completely unprepared or unable to respond. To ease the situation and
open up the discussion, try to clarify what the patient understands about
his/her medical history and recent tests/procedures. Identify any family
members or others on whom the patient might rely. If this is ineffective a=
nd
the patient remains silent, or it appears the patient requires more suppor=
t,
it may be better to reschedule the meeting for a later time.People Handle information differ=
ently,
depending on this situation, their lifetime experiences and their fears and
worries. Each person has the right to decline receiving any information and
may even designate someone else for you to communicate with on their behal=
f.
Ask the patient and family how t=
hey
would like to receive information. If the patient prefers not receive crit=
ical
information, establish specifically to whom you should work with for the
patient.
Possible questions include?
If this condition turns out to be something serious, do you want to
know?
Would you like me to tell you the full details of your condition? If not, =
is
there someone else you would prefer that I speak with for you?
Some pe=
ople
really do not want to be told what is wrong with them, but would rather th=
eir
families be told instead. What do you prefer?On some occasions, family member=
s may
ask the physician not to tell the patient the diagnosis or other important
facts. While it is the physician’s legal obligation to obtain inform=
ed
consent from the patient, an effective therapeutic relationship requires a=
congenial
alliance with the family members. Instead of confronting their requests, i=
nquire
what about the information or how it is or is not communicated may be of a=
n issue
for the family. In situations such as this, it may require significant
negotiations. In difficult cases, support may be needed from the instituti=
onal
ethics committee. However, unless the topic has been discussed with the
patient previously and the patient indicated that they did not want any
information, hiding the diagnosis or important clinical information about
prognosis or treatment from the patient is neither ethical nor legally
acceptable. Always talk with the patient about general preferences for han=
ding
serious medical information and treatment decisions early in the clinical =
relationship
before significant issues come up and a misstep is made.
You may choose to break bad news by using language like:
Mr Gonzales, I feel badly to have to tell you this, but the growth turned =
out
to be cancer.
I’m afraid the news is not good. The biopsy showed that you have
colon cancer.
Unfortunately, there is no question about the results of your test
results – it is cancer.
The phrase “I’m sorr=
y”
may be interpreted to imply that the physician is responsible for the
situation. It may also be misinterpreted as pity or aloofness. If you use =
the phase,
adjust it to show empathy. For example: “I’m sorry to have to =
tell
your this.”
Patients, families may respond i=
n many
different ways, sometimes all at the same time. Outbursts of strong emotions may =
make
some physicians uncomfortable. Give the patient and family time to react. =
Be
prepared to support them with a broad range of reactions. Listen quietly a=
nd
