PALLIATIVE CARE OF

THE DYING
E.MUGI
Intro
• Many people living with a cancer diagnosis will ultimately die of their
disease
• Oncology care providers are uniquely prepared to care for those
patients who are in their final days of life.
• Furthermore, oncology nurses understand the psychological and
spiritual distress expressed by these patients and their families and
are able to address these concerns.
• Oncology nurses often have long-term relationships with these
patients and their loved ones, thus providing continuity of care during
what can be a very stressful time
Cont…
• Oncology providers can ensure a peaceful death for these patients,
ultimately improving the experience for the patient as well as for all
the loved ones in attendance during this process.
Symptoms during the final days of life

• A wide range of symptoms are common during the final stages of life.
• Oncology providers with knowledge and skills regarding palliative care
can effectively manage these symptoms, reducing the prevalence of
the “difficult death” and ultimately relieving distress experienced by
patients and their families.
• Furthermore, oncology nurses can educate family caregivers providing
assistance to loved ones in the home to reduce symptom distress.
1.Pain

• Pain- common throughout the cancer continuum, yet is particularly

prevalent toward the end of life.
-Unique aspects of pain control at the end of life include
a. assessment in the cognitively impaired,
b. delivery of drugs when the oral route is no longer feasible, and
c. concerns by family and professionals that opioids hasten death
Cont..pain

• Assessment of pain-Assessment of pain in the final days of life may be

complicated when the patient is no longer able to report the intensity or
presence of pain.
• In nonverbal patients, examine the brow for tightening or furrowing.
• Treat the pain empirically and reassess. If the furrowed brow becomes
smooth, assume that the patient was in pain and continue treatment.
• If the brow remains furrowed, consider other causes of discomfort, such as
impaction, a distended bladder, or spiritual concerns.
• Standardized assessment tools that have been found to be valid and reliable
in patients with cancer who are cognitively impaired are currently being
tested.
Pain mx

• Opioids and time of death-Family members and clinicians express

great fear that they will hasten the patient’s death through the use of
opioids
• Fear may lead to undertreatment of pain during the dying process.
There will always be a last dose of opioid.
• The implication for oncology providers is that patients can obtain
good control of pain and other symptoms through appropriate
titration of opioids.
2 . Myoclonus
• Spasmodic jerky contraction of groups of muscles.
• Myoclonus, characterized by sudden, uncontrollable, and
nonrhythmic jerking, usually of the extremities, is relatively
uncommon at the end of life,
• However, this neuroexcitatory toxicity of opioids can be devastating
when it occurs.
• Given in high doses, opioids, including morphine, hydromorphone,
methadone,meperidine,and transdermal fentanyl,may result in
myoclonus.
• Patients may first present with nocturnal myoclonus, and thus
providers should be attuned to early identification of this syndrome,
particularly in patients receiving high doses of opioids.
Mx of myoclonus

1. Rule Out Potential Causes

• Opioids, metoclopramide, and chlorambucil are the most common pharmacological causes
• Nonpharmacological causes include hypoxia, AIDS dementia, surgery to the brain, and paraneoplastic
syndrome
2. Rotate the Opioid
Calculate the equianalgesic dose of the existing opioid, using a standard table
• Convert to another opioid, based on the patient’s past experiences with these medications
• Reduce the dose by 25%–50% to account for cross-tolerance
• Reassess frequently, as these equivalents are only a guide; there is significant variation in response
among individuals
3. Reduce the Dose of the Opioid by:
• Adding adjuvant analgesics
• Considering interventional therapies
4. Add a Benzodiazepine
• Clonazepam 0.5 mg orally twice daily, and increase upward
• Midazolam 0.5 mg intravenous or subcutaneous if unable to swallow, and titrate upward
3. Seizures

• As was mentioned earlier, opioid-induced myoclonus can progress to

seizures.
• When more severe neurotoxicities occur, the opioid dose should be
reduced by at least 50% or more.
• Naloxone is not effective in reversing this toxicity.
• If seizures occur, first- and second-line therapies include phenytoin
and benzodiazepines, such as diazepam or lorazepam.
Mx of seizures

