MES-016 Breaking Bad News

“信息不对等”是这些年常听到的东西，它的意思是说，医生和患者对于疾病或患者所处的状态的认知和知识存在差距。而信息不对等，常常使得医患双方对同一件事的认知不统一，进而导致误解和矛盾。比较夸张，但是确实存在的例子有：“医生你在骗我”和“病人是医生治死的”。

“医生让我死，我Facebook”

但是这些疯人疯语，一部分是因为当事人人性和素质过于低劣，完全不顾法理人伦，还有另外一部分，是因为“信息不对等”带来的差距没有事先磨平。前一半原因，可以诉诸法律；后一半原因，则是我们可以完善的。所以今天，我为大家带来的是“如何告知坏消息”。——How to BREAK BAD NEWS.

在展开我们这次讨论之前，大家先耐心看看下面这个场景：

A 57-year-old woman comes to the physician for a follow-up visit regarding her lower back pain. She originally presented last month with significant continuous lower back pain that was worse at night and would awaken her from sleep. She tried OTC ibuprofen, with no relief of her symptoms. When her pain persisted, the patient was scheduled for MRI of her back. The report returned today and shows findings consistent with metastatic lesions in her spine. The source of the primary neoplasm remains undetermined. The patient has not yet been told about the findings and is waiting in a private room. Which of the following is the most appropriate next step in initiating a conversation about her condition?

想想如果是你，你会怎么和患者开口？下面的几种方法，你选择哪个？

• Have you considered whether you want to know the test results, regardless of the outcome?

• I’m sorry to have bad news about your test results; it seems that cancer has metastasized to your back.

• It looks like you have cancer in your back, and we should be able to do something about it with radiation and chemotherapy.

• The test results are not good. Do you want to know them?

• What do you think is going on with your back?

在告知坏消息的过程中，有很多需要注意的地方。为了方便记忆，人们总结出了“SPIKES”原则。

• Setting up situation

  Arrange for privacy

  注意隐私

  Include all appropriate participants

  参与人员到位

  Provide facial tissue

  准备面巾纸

  Sit down and maintain eye contact

  入座，保持眼神交流

  Introductions of family and team members

  熟悉家属，介绍医疗团队

  Eliminate or minimize interruptions

  消除或尽量减少干扰

• Assess family’s Perception

  Use open-ended questions to assess the family’s perception of the medical situation

  用开放式问题评估家属对患者当前疾患的认知

• Obtain family’s Invitation

  Ask family how much information they would like to know

  询问家属希望了解到什么程度

• Give Knowledge and information

  Warn the family that bad news is coming

  铺垫情况不乐观

  Speak in simple and straightforward terms

  用简单直白的语言

  Stop and check for understanding

  适当暂停，保证家属理解

• Use Empathic statement

  Use empathic statements when responding to emotions

  用共情安抚患者及家属的情绪

• Strategy and summery

  Summarize and create follow through plan, including end-of-life discussions if applicable

  总结并给出下一步方案，包括临终的话题

有的人是纯技术派的拥趸，认为医生需要纯粹的治病。但是交流其实也是一门技术。如何让患者了解自己的疾病情况，如何让患者配合治疗，如何缓和患者的情绪全都是一门值得学习，需要掌握的技能。而SPIKES原则，不仅可以应用在告知坏消息上，在进行术前谈话或是重要的治疗改变的告知时，都是行之有效的。

而且，详尽的告知也是在保护患者的知情权，这是每一位医生不能忽视的。

希望本期推送可以让在临床工作中的你在面对患者及家属时，更加自信，游刃有余。把该说的说得让人听得明白，听着舒服。

写在文末：

MES终于迎来了她的第500名关注者，之前在心底里为自己定了一个“小目标”——要在关注者到500人时，多找几个帮手，认认真真为大家准备每一期的内容。我曾经“支撑”着实习医院里一个小小的英语社团，不过二、三十人，但是现在我面对的是500人，就不得不认真起来了。医学生/医生学习英语的重要性我相信根本不用我在这里赘述。本人是临床专业的学生，肯定难以照顾到科研文章中的英文写作，所以也希望吸纳这方面的人才，增加这方面的资料。无论如何，我都会将医学英语继续推广下去。也希望大家保持一颗热切的心。