attentively. Acknowledge their emotions. Ask them to describe their
feelings:
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------=_NextPart_01C7CAE3.D8E93EA0
Content-Location: file:///C:/0A78A353/Module2CommunicatingBadNews_files/script.js
Content-Transfer-Encoding: quoted-printable
Content-Type: application/javascript; charset="us-ascii"
function LoadSld()
{
var sld=3DGetObj("SlideObj")
if( !g_supportsPPTHTML ) { =09
sld.style.visibility=3D"visible"
return
}
if( MakeNotesVis() ) return
runAnimations =3D _InitAnimations();
=09
if( IsWin("PPTSld") )
parent.SldUpdated(GetSldId())
g_origSz=3DparseInt(SlideObj.style.fontSize)
g_origH=3Dsld.style.posHeight
g_origW=3Dsld.style.posWidth
g_scaleHyperlinks=3D(document.all.tags("AREA").length>0)
if( g_scaleHyperlinks )
InitHLinkArray()
if( g_scaleInFrame||(IsWin("PPTSld") && parent.IsFullScrMode() ) )
document.body.scroll=3D"no"
_RSW()
if( IsWin("PPTSld") && parent.IsFullScrMode() )
FullScrInit();
=09
MakeSldVis();
ChkAutoAdv()
if( runAnimations )
{
if( document.all("NSPlay") )
document.all("NSPlay").autoStart =3D false;
if( sld.filters && sld.filters.revealtrans )
setTimeout( "document.body.start()", sld.filters.revealtrans.duration * =
1000 );
else
document.body.start();
}
}
function MakeSldVis()=20
{
var fTrans=3Dg_showAnimation && SldHasTrans()
if( fTrans )=09
{
if( g_bgSound ) {
idx=3Dg_bgSound.indexOf(",");
pptSound.src=3Dg_bgSound.substr( 0, idx );
pptSound.loop=3D -(parseInt(g_bgSound.substr(idx+1)));
}
SlideObj.filters.revealtrans.Apply()=09
}
SlideObj.style.visibility=3D"visible"
if( fTrans )
SlideObj.filters.revealtrans.Play()
}
function MakeNotesVis()=20
{
if( !IsNts() ) return false=20
SlideObj.style.display=3D"none"
nObj =3D document.all.item("NotesObj")
parent.SetHasNts(0)
if( nObj ) {=20
nObj.style.display=3D""
parent.SetHasNts(1)
}
return 1
}
function ChkAutoAdv()
{
if(SldHasTrans())
SlideObj.onfilterchange=3DAutoAdv
else
AutoAdv()
}
function AutoAdv()
{
if(!IsWin("PPTSld") || !gUseSldTimings )return
var sld=3DGetCurSld()
if( (sld.mAdvDelay>0) && !parent.IsFramesMode() )
setTimeout("parent.GoToNextSld()",sld.mAdvDelay)
}
function GetObj(id)
{
if(g_supportsPPTHTML) return document.all(id);
else return document.getElementById(id);
}
function SldHasTrans() { return SlideObj.style.filter !=3D ""; }
function GetSldId() { return sId=3Dlocation.href.substring(location.href.la=
stIndexOf('/')+1) }
function HideMenu() { if( frames["PPTSld"] && PPTSld.document.all.item("ctx=
tmenu") && PPTSld.ctxtmenu.style.display!=3D"none" ) { PPTSld.ctxtmenu.styl=
e.display=3D'none'; return true } return false }
function IsWin( name ) { return window.name =3D=3D name }
function IsNts() { return IsWin("PPTNts") }
function IsSldOrNts() { return( IsWin("PPTSld")||IsWin("PPTNts") ) }
function SupportsPPTAnimation() { return( navigator.platform =3D=3D "Win32"=
&& navigator.appVersion.indexOf("Windows")>0 ) }
function SupportsPPTHTML()
{
var appVer=3Dnavigator.appVersion, msie=3DappVer.indexOf("MSIE "), ver=3D0
if( msie >=3D 0 )
ver=3DparseFloat( appVer.substring( msie+5, appVer.indexOf(";",msie) ) )
else
ver=3DparseInt(appVer)
return( ver >=3D 4 && msie >=3D 0 )
}
function _RSW()
{
if( !g_supportsPPTHTML || IsNts() ||
( !g_scaleInFrame && (!IsWin("PPTSld") || !parent.IsFullScrMode()) ) )
return