• Consider reversible causes, including

a. Hypoglycemia
b. Metabolic conditions (eg, hyponatremia hypercalcemia, hypoxia, withdrawal from opioids,
benzodiazepines, or alcohol)
• Management Pharmacological •
a. Lorazepam 1–2 mg intravenous or 4 mg rectally (alternatives include rectal diazepam available in
suppository or rectal gel)
b. Phenytoin 18 mg/kg intravenous over 30 min (monitor for bradycardia and hypotension); if able to
swallow, 300 mg orally every 2–3 hrs for 3 doses, followed by 300 mg/day (alternatives, include
fosphenytoin)
If ineffective:
c. Phenobarbital 20 mg/kg intravenous infusion; maximum rate 50–100 mg/min
d. Midazolam 0.5 mg/kg/hr with upward titration (can be given subcutaneously, intravenously, orally,
bucally, sublingually, or rectally)
e. Propofol 1–2 mg/kg intravenous loading dose, followed by infusion of 2–10 mg/kg/hr (incompatible
with most other drugs; contraindicated in patients with egg allergies or soya lecithin hypersensitivity)
f. Lidocaine infusions 1–2 mg/kg/hr intravenous
Seizures mx ct

• Nonpharmacological
a. Pad side rails with pillows
b. Provide calm, soothing, and safe environment
c. Instruct family and caregivers not to place items in mouth
4. Dyspnea

• Dyspnea is a common symptom in people diagnosed with cancer.

• Often described as shortness of breath or air hunger, this symptom
shares many attributes with pain in that self-report is the only reliable
strategy for assessment.
• Laboratory values (eg, oxygen saturation) do not necessarily correlate
with the intensity of the symptom, and opioids are the primary
treatment for both dyspnea and pain.
• As with pain, patients may be reluctant to report the presence of
dyspnea. As a result, oncology providers must routinely ask patients
about this symptom
• Cancer-Related Causes (Direct or Indirect)- Anemia ,ascites,cachexia,
electrolyte abnormalities,hepatomegaly,pericardial effusion,pleural
effusion,pneumonia,superior vena cava syndrome
• Treatment-Related Causes –Surgery,radiation,chemotherapy
• Causes Unrelated to Cancer or Its Treatment Anxiety-Arrhythmias,
asthma,cardiac ischemia,chronic obstructive pulmonary disease
5. Anxiety

• Anxiety is common during the fi nal days of life and is highly

correlated with other symptoms, such as unrelieved pain and dyspnea
• Medications commonly used in palliative care can contribute to the
sense of anxiety, including corticosteroids, neuroleptics (eg,
metoclopramide), bronchodilators, antihistamines, digitalis, and
occasionally benzodiazepines (which can cause a paradoxical reaction
in elderly patients).
Mx of anxiety

• The pharmacological management of anxiety often includes

benzodiazepines,
a. Lorazepam, as it has a short duration of action and generally
produces fewer adverse effects. Initial dosage is 0.5 to 2 mg orally 3
to 4 times daily, with upward titration as needed.
-Lorazepam can be placed sublingually, which is useful when
patients have difficulty swallowing, or given parenterally as a bolus or
infusion.
b. Haloperidol is frequently used for short-term management of severe
anxiety and as an antipsychotic (as discussed in the section on
delirium), with the initial dosage starting at 0.5 to 1 mg orally twice
daily.76
5. Delirium

• Common during the final days of life and includes altered perception,
impaired memory, emotional lability, hallucinations, incoherent
speech, and disorientation to time, place, and person.
• These symptoms may be misdiagnosed as anxiety or depression,
particularly when mild or in the early stages.
• Common causes of delirium at the end of life include medications,
such as opioids, corticosteroids, benzodiazepines, and adjuvant
analgesics, as well as metabolic changes resulting from hypercalcemia
and hyperglycemia, sepsis, central nervous system involvement by
tumor, encephalopathy, and other organ system failure
Cont delirium

