Mrs. Anderson - Clinical Trials
‘A clinical trial? I thought I was done...’
The patient in this scenario has carcinoma of the breast, and has already had surgery. Her lymph nodes were positive; receptors were negative. She has been referred to a medical oncologist without much explanation for the reason. She is a candidate for a clinical trial comparing three different adjuvant therapy regimens so this is a very important interview.
"I thought my treatment was finished..."
In this vignette, we meet Mrs. Anderson for the first time as she arrives for her appointment with the medical oncologist, unaware that she needs additional treatment. The task therefore, is not merely explaining treatment options, but first breaking the bad news to her that her treatment is not complete and she should receive chemotherapy.
Finally, there is the task of explaining clinical trials. Studies show that the chance of patients enrolling in trials--as well as their attitude about any treatment from that time on--will be affected by how this information is presented.
What to watch for
Note the use of the 'SPIKES' breaking-bad-news protocol to disclose to the patient that she is not finished with treatment. Of particular importance to the success of this interview is that the physician asks for her perception of her status before addressing the day's agenda. This helps clarify whether she is simply in denial or is emotionally "bargaining", or whether she has not been told the necessary information.
Watch for the use of plain language as opposed to medical jargon, and for the use of repetition as a technique.
Note that the physician gives the information in chunks and then checks for understanding along the way, and that he provides a summary or synopsis.
Mrs. Anderson - Recurrence
After two years, Mrs. Anderson has developed back pain. Her bone scan reveals bone metastases and the physician must break this news to her and discuss the implications.
The period after treatment can be distressing, but many women regain their emotional equilibrium and adapt to their illness. Still, the diagnosis of recurrence causes distress and creates a new set of challenges, which for this patient include questioning her initial treatment, the eventual outcome of the illness and telling her family.
What to watch for
Note the physician's use of the narrative approach, a recap or summary of the situation so far, and his use of empathic responses: Exploring, validating and empathizing (EVE). Note that the exploration part of this interaction turns out to be very important here: in exploring her reaction to the news of her disease progression, the physician is able to elicit one of her most pressing issues, which is something he can help her with.
Note how helpful it can be to use the biologic behavior of cancer to explain symptoms and progression.
Mrs. Anderson - Saying Goodbye
In the following vignette, Mrs. Anderson's cancer has progressed, and the treatment is not controlling her disease, so any further treatment will be for palliation and symptom control.
As healthcare professionals we often feel sad when our patients are dying. We may even feel as if we have failed the patient. Although he may see her many more times, this interview is, in some respects, "saying goodbye" in the sense of going beyond simple disclosure of the situation to actually providing some closure, which can be therapeutic for both the patient and the physician.
What to watch for
This example illustrates several important areas. First, reviewing the course of the illness by use of the narrative approach; secondly, asking if there are any unanswered questions or other things that need to be done, and lastly the physician shares his own sadness and compliments the patient on her courage.
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