var padding=3D0;
if( IsWin("PPTSld") && parent.IsFramesMode() ) padding=3D6
cltWidth=3Ddocument.body.clientWidth-padding
cltHeight=3Ddocument.body.clientHeight-padding
factor=3D(1.0*cltWidth)/g_origW
if( cltHeight < g_origH*factor )
factor=3D(1.0*cltHeight)/g_origH
newSize =3D g_origSz * factor
if( newSize < 1 ) newSize=3D1
s=3DSlideObj.style
s.fontSize=3DnewSize+"px"
s.posWidth=3Dg_origW*factor
s.posHeight=3Dg_origH*factor
s.posLeft=3D(cltWidth-s.posWidth+padding)/2
s.posTop=3D(cltHeight-s.posHeight+padding)/2
if( g_scaleHyperlinks )
ScaleHyperlinks( factor )
}
function _InitAnimations()
{
animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined';
isFullScreen =3D (window.name =3D=3D "PPTSld") && !parent.IsFramesMode();
g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc=
reen && parent.IsSldVisited());
if( g_animUseRuntime ) {
collSeq =3D document.all.tags("seq");
if( collSeq !=3D null ) {
for(ii=3D0;ii numSlds )
gSldJumpIdx =3D numSlds;
if ( gSldJumpIdx >=3D 0 ) {
if ( gSldJumpIdx =3D=3D 0 )
gSldJumpIdx =3D 1;
var jumpTo =3D parseInt(gSldJumpIdx);
gSldJump =3D 0; gSldJumpIdx =3D "";
win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref )
}
}
}
function _KDH()
{
if( event.keyCode =3D=3D 8 ) {
event.returnValue =3D 0;
parent.GoToPrevSld();
}
}
var g_HLinkArray =3D new Array();
=20
function IMapAreaObj( areaObj, coords )
{
this.areaObj =3D areaObj;
this.coords =3D coords;
}
function InitHLinkArray()
{
var appVer =3D navigator.appVersion;
var msie =3D appVer.indexOf ( "MSIE " )
var ver =3D 0;
if ( msie >=3D 0 )
ver =3D parseInt ( appVer.substring( msie+5 ) );
linkNum =3D 0;
for (i=3D0; i 4 ) )
g_HLinkArray[linkNum++] =3D new IMapAreaObj( areaObj, ParseCoords( ar=
eaObj.coords ) );
}
}
function ScaleHyperlinks( factor )
{ =20
for ( ii=3D0; ii< g_HLinkArray.length; ii++) {
coordsStr=3D"";
imaObj =3D g_HLinkArray[ii];
for ( jj=3D0; jj < imaObj.coords.length-1; jj++ )
coordsStr +=3D (imaObj.coords[jj]*factor) + ",";
coordsStr +=3D (imaObj.coords[jj]*factor);
imaObj.areaObj.coords =3D coordsStr;
}
}
function ParseCoords( coordsStr )
{
var numArray =3D new Array();
var i =3D curPos =3D commaPos =3D 0;
while ( ( commaPos =3D coordsStr.indexOf(",", curPos) ) !=3D -1 ) {=20
numArray[i++] =3D parseInt( coordsStr.substr( curPos, commaPos ) );
curPos =3D commaPos + 1;
}
numArray[i] =3D parseInt( coordsStr.substr( curPos ) );
return numArray;
}
function DocumentOnClick()
{
if( IsNts() || parent.HideMenu() ) return;
if( ( g_allowAdvOnClick && (window.name=3D=3D"PPTSld") && !parent.IsFrames=
Mode() ) ||
(event && event.keyCode=3D=3D32) ) {
=09
if( g_animUseRuntime && g_animMainSequence && g_animMainSequence.cangonex=
t )
return;
parent.GoToNextSld();
}
}
var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""=
, g_bgSound=3D"",
g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser =
=3D 0, gLoopCont =3D 0, gUseSldTimings =3D 1;
var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w=
indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va=
r g_animManager =3D null;
var g_animUseRuntime =3D false;
var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime;
var g_animMainSequence =3D null;
var ENDSHOW_MESG=3D"End of slide show, click to exit.", SCREEN_MODE=3D"Fram=
es", gIsEndShow=3D0, NUM_VIS_SLDS=3D32, SCRIPT_HREF=3D"script.js", FULLSCR_=
