《坏消息的告知》PPT课件.ppt

1,壞消息的告知,陳祖裕,2,影片的兩個印象,醫師還不如法師 不要倚賴家屬來告知病情,3,臨床溝通技巧下學期授課進度表,日期 授課內容 3/05 課程介紹及特殊狀況的臨床溝通技巧 3/19 同理心與溝通技巧 3/26 壞消息的告知：詮釋及體驗 4/16 困難病人：觀念認知及體驗 4/23 困難狀況（一）（video 上） 4/30 & 5/07 演練（一） 5/14 困難狀況（二）（video 下） 5/21 & 6/04 演練（二） 6/18 期末考試 （筆試、演練）,*希望可以安排到教學門診觀摩一次,4,壞消息的告知,有關告知壞消息的一些倫理議題 台上演練： 相關議題：錯誤的處理,5,一位門診的複診病人，上次因排便習慣改變而被安排大腸鏡檢查。 輪到他看診時有一位較年輕的女仕率先步入，並回頭吩咐兩個較年輕的男性：先陪爸在外頭等一下。 然後就向你（門診醫師）說：家父（指病人）在上週檢查大腸，檢查的醫生說腸子裡長了一個瘤子，看來像是癌症，今天是來看切片的報告，請先告訴我結果。因為家父已經七十多歲，又有心臟病，我們全家都怕他受不了刺激，所以如果是癌症，千萬不能讓他知道。 你在電腦上查得病理報告是：adenocarcinoma, well differentiated。 你要怎麼說？,教案壞消息的告知,6,要說慌嗎？,7,說謊的時機,謊言：做錯事，怕有糾紛 白色的謊言：怕壞消息會傷害到病人,8,為何壞消息會傷害到病人？,消息實在太壞，怕病人受不了 消息不是太壞，但病人太脆弱了,9,說謊有好處嗎？,留給病人一線希望 與病魔搏鬥的力量 減除心理的痛楚 避免不幸事件的發生（殺人、自殺） 至少可減少哭泣及失眠,10,說謊有壞處嗎？,不知真相，難以作出決定 失去珍惜餘生的機會：家人共聚、財產分配、達成心願 病人與家屬間互相猜疑，雙方承受的壓力比知道真相時更大 醫生本身也承受壓力：病情不易解釋、要不斷地圓謊 謊言被拆穿時，醫病關係盡毀 違反醫學倫理？ 違反醫事法規？,11,生命倫理四原則,尊重自主 不傷害 行善 公正,12,生命倫理四原則,尊重自主：病人要作出醫療決定，所以要告知 不傷害：告知有時會造成對病人的傷害，所以不應告知 行善：告知有時會對病人有益，所以應該告知 公正：應該人人都告知或人人都不告知,13,生命倫理四原則：一個古老笑話,從前有個小瓜呆 父母外出叫他看門 臨行告知若有人來訪時如何應對： 債主找爸爸：到深山去向老和尚請示人生哲理 外公找媽媽：去大姐家坐月子 鄰居取山羊：牠在後花園吃草 媬母看娃兒：她在等你幫她洗澡,14,生命倫理四原則,從前有個小瓜呆 父母外出叫他看門 果然，那些人都來了： 鄰居取山羊：到深山去向老和尚請示人生哲理 媬母看娃兒：去大姐家坐月子 債主找爸爸：牠在後花園吃草 外公找媽媽：她在等你幫她洗澡,15,生命倫理四原則,只有小瓜呆才會被此四原則所約束 我們如能運用智慧，四原則就像是四件法寶,16,研究倫理七原則,尊重自主 不傷害 行善 公正 保密 真實 誠實,所以，不能說謊，包括白色的,17,凡事誠實容易嗎？,有時候難以啟齒 病人的反應難料 家屬堅持不誠實 病人不願知真相？,18,一位主治醫師的告白,I was 25 years old and working in an emergency department. A young boy was brought in with severe head injuries following a traffic accident. We tried to resuscitate him, but it was obviously useless. I had to go out and tell his parents. Id never told anyone before that their child was dead and didnt have a clue what to say. I just blurted it out and the mother started screaming I didnt know how to handle the situation. I just said Sorry and ran out of the room. I can still hear that womans screams. That was over 30 years ago and I dont think things are really much better in terms of helping young doctors learn how to break bad news.,19,回顧剛才的案例,一位門診的複診病人，上次因排便習慣改變而被安排大腸鏡檢查。 輪到他看診時有一位年約四十多的女仕率先步入，並回頭吩咐兩個較年輕的男性：先陪爸在外頭等一下。 然後就向你（門診醫師）說：家父（指病人）在上週檢查大腸，檢查的醫生說腸子裡長了一個瘤子，看來像是癌症，今天是來看切片的報告，請先告訴我結果。因為家父已經七十多歲，又有心臟病，我們全家都怕他受不了刺激，所以如果是癌症，千萬不能讓他知道。 你在電腦上查得病理報告是：adenocarcinoma 你要怎麼說？