A 57-year-old woman comes to the emergency department experiencing severe lower back pain. The pain began 4 weeks ago and is getting progressively worse. At night, the pain has become so severe that it awakens her from sleep. The patient has tried over-the-counter ibuprofen with no relief of symptoms. She also reports feeling more tired than usual but says, "It is probably because my kids are home for the holidays and are keeping me busy." The patient has a history of breast cancer that has been in remission for 2 years. Her physical examination is significant for weakness and numbness of the left lower limb. Radiographic findings are consistent with metastatic lesions in her spine. Which of the following is the most appropriate next statement in initiating a conversation about this patient's condition?

Question

A 57-year-old woman comes to the emergency department experiencing severe lower back pain.  The pain began 4 weeks ago and is getting progressively worse.  At night, the pain has become so severe that it awakens her from sleep.  The patient has tried over-the-counter ibuprofen with no relief of symptoms.  She also reports feeling more tired than usual but says, "It is probably because my kids are home for the holidays and are keeping me busy."  The patient has a history of breast cancer that has been in remission for 2 years.  Her physical examination is significant for weakness and numbness of the left lower limb.  Radiographic findings are consistent with metastatic lesions in her spine.  Which of the following is the most appropriate next statement in initiating a conversation about this patient's condition?

Quizplus · Accepted Answer

Breaking bad news is one of the most difficult situations a physician will encounter. A sensitive, patient-centered approach that is responsive to the patient's needs is preferred rather than expressing excessive sympathy or prematurely suggesting treatment options. An important first step is to find out how much the patient already knows and what the patient believes about his or her condition. This patient has a previous diagnosis of breast cancer, but to what extent she has been informed or understands her risk for metastatic disease is unclear. First listening to how the patient discusses her condition and fears will help the physician phrase the information accordingly. The physician can then communicate his or her suspicions and concerns in an empathic manner using language that is understandable to the patient, considering any religious or cultural issues, and adjusting the level of detail according to how much the patient wants to know. Let the patient ask questions but do not overload him or her with too much information. Information may need to be repeated later after the emotion of the situation has been absorbed. Although each situation is different and the physician's response should be guided by the patient, a protocol such as SPIKES can be used for general guidance. SPIKES (Choice A) Immediately stating the likely diagnosis without any preparation or assessment of this patient's perception is not an optimal way to begin the discussion. Using simpler vocabulary rather than medical terms such as "metastatic disease" may also be preferable. (Choice B) Physicians should generally determine how much the patient wants to know. However, beginning the discussion this way suggests bad news and would likely raise this patient's anxiety level, especially if she has not considered metastases as a possibility. (Choice C) This approach delivers the news abruptly and then expresses excessive sympathy without allowing this patient to express her own emotions. This approach can engender hopelessness and hinder appropriate information exchange. (Choice D) Stating that this patient likely has cancer in her back and then jumping straight to treatment options is insensitive and premature. The physician should pause after delivering bad news and allow the patient to express emotion and ask questions. Educational objective: When delivering potentially bad news, a physician should first assess the patient's comprehension, fears, and desire for information to deliver the news in an empathetic yet comprehensible manner. References: Delivering bad news to patients. (http://www.ncbi.nlm.nih.gov/pubmed/26722188) Breaking bad news education for emergency medicine residents: a novel training module using simulation with the SPIKES protocol. (http://www.ncbi.nlm.nih.gov/pubmed/21063562) Recipients' perspective on breaking bad news: how you put it really makes a difference. (http://www.ncbi.nlm.nih.gov/pubmed/16081235)

A 57-Year-Old Woman Comes to the Emergency Department Experiencing Severe