HREF=3D"fullscreen.htm";
var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO=
tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true
window.gPPTHTML=3DSupportsPPTHTML()
var gMainDoc=3Dnew Array(new hrefList("slide0028.htm",1,-1,1),new hrefList(=
"slide0002.htm",1,-1,1),new hrefList("slide0030.htm",1,-1,1),new hrefList("=
slide0031.htm",1,-1,1),new hrefList("slide0033.htm",1,-1,1),new hrefList("s=
lide0034.htm",1,-1,1),new hrefList("slide0035.htm",1,-1,1),new hrefList("sl=
ide0003.htm",1,-1,1),new hrefList("slide0004.htm",1,-1,1),new hrefList("sli=
de0005.htm",1,-1,1),new hrefList("slide0019.htm",1,-1,1),new hrefList("slid=
e0006.htm",1,-1,1),new hrefList("slide0007.htm",1,-1,1),new hrefList("slide=
0020.htm",1,-1,1),new hrefList("slide0009.htm",1,-1,1),new hrefList("slide0=
021.htm",1,-1,1),new hrefList("slide0010.htm",1,-1,1),new hrefList("slide00=
22.htm",1,-1,1),new hrefList("slide0011.htm",1,-1,1),new hrefList("slide001=
2.htm",1,-1,1),new hrefList("slide0024.htm",1,-1,1),new hrefList("slide0013=
.htm",1,-1,1),new hrefList("slide0023.htm",1,-1,1),new hrefList("slide0014.=
htm",1,-1,1),new hrefList("slide0025.htm",1,-1,1),new hrefList("slide0015.h=
tm",1,-1,1),new hrefList("slide0026.htm",1,-1,1),new hrefList("slide0016.ht=
m",1,-1,1),new hrefList("slide0027.htm",1,-1,1),new hrefList("slide0017.htm=
",1,-1,1),new hrefList("slide0036.htm",1,-1,1),new hrefList("slide0029.htm"=
,1,-1,1));
/*********************************************
Frameset functions
These functions control slide navigation
and state of the frameset.
**********************************************/
function FullScrInit()
{
g_allowAdvOnClick =3D GetCurSld().mAdvOnClk
document.body.style.backgroundColor=3D"black"
document.oncontextmenu=3Dparent._CM;
document.onkeydown =3D _KDH;
document.ondragstart=3DCancel
document.onselectstart=3DCancel
self.focus()
}
function Redirect( frmId )
{=09
var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId()
if(idx>=3D0) str=3Dstr.substr(1);
if( window.name !=3D frmId && ( sId !=3D str) ) {
obj =3D GetObj("Main-File")
window.location.href=3Dobj.href+"#"+sId
return 1
}
return 0
}
var MHTMLPrefix =3D CalculateMHTMLPrefix();=20
function CalculateMHTMLPrefix()
{
if ( document.location.protocol =3D=3D 'mhtml:') {=20
href=3Dnew String(document.location.href)=20
Start=3Dhref.indexOf('!')+1=20
End=3Dhref.lastIndexOf('/')+1=20
if (End < Start)=20
return href.substring(0, Start)=20
else=20
return href.substring(0, End)=20
}
return '';
}
function GetTags(base,tag)
{
if(g_supportsPPTHTML) return base.all.tags(tag);
else return base.getElementsByTagName(tag);
}
function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP=
refix+GetHrefObj( gCurSld ).mNtsHref ) }
function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() }
function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() }
function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() }
function SetHasNts( fVal )
{
if( gHasNts !=3D fVal ) {
gHasNts=3DfVal
UpdNavPane()
}
}
function ToggleOtlText()
{
gOtlTxtExp=3D!gOtlTxtExp
UpdOtlPane()
}
function ClearMedia()
{
// Clear any sounds playing before launching another browser window. Other=
wise,
// in fullscreen mode, you'll continue to hear the sound in the frames mod=
e.