,20,壞消息的告知,若壞消息不經意地揭露，醫病皆輸 病家：持續，不必要的苦痛、誤判誤斷 醫生：挫折感 溝通技巧訓練不足就不能適切地告知壞消息,21,告知壞消息的三種方法 (Brewin 1991),因認為無論怎麼說病人都會難過，故呈現得直率及欠缺感情 仁慈且悲傷，但沒有支持、鼓勵或希望 善解人意、正向、機靈的保證及具備同理心,22,The Third Way,須有以病人為中心的理念，兼顧生理 心 理 社會層面 要有充分的機會讓病人發問及互動，並了解他們的感受 若錯估病人對獲悉壞消息的反應而對消息作不適切的剪裁，可導致更多的焦慮與不確定 必須了解病人的背景,23,壞消息難以告知的理由,訓練不足而不知如何獲知病家感受 害怕遭受責備 害怕場面失控 不知如何處理情緒 害怕感受自己的情緒 須面對死亡或重症的恐懼,24,被告知壞消息後的情緒反應,驚惶而沉默 憤怒 不相信 悲痛 內疚 歸咎他人,25,被告知壞消息後情緒反應的處理,要容許病人哭 病人對於臨哭不亂的醫生會有高度評價 太常見的是醫生把流淚視同出血，想盡快停止 第一個動作常是遞給病人紙巾 較佳的處理方式是靜待病人哭泣 勿以牙還牙，以怒還怒 此刻有情勝無情：冷漠比哭泣更糟,26,告知壞消息非緊急情況,有充分時間準備 必須不斷地注意病人的感受 提供資訊及發問的時間 可能的話不要給其他的事（如討論診療計畫）所干擾 Hogbin and Fallowfield (1989)將 “bad new” consultations 的錄音帶提供給病人：心情較不煩亂時再聽、播給家人聽,27,告知壞消息的能力養成,演練 個人心智成長、人文素養,28,告知壞消息的考量要點,充分的準備、合宜的場所、足夠的時間 確認病家知悉談話的目的 緊記：你所認為有希望的消息對病人而言就是壞消息（反之亦然） 不要以為還會有人向病人解說 儘量給予正面的訊息但要避免不正確的保證 確定病人有充足的時間領悟 安排追約談，給予輔導機構的電話和地址 在接見下一個病人之前先檢視自己的感受,29,告知壞消息的“SPIKES”步驟 (R. Buckman, 1992),1. Setting：建立一個恰當的情境。提供一個保護病人隱私而舒適的場所，不受干擾的時間，與病人面對面平坐。依病人的意願，邀請其他重要相關親友在場。這一切都在於建立良好的醫病關係。 2. Patients Perception ：探詢病人對自己病情的了解。譬如說：告訴我，您知道我們為什麼要做這些檢查？ 3. Patients Invitation ：引導病人來詢問有關病情的細節。譬如說：要是檢驗結果都出來了，您要知道全部詳細的內容嗎？（不管什麼都要知道嗎？） 4. Knowledge ：提供知識與資訊給病人。提供資訊時，最好採漸進式分段給，並要不斷試探病人是否消化了他所得到的資訊，避免用醫學上的專業用辭。 5. Empathize ：要能發掘病人情緒的變化，進而表示同情。如：當病人哭泣時，說看來您並沒有預期這樣情況，或說這個結果一定讓您很難接受。 6. Summary ：最後，將所有的資訊綜合，做一個摘要，並且經由與病人溝通，去達成一個治療或追蹤的方案。 Buckman R. How to break bad news. Johns Hopkins Univ. Press, 1992:65-97. Baile WF, et el, Cancer 1999;86(5):887-97.,王金龍醫師,考試重點,30,SPIKES,Setting：建立一個恰當的情境 提供一個保護病人隱私而舒適的場所，不受干擾的時間，與病人面對面平坐 依病人的意願，邀請其他重要相關親友在場 這一切都在於建立良好的醫病關係,31,SPIKES,Patients Perception ：探詢病人對自己病情的了解 譬如說：告訴我，您知道我們為什麼要做這些檢查？,32,SPIKES,Patients Invitation ：引導病人來詢問有關病情的細節 譬如說：要是檢驗結果都出來了，您要知道全部詳細的內容嗎？（不管什麼都要知道嗎？）,33,SPIKES,Knowledge ：提供知識與資訊給病人 採漸進式，分段提供 要不斷試探病人是否能消化了 避免用醫學上的專業用辭,34,SPIKES,Empathize ：要能發掘病人情緒的變化，進而表示同情，如：當病人哭泣時，說 看來您並沒有預期這樣情況 這個結果一定讓您很難接受,35,SPIKES,Summary： 將所有的資訊綜合，做一個摘要 經由與病人溝通，去達成一個治療或追蹤的方案,36,壞消息的告知,有關告知壞消息的一些倫理議題 台上演練： 家屬 病人 相關議題：錯誤的處理,37,一位門診的複診病人，上次因排便習慣改變而被安排大腸鏡檢查。 輪到他看診時有一位較年輕的女仕率先步入，並回頭吩咐兩個較年輕的男性：先陪爸在外頭等一下。 然後就向你（門診醫師）說：家父（指病人）在上週檢查大腸，檢查的醫生說腸子裡長了一個瘤子，看來像是癌症，今天是來看切片的報告，請先告訴我結果。因為家父已經七十多歲，又有心臟病，我們全家都怕他受不了刺激，所以如果是癌症，千萬不能讓他知道。 你在電腦上查得病理報告是：腺癌,教案壞消息的告知,你怎麽說？,38,處理方式,與家屬作具同理心的溝通 運用SPIKES來解釋病情,39,與家屬作具同理心的溝通,從對話中了解： 家屬的要求 理由 感受家屬的感受 表達了解並肯定家屬的關切 告知家屬為何要病人病情：尊重自主、診療需要 告知SPIKES的方式並徵詢意見 承諾陪伴與支持 共同達成目標,40,一位門診的複診病人，上次因排便習慣改變而被安排大腸鏡檢查。 輪到他看診 你在電腦上查得病理報告是：腺癌,教案壞消息的告知,你怎麽說？,41,SPIKE,1. Setting：建立一個恰當的情境。提供一個保護病人隱私而舒適的場所，不受干擾的時間，與病人面對面平坐。依病人的意願，邀請其他重要相關親友在場。這一切都在於建立良好的醫病關係。 2. Patients Perception ：探詢病人對自己病情的了解。譬如說：告訴我，您知道我們為什麼要做這些檢查？ 3. Patients Invitation ：引導病人來詢問有關病情的細節。譬如說：要是檢驗結果都出來了，您要知道全部詳細的內容嗎？（不管什麼都要知道嗎？） 4. Knowledge ：提供知識與資訊給病人。