Tuesday, May 7, 2013

Using YouTube Movie Clips to Teach Breaking Bad News




Some of my favorite teaching incorporates video.  Recently, I saw an End-of-Life Nursing Education Consortium (ELNEC) DVD with movie excerpts.  A GIANT THANK YOU to whoever put the ELNEC DVD together!  It's a fantastic teaching tool!!!

I can't reproduce the DVD, but I thought it would be fun to try and find some of these and other movie excerpts on YouTube and create a teaching guide.  

I have tried pieces of what I'm publishing below, but never all of it together.  Please let us know in the comments if you try it, what works or doesn't work, or if you have other suggestions for online movie experts.


Time 30 min -1 hr, depending on how many excerpts you show, and how long you let discussion after each clip continue.  Excerpt times are included at the start of each video.

Format: Show video clip, then discuss.  Questions for discussion are included after each clip - feel free to come up with your own. Some of these are in-your-face, and some more nuanced.

Target Audience: Health Professionals or trainees - medical students, nurses, residents, fellows, social workers, doctors, physician's assistants, nurse practicionners - any health professional really.

Intro:  All of you will have to break bad news multiple times in your professional careers.  Today we're going to view movie clips that can help us become better at breaking bad news.  After each video we will have a discussion.

Some of these excerpts are short, some of them long.  Some of them are with physicians or nurses, some of them are not with health professionals at all.  But all have some lessons for us about how to talk in a humanistic way about a potentially terrifying subject.

Legal: Using these video clips for teaching purposes is legal - see this link.

Materials: Eric tried this with our Geriatrics fellows, and recommends brining tissues - the last clip from WIT is a doozy.


1. 3:30 CLIP The first video is from the movie WIT, starring Emma Thompson, based on the play by the same name.  (play this link from 30 sec to 4:05. It has Spanish subtitles, I couldn't find an excerpt without them.  In this excerpt an oncologist tells a patient she has advanced cancer and leaps into discussing treatment.)



What went well about this breaking bad news discussion (this will be a challenge for the trainees, who may audibly groan at all the poor communication skills displayed.  Some things did go well - checking in with the patient, making eye contact, trying to relate to her as a professor).

What did not go well? (long list, includes leaping from diagnosis to treatment without pausing, most patients don't remember anything said after the diagnosis -- use the first 2:30 sec of this how-to-break-bad-news documentary to make this point, no attention to the emotional reaction of the patient, lack of empathetic body language, use of medical terminology rather than lay language, no space for questions, no discussion of benefits and risks of chemo and impact on prognosis, or any discussion of prognosis, etc, etc)

2. 30 SEC CLIP.  The second video is from the movie the Shootist, staring John Wayne as an aging sharpshooter cowboy receiving a diagnosis of advanced cancer from a doctor, played by James Stewart.  (play the first 28 seconds of this link).



What went well about this discussion? (fires a warning shot, acknowledges how hard the discussion is, and when asked to give the news "flat out" he does, in no uncertain terms.  He almost challenges the cowboy in an aggressive way, in a somewhat shocking manner, but this confrontational style seems suited to a sharpshooter cowboy.  Difficult to see a hug working in this situation.  Underlying message is you need to tailor your conversation to the patient, rather than taking a cookbook or one-size-fits-all approach)

What could have gone better? (Hard to say)

3. TWO 60 SEC CLIPS. In this clip from the movie 50:50, the Joseph Gordon Levitt character tells his friend that he has cancer.  His friend, played by Seth Rogan, hears the bad news and feels sick.  (play this whole clip, there is an add at the beginning, but you can skip it after 10 seconds; for a slightly funnier version with profane language, click here).



In this 60 second clip from Dumb and Dumber, staring Jim Carrey, he asks a woman he likes to estimates his chances with her. (play this whole excerpt).



