Breaking Bad News 2

Setting:

You are a Foundation Year doctor working in a urology clinic. You have been asked to talk to a patient to explain the reason for recent tests and to explain the diagnosis to the patient.

Adam Smyth

Tasks:

1. Take a brief history from the patient.

2. Review the results that the examiner will show you.

3. Explain the diagnosis to the patient.

4. Answer any questions the patient may have.

Briefing

Diagnosis: Prostate Ca Bad News Actor
You are Adam Smyth (age: 77)
You have presented to the urology clinic awaiting results of your recent investigations.

Appearance and Behaviour

Nervous, leg shaking.

Opening statement

“Well doctor I’ve had all these tests done recently and they’ve told me I needed to come in for you to tell me what’s going on. They said it might be something serious on my blood test and when they examined my back passage so I had to have these biopsies done but I can’t remember what they said about the blood test.”

Presenting Complaint

The doctor should attempt to gain further information about your initial symptoms
“It first started that I was having difficulty with weeing, it was starting then stopping and if I’m honest I was finding that it was dribbling at the end”
Symptom – Urinating difficulty
Onset – not sure when it first started but it became more noticeable about 2 months ago
Character – you struggle to start urinating and when you do the stream isn’t very strong. You find that even once you stop urinating you notice you have dribbled in your underpants.
Associated symptoms

You have been quite tired recently and noticed you’re falling asleep earlier in the day.

You have been feeling full after small meals recently and think you have maybe lost a bit of weight, you’re not sure how much but friends have said you look a bit skinnier than last time they had seen you.

You’ve also got this back pain that’s been bad for the last month or so- it’s in the middle of your back, you can almost pinpoint the pain, achey pain, doesn’t spread, ibuprofen doesn’t help.

No pain on urination, no blood in urine

Timing – It began with difficulty starting to urinate and now you have trouble maintaining a stream of urine. This has got worse over the last 2 months
Exacerbating/relieving factors - nothing makes it better, having to go to the toilet more frequently as you are worried that you may leak through your underwear and it would be embarrassing.
Severity – It’s really affecting your life, you feel tired and it is embarrassing you.

Past Medical History

Previous similar episodes - nil
Other medical conditions - asthma, carpal tunnel syndrome
Previous surgeries - nil

Drug History

Prescribed - salbutamol inhaler, paracetamol, codeine as required, senna as required for constipation from analgesia
Over the counter - nil
Allergies - penicillin- rash

Family History

Father had benign prostatic hyperplasia
Uncle- lung cancer

Social History

Smoking history - smoked 5 a day for about 50 years. You quit a couple of years ago when you became a grandparent
Alcohol - wine at the weekend
Illicit substances - nil
Home - Live alone, your wife died last year.
ADLs - no issues but struggling with energy to do things that you used to love e.g. playing golf. Uses a walker to get around.
Job - retired shopkeeper

Systems Review

General/red flags - weight loss, loss of appetite
Neuro - nil
ENT - nil
Resp - nil
Cardio - nil
GU - nil
Joints - back pain (started 1 month ago in the middle of your back, you can almost pinpoint the pain, achey pain, doesn’t spread, ibuprofen doesn’t help)

Ideas / Concerns / Expectation

Ideas - You know it might be something serious, they mentioned the word cancer last time you had an appointment and they mentioned they had felt a mass when examining your back passage
Concerns - if it is cancer how will you cope
Expectations - The doctor to tell you the results of your investigations

Discussion / Questions

The doctor should start by clarifying your symptoms and your understanding of what is going on. They should specifically try to elicit red flag symptoms from you. They may ask if you want someone in the room with you- if so say it’s alright to have the news by yourself.

The doctor may give a “warning shot” that they have to deliver bad news. If so you may say “oh doctor this doesn’t sound good”

The doctor should then acknowledge that they have the results of your tests and they may repeat your symptoms back to you when explaining the diagnosis and how they have come to the diagnosis of prostate cancer. You may agree with the doctor if they repeat your symptoms back to you.

You are very upset by the diagnosis. The doctor should allow you time to process this, if not become disconnected/shut down from the conversation and explain you are struggling so can the doctor give you some time.

The doctor should show empathy and understanding of the difficulty of the diagnosis. If the doctor is rushed then ask them to slow down as you are struggling to process everything.

Once the doctor has explained the diagnosis they may start explaining the next steps in management, if not, ask them “what happens now?”

The doctor should explain that they want to perform some further scans (CT CAP/ PET) and blood tests (tumour markers, testosterone, FBC, U&E, CRP, LFT).

The doctor may offer to help tell your family- if so say you are happy to let your family know.

The doctor should be supportive throughout, if not then become disconnected from the conversation and ask the doctor to repeat things.

The doctor should end the conversation by summarising the discussion and arranging a follow-up meeting to discuss the next steps. They may offer to put you in touch with specialist services e.g. macmillan nurses which you would appreciate.