if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0;
}
function FullScreen()
{=20
if ( PPTSld.g_animUseRuntime )
PPTSld.document.body.pause();
ClearMedia();
var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF =
: FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref;
if(PPTNav.event.ctrlKey) {
var w =3D (window.screen.availWidth * 1.0) / 2.0
var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW
win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top=
=3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
else
{
win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
}
function ToggleVNarration()
{
rObj=3DPPTSld.document.all("NSPlay")
if( rObj && !PPTSld.g_animUseRuntime ) {
if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) )
rObj.Play()
else if( rObj.playState =3D=3D 2 )
rObj.Pause()
else
return;
}
else if( PPTSld.g_animUseRuntime )
{
narObj =3D PPTSld.document.all("narrationID")
if( narObj )
narObj.togglePause()
}
}
function GetCurSldNum()
{ =20
obj=3DGetHrefObj(gCurSld)
if( obj.mOrigVis =3D=3D 1 )
return obj.mSldIdx
else =20
return gCurSld
}
function GetNumSlds()
{ =20
if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 )
return GetSldList().mNumVisSlds;
else
return GetSldList().mList.length
}
function GetSldNum( href )
{
for(ii=3D0; ii 1 )
PopSldList();
else if( !IsFramesMode() ) {
if( gLoopCont )
GoToFirst()
else
EndShow()
}
}
function GoToPrevSld()
{
ii=3DgCurSld-1
if( ii > 0 ) {
obj=3DGetHrefObj(ii)
while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) )
obj=3DGetHrefObj(--ii)
if( ii =3D=3D 0 ) ii=3D1
GoToSldNum(ii)
}
}
function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) }
function GoToLast()
{
ii=3DGetSldList().mList.length
if( ii !=3D gCurSld )
GoToSld( GetHrefObj(ii).mSldHref )
}
function GoToSldNum( num )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
obj =3D GetHrefObj( num )
obj.mVis=3D1
gPrevSld=3DgCurSld
gCurSld =3D num;
PPTSld.location.replace(MHTMLPrefix+obj.mSldHref)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function GoToSld( href )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
GetHrefObj( GetSldNum(href) ).mVis=3D1
PPTSld.location.replace(MHTMLPrefix+href)
}
function SldUpdated( id )
{
if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return
gPrevSld=3DgCurSld
gCurSld=3DGetSldNum(id)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) }
function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO=
bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) }
function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) }
function CloseWindow() {
if( HideMenu() ) return;
=09
var event =3D PPTSld.event;
if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D=
=3D32 || event.type=3D=3D"click" ) )
window.close( self );
CatchNumKeys( self, event );
}
function Unload() { gIsEndShow=3D0; }
function SetupEndShow() {
gIsEndShow=3D1;
PPTSld.document.body.scroll=3D"no";
PPTSld.document.onkeypress=3DCloseWindow;
PPTSld.document.onclick=3DCloseWindow;
PPTSld.document.oncontextmenu=3D_CM;
}
function EndShow()
{
if( IsFramesMode() ) return
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
doc=3DPPTSld.document
var dir =3D doc.body.dir
if( dir !=3D "rtl" ) dir =3D "ltr";
doc.open()
doc.writeln(' 0) {
PushSldList(sldList,fEnd);
gCurSld =3D 1;
}
else
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
}
function PushSldList(arr,fEnd) {
var ii =3D gSldStack.length;
gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd);
GoToSld( gSldStack[ii].mList[0].mSldHref );
}
function PopSldList() {
if (gSldStack[gSldStack.length-1].fEndShow)
EndShow()
else {
gCurSld =3D gSldStack[gSldStack.length-1].mCurSld;
gSldStack[gSldStack.length-1] =3D null;
gSldStack.length--;
var sldList =3D gSldStack[gSldStack.length-1];
GoToSld( sldList.mList[gCurSld - 1].mSldHref );
}
}
var custShowList=3Dnew Array();
/*********************************************
Navigation button implementation
There are 2 types of buttons: ImgBtn, TxtBtn
implemented as function objects. They share
a similiar interface so the event handlers
can call SetActive, for example, on a button=20
object without needing to know exactly=20
what type of button it is.