• Delirium has been characterized as two subtypes,

a. Hyperactive-hyperarousal, hallucinations, and delusions. Withdrawal from benzodiazepines or
alcohol can result in this type of delirium
b. hypoactive.
Hypoactive delirium leads to lethargy and withdrawal and is more commonly related to encephalopathies
and organ system failure.
Treatment
• Reversing the underlying cause whenever possible.
• Pharmacological therapy includes
a. haloperidol, an agent that blocks dopamine. Low doses (0.5–1 mg) can be given orally, intravenously,
rectally, or subcutaneously.
b. Risperidone and olanzapine are also used, risperidone is not available parenterally and olanzapine is
limited to intramuscular injections.
c. Benzodiazepines such as lorazepam have been found to worsen delirium and cognitive impairment
and, therefore, are not recommended.
Nursing management includes fostering a safe, quiet environment, respecting the patient’s experience,
and supporting
6. Terminal secretions

• Excessive respiratory tract secretions, often called “death rattle” or

“rattle,” are common during the last hours of life.
• Although not likely painful to the patient, these secretions are
extremely disturbing to professionals, family members, and other
loved ones in attendance during this time.
• Studies indicate that terminal secretions typically occur within 16 to
57 hours before death, often preceding other symptoms such as
cyanosis.
• The prevalence of terminal secretions varies greatly (ranging from
23% to 50%),
Cont secretions

• Two categories of secretions have been identified.

a. Type I originates-salivary secretions and appears to respond well to
anticholinergic and other drying agents, with more than 90% of
patients obtaining relief.
b. Type II originates in the bronchi and is likely due to pulmonary
pathology, such as infection, tumor, fluid retention, or aspiration.
These secretions do not seem to respond well to treatment.
Mx
• Hyoscine (scopolamine) is available in transdermal and parenteral
formulation
• Atropine 0.4 mg subcutaneously every 15 minutes as needed or
hyoscyamine (Levsin) 0.125 to 0.25 mg orally
Cont mx of secretions

• Stop or reduce parenteral or enteral fluids

• Diuretics may reduce overhydration
• Reposition to avoid accumulation of fluid
GENERAL CHANGES AS DEATH NEARS

• In addition to the symptoms just described, patients will develop weakness,

fatigue, and anorexia.
• Nausea and vomiting may also occur.
• Patients may become incontinent of urine or feces.
• Greater assistance with the activities of daily living and hygiene will be
required, until total care must be provided.
• Family members require additional support as they witness their loved ones
dying.
• Patients’ lack of interest in food or fl uids is particularly distressing to loved
ones, as nutrition holds such meaning of nurturance in our culture
• Spiritual suffering is not uncommon as patients review their lives and refl
ect on their meaning.
Cont changes

• As the dying process progresses, patients will become more

withdrawn and less interactive with loved ones and caregivers.
• They may develop decreased perfusion in their extremities, leading
to coolness, mottling, and a bluish cast to the skin.
• Changes in breathing, with periods of apnea, may also occur.
• Family members and loved ones often question whether they should
leave the bedside, hoping to be present at the time of death.
PROVIDING SPIRITUAL CARE

• Spiritual needs Regardless of whether patients experience spiritual

distress, spiritual needs are an inherent part of living
• A qualitative study of 28 patients with cancer and family caregivers
identified 7 categories of spiritual needs, which encompass those
observed by previous researchers.
• These categories included:
1. Needs associated with relating to an Ultimate Other (eg, “God”). For
example, the need “get right” with God, or realize that “Something
out there is looking after you.
2. Need for positivity, gratitude, and hope, such as “keeping a positive
attitude” and “not taking life for granted.”
Cont. spiritual needs

3. Need to give and receive love from other persons, such as wanting to
make the world a better place and protecting one’s family from
knowing you suffer.
4.Need to review spiritual beliefs, often initiated by wondering if one’s
religious beliefs are correct, or by asking “why?” questions.
5. Need for meaning and fi nding purpose, such as “getting past asking,
why me?” and remembering that there are others worse off.
6. Religious needs, such as to have quiet time and space, pray, read
scripture, worship (eg, by watching a religious program on television).
7. Need to prepare oneself for death, for example, by balancing
thoughts about death with hoping for health.
Why address spirituality

