BREAKING BAD NEWS: MULTIPLE SCLEROSIS - PasTest

Communication Skills and Ethics: Breaking Bad News – Multiple SclerosisBREAKING BAD NEWS: MULTIPLE SCLEROSISA 33-year old woman has a consultation with you to discuss the results of her recent MRI, which you hadorganised at her previous neurology appointment. She has a 3-year-old daughter but is actively tryingfor a second child. For the last 3 months she has noticed several episodes of visual disturbance andintermittent weakness of her legs. Her MRI is consistent with the diagnosis of multiple sclerosis.Please discuss this result with her.Preliminary thoughts• The course of multiple sclerosis (MS) and its variable nature• Morbidity and mortality of MS• Implications with regard to pregnancy• Treatment options including interferon and the NICE guidelines• Inheritance of MS.A good candidate• Will explore the patient’s knowledge of why she had the tests and MS• Will not take all hope away and will explain the variable nature of MS.Goals for consultationFor her to understand:• The diagnosis and its implications• The need for a multidisciplinary approach• The variable nature of progression of the disease; few patients progress rapidly• Treatment options.Key points in the consultation:• Introduction and establish a good rapport• Ask if she wishes for anyone else to be present.• Explore the patient’s understanding of her condition and expectations/ suspicions of what maybe wrong: ‘Did the previous doctors tell you why they were doing the MRI or what they thoughtwas causing the weakness?’Directions of the consultationScenario AThe patient has never heard of MS and has no idea of its implications.1 PasTest Ltd © 2012

Communication Skills and Ethics: Breaking Bad News – Multiple Sclerosis• The patient should be given small pieces of information in a logical manner; pauses are essentialand give the opportunity for questions.• Patients can be given too much information in one consultation after receiving bad news. It ispreferable to establish one or two key points.• Further consultations can address more detailed information. They may choose to bring a friendor relative.Scenario BThe patient is suspicious that MS is the cause and knows a great deal about it.• A discussion about exactly what she understands and expects is important.• The Press tend to report the more disabling end of the disease spectrum, heightening patientanxiety.• Emphasise the variable progression of the disease. Often remitting/relapsing. There can be longperiods with few symptoms. Few patients progress rapidly.• Discuss available treatment options such as steroids and interferon (in outline only).• Discuss the implications for pregnancy and whether this should be pursued– MS has no effect on fertility and does not affect pregnancy outcome.• Reassure her that it is not hereditary.What does he understand might be wrong?Finishing• Summarise what has been discussed• Ask if there is anything that she would like repeated or if she has any questions• Arrange follow-up and put her in touch with relevant support groups.Discussion• Patients do not absorb masses of information from consultations. This is worse in stressful,anxious situations. For this reason it is preferable to give and repeat a little information well, to2 PasTest Ltd © 2012

Communication Skills and Ethics: Breaking Bad News – Multiple Sclerosiswrite it down if possible and to arrange to discuss issues further at the next appointment.Having a relative or friend present is reassuring and helps in the amount of information recalled.• It is best to give a little information well rather than a lot badly.• It is not necessary to discuss all of the details of MS in the first consultation.3 PasTest Ltd © 2012