**********************************************/
//----------------------------------
function ImgBtn( oId,bId,w,action )
//----------------------------------
{
var t=3Dthis
t.Perform =3D _IBP
t.SetActive =3D _IBSetA
t.SetInactive=3D _IBSetI
t.SetPressed =3D _IBSetP
t.SetDisabled=3D _IBSetD
t.Enabled =3D _IBSetE
t.ChangeIcon =3D null
t.UserAction =3D action
t.ChgState =3D _IBUI
t.mObjId =3D oId
t.mBorderId=3D bId
t.mWidth =3D w
t.mIsOn =3D t.mCurState =3D 0
}
function _IBSetA()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _IBSetI()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0=20
}
}
function _IBSetP()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 )
obj.style.posLeft+=3D1; obj.style.posTop+=3D1
}
}
function _IBSetD()
{ =20
obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 )
obj.style.posTop=3D0=20
}
function _IBSetE( state )
{
var t=3Dthis
GetObj( t.mBorderId ).style.visibility=3D"visible"
if( state !=3D t.mIsOn ) {
t.mIsOn=3Dstate
if( state )
t.SetInactive()
else
t.SetDisabled()
}
}
function _IBP()
{
var t=3Dthis
if( t.mIsOn ) {
if( t.UserAction !=3D null )
t.UserAction()
if( t.ChangeIcon ) {
obj=3DGetObj(t.mObjId)
if( t.ChangeIcon() )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth
else
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth
}
t.SetActive()
} =20
}
function _IBUI( clr1,clr2,nextState )
{
var t=3Dthis
SetBorder( GetObj( t.mBorderId ),clr1,clr2 )
obj=3DGetObj( t.mObjId )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj=
.style.posTop
t.mCurState=3DnextState
return obj
}
//-----------------------------------------
function TxtBtn( oId,oeId,action,chkState )
//-----------------------------------------
{
var t=3Dthis
t.Perform =3D _TBP
t.SetActive =3D _TBSetA
t.SetInactive=3D _TBSetI
t.SetPressed =3D _TBSetP
t.SetDisabled=3D _TBSetD
t.SetEnabled =3D _TBSetE
t.GetState =3D chkState
t.UserAction =3D action
t.ChgState =3D _TBUI
t.mObjId =3D oId
t.m_elementsId=3D oeId
t.mIsOn =3D 1
}
function _TBSetA()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gHiliteClr,gShadowClr,0,0 )
}
function _TBSetI()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
}
function _TBSetP()
{
if( this.mIsOn )
this.ChgState( gShadowClr,gHiliteClr,1,1 )
}
function _TBSetD()
{ =20
this.ChgState( gFaceClr,gFaceClr,0,0 )
this.mIsOn =3D 0
}
function _TBSetE()
{
var t=3Dthis
if( !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
else
t.ChgState( gShadowClr,gHiliteClr,1,1 )
t.mIsOn =3D 1
}
function _TBP()
{
var t=3Dthis
if( t.mIsOn ) {=20
if( t.UserAction !=3D null )
t.UserAction()
if( !t.GetState )
return
if( t.GetState() )
t.SetPressed()
else
t.SetActive()
} =20
}
function _TBUI( clr1,clr2,lOffset,tOffset )
{
SetBorder( GetObj( this.mObjId ),clr1,clr2 )
Offset( GetObj( this.m_elementsId ),lOffset,tOffset )
}
function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle=
ft }
function SetBorder( obj, upperLeft, lowerRight )
{
s=3Dobj.style;
s.borderStyle =3D "solid"
s.borderWidth =3D 1=20
s.borderLeftColor =3D s.borderTopColor =3D upperLeft
s.borderBottomColor=3D s.borderRightColor =3D lowerRight
}
function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] }
function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() }
function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() }
function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() }
function BtnOnUp()
{
b=3DGetBtnObj()
if( b !=3D null )
b.Perform()
else
Upd()
}
function GetNtsState(){ return parent.gNtsOpen }
function GetOtlState(){ return parent.gOtlOpen }
function GetOtlTxtState(){ return parent.gOtlTxtExp }
function NtsBtnSetFlag( fVal )
{
s=3Ddocument.all.item( this.m_flagId ).style
s.display=3D"none"
if( fVal )
s.display=3D""
else
s.display=3D"none"
}
function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etActive() }
function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etInactive() }
function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etPressed() }
function _BSetA_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]=20
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _BSetI_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0
}
}
var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"=
THREEDFACE"
var gBtnArr =3D new Array()
gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan=
e,GetOtlState )
gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt=
lPane,GetOtlState )
gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN=
tsPane )
gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg;
gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg;
gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.=
ToggleNtsPane,GetNtsState )
gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To=
ggleNtsPane,GetNtsState )
gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n=
b_prevBorder",30,parent.GoToPrevSld )
gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n=
b_nextBorder",30,parent.GoToNextSld )
gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent=
.FullScreen )
gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa=
rent.FullScreen,null )
gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent=
.FullScreen,null )
gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice=
","nb_voiceBorder",18,parent.ToggleVNarration )
gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT=
xt","nb_otlTxtBorder",23,parent.ToggleOtlText )
gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts"
gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag
gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState
/*********************************************
Context menu implementation
_CM() is the function that's hooked up to
the oncontextmenu event. Once we're asked to
show the menu, we first build it by creating
DIVs on-the-fly. Then we position it=20
within the screen area so it doesn't get
clipped.