提供資訊時，最好採漸進式分段給，並要不斷試探病人是否消化了他所得到的資訊，避免用醫學上的專業用辭。 5. Empathize ：要能發掘病人情緒的變化，進而表示同情。如：當病人哭泣時，說看來您並沒有預期這樣情況，或說這個結果一定讓您很難接受。 6. Summary ：最後，將所有的資訊綜合，做一個摘要，並且經由與病人溝通，去達成一個治療或追蹤的方案。,42,壞消息的告知,有關告知壞消息的一些倫理議題 台上演練： 相關議題：錯誤的處理,43,錯 誤,44,美國人怎樣看待錯誤？,45,Case 1,An 18-month-old child presents to the clinic with a runny nose. Since she is otherwise well, the immunizations due at 18 months are administered. After she and her mother leave the clinic, you realize that the patient was in the clinic the week before and had also received immunizations then. Should you tell the parents about your mistake?,46,Case 1,The error is a trivial one. Aside from the discomfort of the unnecessary immunization, no harm has resulted. Nonetheless, an open and honest approach to errors is most appropriate. While the parents may be angry initially about the unnecessary injection, they will appreciate your candor. On the other hand, should they discover the error and believe you have been dishonest, their loss of trust will be significant.,47,Case 2,A 3-month-old has been admitted to the hospital with a newly diagnosed ventricular septal defect. She is in early congestive heart failure and digoxin is indicated. After discussing the proper dose with the attending physician, you write an order for the drug. Thirty minutes later the baby vomits and then has a cardiac arrest and dies. You discover that in writing the digoxin order you misplaced the decimal point and the child got 10 times too much digoxin. What is your duty here? Will you get sued if you tell the truth?,48,Case 2,This unfortunate event represents a serious error with profound implications for the patient and family. You owe this family an honest explanation. They need to hear you say that youre sorry. Any attempt to hide the details of the event would be dishonest, disrespectful, and wrong. Though a lawsuit may follow, these parents are less likely to litigate if you deal with them honestly and take responsibility for the error.,49,Case 3,A 3-year-old presents to the emergency department. She was diagnosed with pyelonephritis by her physician yesterday, treated with an intramuscular injection of antibiotic and sent home on an oral antibiotic. She is vomiting today and unable to keep the antibiotic down. As you prepare to admit her, you feel she should have been admitted yesterday. Should you tell the parents that their physician made a mistake? How should you handle this