I’m writing a reflective essay based on Gibb’s model of refection, this is a six stage evaluation process and promotes good practice through evaluation of experiences, aids learning and better understanding on how to deal with similar situations in future practice, the six stages comprise of description, feelings, evaluation, analysis, conclusion and finally an action plan (Gibbs, 1998). The department of health (DoH) advises primary care, to use reflective practice and encourages integrated working with all professional within the community and hospitals of the local trust (DoH, 2000), which is incorporate in my reflection.
All names and identities have been changed to maintain confidentially in accordance with the code of conduct (NMC, 2009). I will explore an experience I had whilst based in a local trust hospital, discussing a situation that I felt uncomfortable with and unsure how to manage emotionally, psychologically and professionally. This situation evolved after a patient had been giving bad news by a doctor and talks about the events after this occurred.
I feel it is important to discuss breaking bad news as this area of communication is often an area that even the professional person finds difficult (Brewin, 1998). The inter-professional teams all have different education and preparation leading to different views as to how the subject should be managed and the best way to break bad news. Schildman et al. (2005) stated there is a need for specific education on breaking bad news, ensuring all professionals where proficient in this area with an aim to improve skills and continuity.
By “bad news” Buckman (1984) described as any information given that is likely to dramatically alter a patient’s view of their future. The bad news that is delivered may not be about terminal illness or death but could be a lifestyle altering condition like diabetes, heart disease or HIV (Peate, 2006). Arber & Gallagher (2004) defined bad news as any information given that is not welcome. Traditionally delivering bad news has been considered the doctors role, despite having little education or preparation in this area (Vandekieft, 2001). Although a nurse may not be delivering bad news directly, it is an inescapable part of healthcare (Price, 2006) and an integral part of their role (Tobin & Begley, 2008). It is however, important to remember that the role of breaking bad news is not the responsibility of just one profession but should be a shared responsibility with all the inter-professionals within the multi disciplinary team (Jevon, 2010).
Mr M, 72 year old male, admitted to the ward and initially presented with intense intermittent pain in pelvic area and legs. After several investigations with other hospital inter-professional teams Mr M underwent tests such as x-rays, cat scans and MRI scans. This led to a diagnosis that Mr M had bone and lung metastases, this is also known as secondary cancer. Metastatic cancer occurs when the cancer cells breaks from the primary site, relocate to another area of the body and then forms secondary tumours (American Cancer Society, 2010). Cancer is deemed as the most feared diagnosis in today’s society (Kalber, 2009). The junior doctor had discussed these results with Mr M, whilst he remained on the ward and without another member of staff with him during the conversation. It is suggested that bad news should be delivered to the patient by someone they know (Lomas et al, 2004). This leads to a much debated subject as to who should break bad news (Brewin, 1998), due to the belief that some doctors are not well prepared and have lack of training and preparation for this task (Vandekeift, 2001). Whereas, the nurses have more communication with the patient and can build a better rapport (Jevon, 2010). The doctor with Mr M should have made him aware, that he had terminal cancer but we were unable to verify this. The written information in Mr M’s notes where thought by the nurses to be to brief and therefore not well recorded due to a lack of in-depth detail but the doctor could argue the notes were ok, they had acknowledge he had spoken to Mr M about his results.
After the doctors consultation Mr M was positive and upbeat and still trying to do as much as he could for himself. Later that day he had spoken to me stating that the doctor wanted to run more test, informing me that they were going to look for the primary cancer site as this may be treatable. My intrinsic feeling was that Mr M thought he could be cured. This made me feel awkward and uncomfortable being around him and I found it difficult to know what to say to him, as I was aware of his terminal diagnosis. I was unsure as to what information the doctor had told Mr M or if the doctor had checked he had understood. As doctors have different education and views than the nursing staff it leads to professional indifferences. Mr M’s behaviour may have been his way of coping and could have indicated that he was in denial. Denial is a way for the individual to cope and regain some control, when bad news is delivered leading to an uncontrollable situation like a diagnosis of terminal illness (Burgess, 1994). I felt as if I was withholding information from him that he should be aware of. This made me feel as if I was lying to Mr M, something I was uncomfortable with and I felt compromised ethically, as I was more that aware of his rights to be informed and my code of conduct that states I should be open and honest (NMC, 2008). This made me want to avoid conversation with Mr M as I was unsure how to manage the situation and was worried in case he asked me any questions, as this could have led to further distress to myself or Mr M. However, it is normal when giving or receiving bad news to feel psychological distress but if supported and managed well you can avoid damaging long terms effects (Fukui et al, 2009). I had discuss with nurse in charge that I had concerns about Mr M and queried if he had definitely been told of his terminal diagnosis. Mr M’s mood and behaviour was monitored by the nursing staff over the next two weeks, with occasional subtle prompts for him to ask any questions or to comment on how he felt. After this time the palliative care team were informed of Mr M’s situation and invited to the ward by the nursing team, to talk to Mr M and explain his illness was terminal, help him acknowledge this and start to come to terms with his situation and prepare himself and his family with what was to come. The palliative care team have more experience and practice in communication with those diagnosed with terminal cancer.