Creating the DIVs using createElement() means
we don't have to write out any extra HTML
into the slide HTML files.
**********************************************/
var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr=
row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval"
function ShowMenu()
{
BuildMenu();
var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y=
=3DPPTSld.event.clientY+doc.scrollTop
m =3D PPTSld.document.all.item("ctxtmenu")
m.style.pixelLeft=3Dx
if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) )
m.style.pixelLeft=3Dx-m.scrollWidth
m.style.pixelTop=3Dy
if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) )
m.style.pixelTop=3Dy-m.scrollHeight
m.style.display=3D""
}
function _CM()
{
if( !parent.IsFullScrMode() ) return;
if(!PPTSld.event.ctrlKey) {
ShowMenu()
return false
} else
HideMenu()
}
function BuildMenu()
{
if( PPTSld.document.all.item("ctxtmenu") ) return
var mObj=3DCreateItem( PPTSld.document.body )
mObj.id=3D"ctxtmenu"
mObj.style.visibility=3D"hidden"
var s=3DmObj.style
s.position=3D"absolute"
s.cursor=3D"default"
s.width=3D"120px"
SetCMBorder(mObj,"menu","black")
var iObj=3DCreateItem( mObj )
SetCMBorder( iObj, "threedhighlight","threedshadow" )
iObj.style.padding=3D2
CreateMenuItem( iObj,sNext,M_GoNextSld,M_True )
CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld )
=09
CreateSeparator( iObj )
CreateMenuItem( iObj,sEnd,M_End,M_True )
mObj.style.visibility=3D"visible"
}
function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa=
lue=3Dfalse }
function Highlight() { ChangeClr("activecaption","threedhighlight") }
function Deselect() { ChangeClr("threedface","menutext") }
function Perform()
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() )
e.Action()
else
PPTSld.event.cancelBubble=3Dtrue
}
function ChangeClr( bg,clr )
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() ) {
e.style.backgroundColor=3Dbg
e.style.color=3Dclr
}
}
function M_HasPrevSld() { return( parent.HasPrevSld() ) }
function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() }
function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();=
PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() }
function M_True() { return true }
function M_End() { window.close( self ) }
function CreateMenuItem( node,text,action,eval )
{
var e=3DCreateItem( node )
e.type=3D"menuitem"
e.Action=3Daction
e.IsActive=3Deval
e.innerHTML=3Dtext
if( !e.IsActive() )
e.style.color=3D"threedshadow"
e.onclick=3DPerform
e.onmouseover=3DHighlight
e.onmouseout=3DDeselect
s=3De.style;
s.fontFamily=3DsFont
s.fontSize=3D"9pt"
s.paddingLeft=3D2
}
function CreateSeparator( node )
{
var sObj=3DCreateItem( node )
SetCMBorder(sObj,"menu","menu")
var s=3DsObj.style
s.borderTopColor=3D"threedshadow"
s.borderBottomColor=3D"threedhighlight"
s.height=3D1
s.fontSize=3D"0px"
}
function CreateItem( node )
{
var elem=3DPPTSld.document.createElement("DIV")
node.insertBefore( elem )
return elem
}
function SetCMBorder( o,ltClr,rbClr )
{
var s=3Do.style
s.backgroundColor=3D"menu"
s.borderStyle=3D"solid"
s.borderWidth=3D1
s.borderColor=3DltClr+" "+rbClr+" "+rbClr+" "+ltClr
}
------=_NextPart_01C7CAE3.D8E93EA0
Content-Location: file:///C:/0A78A353/Module2CommunicatingBadNews_files/fullscreen.htm
Content-Transfer-Encoding: quoted-printable
Content-Type: text/html; charset="us-ascii"
Module 2
------=_NextPart_01C7CAE3.D8E93EA0--
I see that this is very difficult news…
You appear angry…
This nes seems to have frightened you…
What worries you the most…
Is there anyone you would like for me to call or speak with…
Be supportive and verbalize that=
their
responses are normal under this situation. Be aware of your
“non-verbal” communications. Don’t attempt a hurried exit
from the situation. Let the patient and the family express all of their
immediate feelings. Don’t rush them.
