The Shock of a Cancer Diagnosis
Setting the Scene
Gyne-oncology patients are counselled pre-operatively about the high probability of a cancer diagnosis. However the shock experienced postoperatively is challenging for patients and for the staff caring for them.
Case Study
It is your patient’s first day after surgery and morning rounds have just finished. You enter your patient’s room after rounds and find her either crying or on the verge of tears. She has just found out that the growth in her abdomen is cancerous and she will need to have chemotherapy. She heard she has 3 years left to live. What do you say? What do you do? You literally feel like your task is to “pick up the pieces”. You have 4 patients in your assignment, you need to give 0800 meds, answer call bells, do assessments and hopefully get at least one bed bath started before 0900.
On weekdays you can rely upon your multidisciplinary team (e.g. our liaison nurse or social worker) to follow-up and help. However, on the weekend it is the nurse who becomes frontline psychosocial support. This newsletter focuses on some communication strategies to use when patients have just been given “bad news”.
Effective Communication Strategies
Attending Behavior
Visuals: eye contact
Vocals: vocal quality
Verbals: verbal tracking
Body language: attentive, authentic and congruent
Also known as unconditional positive regard. Body language is an important aspect of communication and needs to be congruent with verbal communication. You are in action mode with an already prioritized set of tasks. SLOW DOWN, take a deep breath and sit beside the patient, use touch and eye contact if culturally appropriate. “Mirror” your patient’s body language.
Buckman’s research with medical students has shown that empathic communication takes less time than anticipated. Silence may be effective if the patient is crying. Tears can be therapeutic and a great release of tension.
Acknowledge Feelings
Using both verbal and non-verbal communication, acknowledge the feelings. Saying something like, “You look upset” may be all you need to say to encourage the patient to share. Avoid premature reassurances such as “Don’t worry. It will be okay.”
Patient’s Perception
It is important to find out what the patient knows/has understood about his/her condition. Find out from the physician what was discussed and hopefully the physician can return to clarify information. If not, call the physician and let him/her know that follow-up and clarification is needed. For example, with the patient who thought she had 3 years left to live, misinterpretation of what was said was the case. The patient had asked the physician about treatment options and in the course of the discussion he had mentioned that the effectiveness of chemotherapy decreased after 3 years.
Re-prioritize
Attempt to stay with the physician while he/she clarifies and communicates with the patient. This allows you to know what has been discussed.
SPIKES is an acronym for delivering bad news. Delivering a diagnosis is not a nursing act, however nurses can use aspects of the SPIKES method for communicating bad news.
SPIKES: a physician aid for breaking bad news
Setting
Patient perception
Invitation
Knowledge
Empathy/exploring
Strategy/summary
Re-prioritizing your workday at this stage may help or perhaps other nurses can cover for you for a short period. If not, let the patient know her needs are important to you and set a time when you can return. Offer to phone a family member or friend.
Summary Points
· Build trust. Follow-up on your promise to check back.
· Encourage and strengthen past coping strategies
· Listen more. Talk less. The patient is the focus.
· Elicit feedback (paraphrasing, summarizing are effective strategies)
· The relationship between patient and nurses/physicians has a power differential that can inhibit communication. Try to remove barriers.
· Use open-ended questions to encourage patient communication.
· Be culturally sensitive.
· Be genuine.
“The art of communication is an important part of therapy: occasionally it is the only constituent. It usually requires greater thought and planning than a drug prescription and unfortunately it is commonly administered in sub-therapeutic doses.” R. Buckman
Bibliography
Anderson, I. (2000). Continuing education program on end-of-life care.
Retrieved from http://www.cme.utoronto.ca/endoflife/Modules.htm
Baile, F., Buckman, R., Lenzi, R., Glober, G., Beale, E. & Kudelka, A. (2000). SPIKES- a six step protocol for delivering bad news. The Oncologist, 5: 303-311
Ivey, E., Ivey, M. & Zalaquett, C. (2010). Intentional interviewing & counselling. (7th Ed.) Brooks/Cole: Belmont, CA.
Malloy, P., Virani, R., Kelly K. & Munevar, C. Beyond bad news-communication skills of nurses in palliative care. Journal of Hospice and Palliative Nursing 12(3): 166-174
Pereira, J. (2008). The Pallium Palliative Pocketbook. Canada. The Pallium Project. For more information go to http://www.palliativetool.info