The terminal patient can experience many different emotions (Peate, 2006), these have been studied by Kulber-Ross in the 1960’s and Murry-Parkes in the 1980’s. They both suggest that there are five stages of grief and structured these into models of bereavement (sometime known as the grief cycle). Kulber-Ross (1969) stated that not every person will react in the same way or go through all the stages in order. The five stages are Denial, Anger, Bargaining, Depression or grief and then Acceptance. A dying patient will often go through these stages whilst coming to terms with their own death (Kulber-Ross, 1969).
I felt it was good that Mr M had taken onboard some of the information the doctor had told him and he was in good spirits and trying to do as much as possible. That Mr M was able to communicate well with the nursing team and had benefited from the expertise, kindness and knowledge from all the inter-professional teams from the porters who regularly moved Mr M and showed patience and understanding regarding his pain, to the reassurance given him by the radiographers and their expertise to minimise his discomfort, pain and the palliative care team who showed patience and understanding and with their unique knowledge were able to help Mr M come to terms with his terminal cancer, understand it better and help him cope with his situation. All these people are specialist in their own fields and were involved with Mr M’s care amongst several others. It was good that personally I had built a good rapport with Mr M, which helped me to be aware of his behaviour and highlight my concerns with the nurses. Enabling me to raise awareness and question the nurses as to if Mr M had been informed of his diagnosis or question ‘was he in denial?’
I thought it was bad that no-one who had worked regularly with Mr M i.e. a nurse was with the doctor when he was told his diagnosis and that it was a junior doctor that Mr M did not know very well. The information about the discussion hadn’t been recorded in detail, as to what was said and if Mr M had understood this information. So we had to make assumptions due to the lack of detail, we could only ascertain if Mr M was in denial through time. Also that I felt I had to avoid communication with Mr M as I found it difficult due to his terminal illness and was unsure what to say to him. I realised talking about dying directly with the dying patient an area I was uncomfortable with and felt unprepared for and therefore avoided the situation. This is echoed by Trovo de Arujo and de Silva (2004) where he suggested that many people will approach communication differently with a dying patient; this includes avoidance patterns, which may be due to difficulties in coping with human suffering and death.
I have to assume the doctor had given Mr M the correct information about his diagnosis, which left the conclusion that Mr M had not fully understood this information or was in denial about his terminal cancer. I should have contacted the doctor who consulted with Mr M to ascertain as to how the information was given and how he felt Mr M had responded to this. Explaining Mr M’s current behaviour and his understanding that they were still looking for the cause of the cancer and this when located could be treated. This may have improved the situation, by leading to the doctor returning to re-explain to Mr M with another member of the ward. It is now thought that the doctor may not be the most appropriate person to give bad news and in some situations it may be better for a nurse to do this role (Resuscitation Council UK, 2006).
If I was presented with a similar situation, I now feel I would manage the situation better, as I have learnt through reflection of these events. Sometimes caring for a dying patient can be daunting as in our nursing role we believe we are there to improve a patient’s health so they will get better (Peate, 2006) but the reality is we have a unique role to assist the patient to health or to a peaceful death (Henderson, 19996). Common sense and forward planning, the use of a structured model can help prevent any distress or communication disasters (Walker et al, 2001). I feel that the communication of bad news should be delivered to a patient avoiding medical terminology (Back et al, 2005), as this reduces misinterpretation (Innes, 2009). The inter-professional teams will benefit the individual by supporting each other and drawing on each other’s knowledge, helping to reduce long term distress (Fukui et al, 2009) or further avoidance of distressing situations. It is also important to be aware that every patient will react differently to bad news (Kulber-Ross, 1969) and to remember their family will also require lots of information and support at this time (Dougherty & Lister, 2008).