Reassure the patient and family =
that
they are not being abandoned and that the physician will be actively engag=
ed
in an ongoing plan to help. Indicate how the patient and family can reach =
the
physician for additional questions or concerns. Establish a specific time =
for
follow up. Be prepared to re=
peat
the information shared with the patient and family over again. It may need=
to
be revisited several times.
It is important to brief transla=
tors
before meeting with the patient and assure them their role is only to
translate. Be sure that the translator is comfortable in communicating the=
bad
news. If possible avoid using family members as primary translators. It
becomes confusing what their role is (translator versus family member). Ad=
ditionally,
family members may not know how to translate specific medical terms or
concepts and they might modify the news based on their own comfort level t=
o protect
the patient.
When working with a translator, =
sit in a
triangular arrangement so that you can face and speak directly to the pati=
ent,
yet sill be able to see the translator. Speak in short segments, then give=
the
translator time to repeat the information. Verify the patient’s and =
the
family’s understanding and what is communicated.
Patients may ask about their pro=
gnosis.
There are many motivations for the request. Some want to have a sense of t=
heir
future so they can plan. Others are terrified and hope that you will reass=
ure
them that things are not so serious.
Consider the implications of the
prognostic information provided. Patients who wish to plan their lives want
information that is very detailed. Those who are terrified may do better w=
ith
answers that are more general. Definitive answers, such as “You have=
six
months to lives” may increase the risk of producing disappointment if
the time proves to be less and anger if the time is longer.
Consider responding by giving a =
range of
time that encompasses an average life expectancy, such as “hours to
days”, days-to weeks”, weeks to month”, months to years&=
#8221;.
Alternatively, indicate averages such as “about one-third of people =
will
do well a year from now, half will live about 6 months. What will happen f=
or
you I can not exactly know.
Consistently suggest that patien=
ts and
families attempt to get their affairs in order so they won’t be so
vulnerable to something unexpectedly happening. Help clarify what can be d=
one
realistically and what might be wished for. Identify the miraculous for wh=
at
it is – something outside of usual experience that happens exceeding=
ly
rarely.
It is critical that sharing info=
rmation
with caregivers is continuous. Ensure that clinical data is recorded
accurately and is accessible to the team. In an emergency situation, there
should be no questions as to the likes and dislikes; wants and not to do
things for the patient.
The Key-points are that the vast
majority of Americans want to know if they have a life-threatening illness/
injury.
Using the 6-Step approach can improve communication and can
strengthen the patient-physician relationship.
Using a 6-Step protocol for deli=
vering
bad news offers specific guidelines and practical suggestions on how to
communicate any medical information effectively and compassionately; and
respond to the patient's and family's feelings and needs.
This protoco=
l is
a framework for approaching this important task. It is not meant to be a r=
igid
set of rules. However the key elements are clear communication that streng=
thens
the physician-patient relationships
' + ENDSHOW_MESG + '
![](3D"notes_flag.gif")
No=
tes![](3D"buttons.gif")
![](3D"slide0030_image004.jpg"){kind=link}