disagreement?,50,Case 3,The practice of medicine is not an exact science. Frequently physicians will disagree about what constitutes the most appropriate management in a given case. Often these are legitimate disagreements with more than one acceptable course of action. Simply because you would have managed a patient differently does not mean the other physician made a mistake. In this case, you may wish to discuss the case with the other physician and explain why you manage children with pyelonephritis differently. However, in situations where standard practice varies, the parents should not be told that a mistake has been made.,51,The Ellen Roche Story,Ellen Roche was a healthy 24 year old lab technician at the Johns Hopkins (JH) Asthma Center. She volunteered to take part in an experiment to understand the natural defenses of healthy people against asthma. Roche was part of a group that inhaled hexamethonium, a drug which induced a mild asthma attack. Physicians stood by in case of complications and to measure how the subjects responded to the asthma attack. Within 24 hours of inhaling the drug, Roche had lost one-third of her lung capacity. Within a month she was dead.,52,The consent form she signed warned of coughing, dizziness, and tightness in the chest, but not death. It called hexamethonium a “medication“ although its approval by the FDA (as a treatment for high blood pressure) had been withdrawn in 1972. Dr. Alkis Togias, the director of the experiment, apparently limited his hexamethonium research to one contemporary textbook and PubMed.,The Ellen Roche Story,53,The use of hexamethonium in the 1950s to treat high blood pressure created an evidentiary trail revealing some disturbing risks. Several articles published in print journals during the 1950s showed that hexamethonium could cause fatal lung inflammation. Unfortunately, PubMeds coverage starts in the mid-1960s. When the FDA withdrew its approval of hexamethonium in 1972, it cited the drugs “substantial potential toxicity“. Unfortunately, PubMed covers medical research, not FDA rulings.,The Ellen Roche Story,54,Ellen Roche died on June 2, and the Roche family has apparently not yet filed a lawsuit. However, JH still faced a serious sanction. On July 19 the federal Office for Human Research Protection (OHRP) suspended all JH research on human subjects. This halted 2,400+ ongoing experiments with 15,000+ human subjects.,The Ellen Roche Story,55,The dis