The pathways which may explain the contribution of R/S to physical and mental health include:
• R/S creates a sense of meaning, and meaning in life is related to psychological and physical
well-being.
• Social support, which is inherent in affi liating with a religion, is linked with health—especially
when experienced within a faith community.
• Body sanctification or pursuing a lifestyle that appreciates the sacredness of one’s body or
health (eg, viewing
• Health locus of control, or how one believes self, others, chance, or God control their health,
may have an impact then on health behaviors.
• Gratitude, hope, optimism, and compassion may contribute to a sense of meaningfulness
and social connection, which as discussed above appear to enhance well-being.
• Health behaviors such as prayer and meditation, in addition to the religious proscriptions
mentioned above, appear to have stress-buffering effects which can also contribute to
health.
• Positive religious coping and other aspects of religion that produce a positive affect also
appear to have a stress-buffering effect.
PROVIDING SPIRITUAL CARE

• Spiritual or religious coping, often described in terms of “strategies” or

“resources,” appears to be an important mechanism that often promotes
adaptation for patients with cancer and their families
• Given that persons with cancer and their family members often use spiritual
coping strategies and that SWB contributes to adjustment and QOL, it follows
that nurses should support these coping strategies and nurture SWB in ways
that are patient-centered and ethical.
• .An oncology provider, therefore, must conduct a spiritual assessment that
includes questions such as “How can we nurses best support your spiritual
health?”
• Approaches to spiritual care have been provided by cancer care institutions.
• Churches, especially those serving African American communities, have
collaborated with nurses to promote cancer screening and health promotion
activities.
Cont. spiritual support

• Although not a spiritual care specialist, the provider can be a spiritual care
generalist.
• A provider must possess basic spiritual assessment skills, be able to provide
fundamental spiritual care such as presencing and empathic listening, and
be able to make referrals to diverse spiritual care experts when unable to
address spiritual needs adequately.
• Experts who nurses may consult, or to whom they can make referrals,
include chaplains, clergy, folk healers, lay ministers, spiritual directors,
parish nurses, mental health professionals with sensitivity toward
spirituality, or others with knowledge about various spiritual practices such
as meditation.
• Any persons with cancer do want their physicians to inquire about their
spirituality and possibly address spiritual concerns
Cont. spiritual support

• The two skills that are probably the most fundamental to providing
spirit-nurturing care are
a. Empathic listening and
b. presencing.
Four levels of empathic listening have been identifi eg:
a. Listening intellectually;
b. Listening intellectually and emotionally;
c. Listening intellectually, emotionally, and physically; and
d. Listening intellectually, emotionally, physically, and spiritually.
A holistic listener, one who listens at this fourth level, is a “holy”
listener.
Supporting spiritual or religious coping

• After assessment, the nurse may determine that religious beliefs or practices need to
be supported.
• Prayer is likely the most frequent religious practice benefi ting from support.
• Other religious beliefs and practices may need to be respected or incorporated in the
plan of care.
The following are guidelines developed by an ethicist and nurse:
a. First, try to understand the patient’s spiritual needs, resources, and preferences
b. Employ religious practices with permission; respect the patient’s expressed wishes
c. Do not prescribe or push religious beliefs or practices
d. Strive to understand your own spiritual beliefs and needs, before addressing
others’
e. When it is appropriate to employ religious practices with patients, do so in a
manner that is authentic and in harmony with your spiritual beliefs.
• Dying entails facing an unknown, the loss of self, the desire to leave a
legacy, the yearning to know that life— and death—possess purpose,
and many other experiences that are inherently spiritual.
• Williams in a meta-analysis identified the following themes:
• Spiritual despair (alienation, loss of self, dissonance)
• Spiritual work (forgiveness, self-exploration, search for balance)
• Spiritual well-being (connection, self-actualization,
DEATH
• Death is a irreversible cessation of circulatory, respiratory function or
the irreversible cessation of all functions of the entire brain.
• Two “roads” to death have been described.
• The “usual death” includes a continuum where patients become
sleepy and withdrawn, lethargic, and obtunded, gradually progressing
to coma and death.
• The “difficult death ” is one where the patient develops confusion and
restlessness, followed by hallucinations, delirium, myoclonus,
seizures, and eventually, coma and death.
• The degree to which patients travel each of these roads is not known,
yet even if less common, clinicians need to be prepared to manage
the disturbing “difficult death.”
Signs of Death

