IMPORTANT NOTE: JAAPA CME activities consist of 2 articles. To obtain credit, you must also read
Initiating HIV antiretroviral therapy: Criteria, evidence, and controversy; the post-test will include questions related to both articles. AAPA Fellow members should complete and submit the post-test on the AAPA Web site by going to
www.aapa.org and searching for keyword
JAAPA post-tests. All others may complete and submit the post-test online at no charge at
www.mycme.com. To obtain 1 hour of AAPA Category I CME credit, PAs must receive a score of 70% or better on each test taken.
LEARNING OBJECTIVES
■ Review the various factors that can create communication problems, and list tools and strategies that can help providers to improve communication
■ Describe utilization of the Buckman protocol
■ Discuss how these strategies can improve patient care in all areas of practice
Every clinician is eventually faced with having to deliver bad news to a patient. These scenarios are sometimes approached with dread, but the opportunity to enter into a deeper, richer relationship with the patient exists for those who remain open to it. As clinicians, we need to be aware that although medicine may no longer be able to offer a cure, the ability to heal still exists. With our unique scope of practice, PAs can have tremendous impact on a patient's quality of care. We can ease suffering, provide education and reassurance, vastly improve communication between the care team and the patient and family, and promote understanding between parties dealing with end-of-life (EOL) issues. Many times, PAs work with members of a multidisciplinary team when dealing with complex medical issues. Team members may include multiple specialty clinicians, nurses, physical therapists, occupational therapists, mental health therapists, spiritual leaders, chaplains, social workers, case managers, and others. Introducing and utilizing these team members are important steps in caring for patients with complex medical conditions. While once limited to EOL care, this holistic approach to all patients is recognized as a valuable facet of practice.
PROVIDING SPIRITUAL CARE
One emerging and vital concept when approaching a patient with bad news is the awareness of the many dimensions in which the patient will be impacted. Medicine has long concentrated solely on the body. We now recognize that both mental and spiritual suffering must be addressed for both patients and their families. Although addressing such suffering was once confined to end-of-life care, clinicians employ this approach with patients who are not terminally ill as well.
To aid in the control of such suffering, a spiritual history should be obtained from patients. A rudimentary spiritual history on all inpatients is required by the Joint Commission on Accreditation of Healthcare Organizations.1 Generally, this information is gathered either from forms filled out by the patient or by nursing interview. Surveys have shown that patients and their families prefer that these conversations begin before the stress and confusion of hospitalization occur.2 Patients also want health care providers, at all levels, to understand their spiritual and religious needs.3 While a spiritual history is not necessary with every patient encountered daily, serious chronic diagnoses and high risk factors for major events do indicate the need for further discussions.
Many models exist for taking a spiritual history, among them the FICA (Faith and beliefs; Importance of spirituality in patient's life; Spiritual Community of support; How spiritual issues should be Addressed) and SPIRIT (Spiritual belief system; Personal spirituality; Integration with a spiritual community; Ritualized practices and restrictions; Implications for medical care; Terminal events planning) models.1 These models should be utilized in the appropriate manner—that is, as a framework for discussion. Obviously, the interview's effectiveness hinges not only on the clinician's comfort in asking the questions but also on the patient's comfort with the clinician. And while a full understanding of spiritual or religious beliefs is not necessary, recognition of the patient's values creates a deeper level of communication and trust.
The medical team should appreciate the patient's faith practices and be familiar with the support network available through the patient's religious community. When faced with grave or terminal illness, patients can receive comfort and relief (and, in some instances, redemption) from suffering through their faith. Religious leaders from the patient's faith practice or hospital chaplains can become key members of the care team. It is, therefore, important to identify and notify them as early as possible.
BREAKING BAD NEWS
If the clinician and patient have already established a relationship through a spiritual history, a common language now exists that can facilitate the conveying of bad news. Hopefully, before hospitalization, some discussion has occurred regarding advance directives (ADs) as well. Still, bad news does have to be delivered. And while it should remain the primary responsibility of the physician to broach the subject, PAs have a vital role in working with the patient during the initial discussion and an increasing responsibility in subsequent encounters. Familiarity with the protocols most commonly used to tell patients bad news is therefore essential.
Commonly known as the Buckman or SPIKES protocol, this series of focus points creates a format for difficult discussions (Table 1). The protocol was developed and eventually published by Robert Buckman.4 Variations of it have gradually been adopted throughout the medical community and provide a loose framework that clinicians can use to discuss difficult news with patients.
The first step in delivering bad news is to arrange the setting. Clinicians should be aware of the time this discussion requires and manage their schedules accordingly. A minimum of 40 minutes, with minimal interruption, is appropriate for the initial conversation. Privacy should be ensured, and the patient's physical comfort and ability to have an extended discussion must also be assessed. Informing the patient a day or two in advance of the meeting and requesting that family members and/or significant others be present gives everyone time to arrange their schedules. Limiting the number of family members to two or three is useful, and sometimes requesting others to leave may be necessary. Sitting close to and at eye level with the patient conveys openness as well as patience with the coming discussion. This simple positioning creates intimacy, a sense of partnership and caring. It also allows for better assessment of the patient's receptiveness and fatigue as the discussion progresses.