• Absence of heartbeat and respirations.

• Fixed pupils
• Skin color turns to a waxen pallor and extremities may darken.
• Body temperatures drops
• Muscles and sphincters relax, sometimes resulting in release of stool
or urine instem.
PHYSIOLOGICAL CHANGES AFTER DEATH

1. Rigor mortis
• Stiffening of the body that occurs about 2-4hrs after death.
• Results from a lack of ATP, which causes the muscles to contract,
which in turn immobilize the joints It starts in the involuntary
muscles( heart, bladder) then progress to head, neck, trunk ,
extremities.
2. Algor mortis
• Gradual decrease of the body temperature after death.
• When blood circulation terminates and hypothalamus ceases to
function , body temperature falls down.
Cont…
3.Livor mortis
Discoloration of body after death. After blood circulation has ceased ,
the RBC broken down , - leads to discoloration of surrounding tissues
4. Decomposition
Tissues after death become soft and eventually liquified by bacterial
fermentation . The hotter the temperature, the more rapid the change.
So bodies are stored in cool places / embalming
DIFFICULT SITUATIONS

1. SUDDEN DEATH
• From events such as hemorrhage, or intractable symptoms including
pain, dyspnea, nausea, and vomiting
• For patients with hematological malignancies, bleeding from any
orifice, such as the mouth, nose, eyes, rectum, urethra, or vagina can
be due to thrombocytopenia or other coagulopathies.
• Sudden death also may involve massive hemoptysis due to pulmonary
or aerodigestive tumors or external hemorrhage from carotid
involvement by tumor.
cont

2.PALLIATIVE SEDATION
• Benzodiazepines, such as lorazepam or midazolam, produce sedation
and can treat neurotoxicity related to opioids. Both have short half-
lives.
Death Confirmation

• Prior to death confirmation, you should check the patient’s resuscitation

status:
• If the patient is not for resuscitation, death confirmation can proceed.
• If there is uncertainty as to the patient’s resuscitation status, CPR should be
commenced whilst this is clarified.
• Review the patient’s notes to gain further details about their medical history.
• Clarify the circumstances surrounding the death with the relevant staff and
family members. This information will need to be documented in the
patient’s notes.
• If family or friends of the patient are present, introduce yourself and offer
your condolences. Explain the need to confirm death and offer the family the
opportunity to leave or stay whilst you do this. Check if the family have
any questions or concerns.
Cont. Death confirmation
To perform death confirmation:
1. Wash your hands and don PPE if appropriate.
2. Confirm the identity of the patient by checking their wrist band.
3. Inspect for obvious signs of life such as movement and respiratory effort.
4. Assess the patient’s response to verbal stimuli (e.g. “Hello, Mr Smith, can you
hear me?”).
5. Assess the patient’s response to pain using one of the following methods:
• Apply pressure to the patient’s fingernail.
• Perform a trapezius squeeze.
• Apply supraorbital pressure.
6. Assess the patient’s pupillary reflexes using a pen torch: after death, the pupils
become fixed and dilated.
Cont.

7. Palpate the carotid artery for a pulse: after death, this will be absent.
8. Perform auscultation in an attempt to identify any heart or respiratory sounds:
• Listen for heart sounds for at least 2 minutes.
• Listen for respiratory sounds for at least 3 minutes.
• The recommended amount of time to listen for heart and respiratory sounds can vary, but it is
generally accepted that a minimum of five minutes of auscultation is required to establish that
irreversible cardiorespiratory arrest has occurred. 1
9. Wash your hands, dispose of PPE appropriately and exit the room, making sure the relevant
doors and/or curtains are closed/drawn behind you.
Death Confirmation

The Final Examination

• When you have been asked to confirm the death of a patient, you should observe the patient for a
minimum of 5 minutes. To ensure that you perform all necessary steps, you can use a systematic A to E
approach:
• Airway / Breathing – Auscultate the lungs for >1min
• There will be no respiratory effort and no audible breath sounds.
• Circulation – Palpate for a pulse for >1min and auscultate the heart for >1min
• There will be no palpable central pulse and no audible heart sounds*
• Make sure you check for any palpable cardiac pacemaker
• Disability – Check for a pupillary response and check for a motor response to pain
• Following 5 minutes of continued cardio-respiratory arrest the patient’s pupils will be fixed, dilated and
unresponsive to light.
• There will be no response to a painful stimulus. This can be tested by applying supra-orbital pressure and looking
for any motor response.
• Exposure – The patient may be peripherally cold (depending on the timing of your assessment)
*In a patient who had been monitored, you may also notice continuous asystole on the cardiac monitor. In
a patient who has an arterial line you can observe an absence of pulsatile flow.
Death documentation

• The above examination will often be documented in the notes as below:

DATE 02/12, TIME: 2310: DEATH CERTIFICATION
• No audible breath or heart sounds for greater than 1 minute.
• No palpable pulse for greater than 1 minute. No palpable cardiac pacemaker.
• Pupils are fixed, dilated and unreactive to light.
• There is no response to painful stimulus.
Cont. death confirmation

• During the process of confirmation of death, you will need to make

yourself available to discuss any issues around the circumstances of
death or hospital admission with the patient’s next of kin.
• If the family are not present at the time of death, it is your duty to
ensure that they are informed immediately.
DEAD BODY CARE

• After death the body undergoes many physical changes.

• So care must be provided as early to prevent tissue damage
/disfigurement of body parts.
• Purpose of dead body care
1. To prepare the body for the morgue.
2. To prevent discoloration or deformity of the body.
3. To protect the body from post mortem discharge.
PROCEDURES IN CARE OF THE DEAD BODY

• Care of dead body ,often depends upon the customs and religious
beliefs. Nurses provide dignity and sensitivity to the client and family
1. Check orders for any specimens
2. Ask for special requests to family (eg: shaving , a special gown , Bible
in hand )
3. Remove all equipments , tubes , supplies and dirty linens.
4. Cleanse the body thoroughly , apply clean sheets
5. Brush and comb the hairs
6. The eyelids are closed and held in place for a few seconds , so they
remain closed.
7. Dentures should be in the mouth to maintain facial alignment.
Cont…Procedure

8. Mouth should be closed.

9. Remove all the ornaments.
10. Absorbent pads are placed under the buttocks to take up any feaces and
urine released because of muscle sphincter relaxation
11. All the orifices should be closed.
12. Cover with a clean sheet up to the chin.
13. Spray a deodorizer to remove unpleasant odor.
14. Apply name tag ( wrist , right big toe)
15. Allow the family members to view the dead body
16. The body is wrapped in a large piece or plastic or cotton material used to
enclose a body after death. Identification is then applied outside of the wrapper.
BREAKING BAD NEWS
WHAT IS A BAD NEWS?
• Bad news is defined as “Any information which adversely and
seriously affects an individual's view of his or her future”
Bad news situations can include:
• Disease recurrence,
• Spread of disease,
• Failure of treatment to affect disease progression,
• The presence of irreversible side effects, or
• Raising the issue of palliative care and resuscitation
EMOTIONAL RESPONSE TO A BAD NEWS

• Denial
• Despair
• Anger
• Bargaining
• Depression
• Acceptance
WHY IS IT DIFFICULT?

• It usually means that biomedical measures cannot help, and thus it

undermines the clinician’s familiar role of the healer.
• The clinician is upset.
• The patient will be upset too, and can respond unexpectedly.
• The patient may blame the clinician, and indeed there may be an element of
medical mishap to complicate matters.
• Clinician’s long-standing relationship with the patient.
• The patient is young.
• When strong optimism had been expressed for a successful outcome.
• Strong emotions such as anxiety, a burden of responsibility for the news, and
fear of negative evaluation. This stress creates a reluctance to deliver bad
news, which is named as “MUM” effect.
WHO SHOULD BREAK THE BAD NEW?

• Ideally, bad news should be imparted by the lead consultant or senior

non-consultant hospital doctor, who is known to the patient or in
whom the patient has trust.
• In the exceptional circumstances of sudden death a senior member
of the nursing staff may have to break bad news.
• Nurses may play a particular role in relation to breaking bad news in
the inpatient clinical setting.
PATIENT’S RIGHT WITH REGARD TO BAD NEWS

Patients have a right to:

• Accurate and true information.
• Receive or not receive bad news.
• Decide how much information they want or do not want.
• Decide who should be present during the consultation, i.e. family.
• Members including children and/or significant others.
• Decide who should be informed about their diagnosis and what
information that person(s) should receive.
TIME FOR BREAKING THE BAD NEWS

• As early as possible in the diagnostic process the multidisciplinary

team should begin to prepare the patient for the possibility of bad
news.
APPROACHES IN BREAKING BAD NEWS

• There are several strategy for braking bad news are described in
various articles.
• The important protocols are SPIKES, ABCDE & BREAK.
SPIKES: A SIX STEP STRATEGY

• The protocol (SPIKES) consists of six steps.

• The goal is to enable the clinician to fulfill the four most important
objectives of the interview:
a. Disclosing bad news,
b. Gathering information from the patient,
c. Transmitting the medical information providing support to the
patient,
d. Eliciting the patient's collaboration in developing a strategy or
treatment plan for the future.
• THE SIX STEPS 
Step 1: S—Setting up the interview.
Step 2: P—Assessing the patient's perception.
Step 3: I—Obtaining the patient's invitation.
Step 4: K—Giving knowledge and information to the patient.
Step 5: E—Addressing the patient's emotions with empathic responses.
Step 6: S—Strategy & summary.
ABCDE MODEL

• Advance preparation,
• Building a therapeutic setting /relationship,
• Communicate well,
• Deal with patient and family responses,
• Encourage and authenticate feelings
BREAK MODEL

• B-Background-  An effective therapeutic communication is

dependent on the in-depth knowledge of the patient's problem
• R-Rapport- Building rapport is fundamental to continuous professional
relationship.
• E-Explore- Whenever attempting to break the bad news, it is easier
for the physician to start from what the patient knows about his/her
illness.
• A-Announce; - A warning shot is desirable, so that the news will not
explode like a bomb.  Euphemisms are welcome, but they should not
create confusion.
• K-Kindling- People listen to their diagnosis differently.  They may
break down in tears. Whatever their reactions may be, the doctor has
to give him time to settle & respond positivel
DO’S IN BREAKING BAD NEWS

• Allow for silence, tears and other patient reactions.

• Allow time.  Be sensitive to the non-verbal language.
• Document and liaise with the multidisciplinary team.
• Ensure honest and simple language is used.
• Ensure privacy and confidentiality and respect both.
• Gauge the need for information on an individual basis.
• Let the patient talk.
• Listen to what the patient says.
DON’TS IN BREAKING BAD NEWS

• Assume that you know what is concerning the patient.

• Criticise or make judgements.
• Distort the truth
• Feel obliged to keep talking all the time.
• Give false reassurance.
• Overload with information.
• Withhold information.
AFTER-DEATH CARE

• After-death care includes-

• preparing the body so that loved ones can see the patient in as
natural a state as possible.
• Cleaning and redressing the patient, as well as removing tubes and
equipment
• assists family members in developing a less painful memory of their
loved one, fostering a healthy bereavement process.
• Cultural practices need to be considered