Why did we play these clips?  What do some patients hear or caregivers hear when we tell them a horrific prognosis?  What does this say about needing to ascertain a patient's core values?  (a prognosis of 50% or .1% will be terrible to some - Joseph Gordon Leveitt's character or the woman from Dumb and Dumber - and terrific to others - the Seth Rogan character and the Jim Carey character.  Some are willing to go through enormous pain and suffering for a remote chance of success.  Others would rather focus on quality of life rather than take such risks).

4. 2:20 CLIP.  This clip from Little Miss Sunshine portrays the reaction of a teenager to the bad news that he is color blind and will be unable to become a fighter pilot.   The teenager had previously taken a vow of silence, and had not uttered a word up until this point in the movie. (play this whole clip).


What does this clip say about our patients reactions to bad news?  (This teenager has a visceral reaction to the news in a family setting.  In a physician's office, patients may try to hold it together for social reasons, but they may be screaming inside.  Contrast his reaction with the Emma Thompson character's reaction in the first clip, for example.)

5. 3:30 - 6:30 CLIP.  This excerpt is from WIT again, this time with a nurse breaking the news to a hospitalized patient that the cancer is not responding to chemotherapy.  (Play this link from the  beginning to 3:25, or if you want to include a DNR discussion that follows the breaking bad news discussion, to 6:30.)


What went well about this discussion?  (Very strong on empathy, comfortable environment, begins with shared experience of popsicles, if you go to the DNR discussions - describes concerns and outcomes of CPR).

What didn't go well?  (This video was controversial when I showed it to a graduate-level nursing class - some felt the nurse overstepped her "role" and undermined the authority of the physicians, particularly by engaging in the DNR discussion; on the other hand, others noted that she said about the physicians was true, and someone needed to break the news and have a frank conversation about code status.  The DNR conversation was about the procedure itself and did not start with her goals and values - this could have been better).

by: Alex Smith @AlexSmithMD


6 comments:

Jim Mittelberger said...

Great post and great information! A concern however is that much of the information on utube is poor, and many patients go to the sources that are inaccurate. We should find better ways to guide patients to the best information. Two of our colleagues, Ben Getter and Wasam Aziz won the Investigator in Training Young Investigator Award at AAHPM this year showing and discussing the inaccuracies in some utube information.

Alex Smith said...

Thanks Jim, good to see you at AGS. This material is really for health professionals, not patients. I was really intrigued by the study by Getter and Aziz. I wonder how many of our homemade videos were included in their study! Completely agree that there's a lot of junk out there aimed at patients. We have an idea for a follow up post (aimed at health professionals again) focusing on expert example videos (Diane Meier, Susan Block) - let us know if you have thoughts.

Alex Smith said...

Check out the twitter stream - Breaking Bad (fan twitter handle for the TV show) tweeted about this post! How funny is that!?!

Anonymous said...

In the "Wit" clip regarding code status discussion, I'm not sure I liked how the nurse kept saying "It's up to you" or "It's your choice". I think we place a lot of weight on patient autonomy but we need to be careful about this approach when a patient can't really understand the choices being presented, or more importantly, if there really is a choice, as if doing CPR on a terminal cancer patient as they are dying would be a good idea, or that such a "choice" has the tacit approval of medical professionals. We also heap upon our patients potentially a lot of guilt and anxiety about these choices, when some patients may prefer to have a professional make that decision for them and feel relieved to know that such "decisions" are out of their hands.

Anonymous said...

Thank you for the Guide, used this today for my nursing students. Showed the clips prior to having a simulation on communicating with a patient who has received a poor prognosis. Helped to ease their anxiety on a difficult topic.

Alison Anderson said...

I strongly disagree with you. A major loss patients experience in this situation is loss of control. Giving them a choice and. control in this crucial decision is vitally important. I think the nurse explained the options clearly and concisely. I had a patient who came from surgery with extensive cancer throughout his lungs. His family made him a DNR before he was fully conscious from O.R. When he was finally awake & lucid he didn't want to be a DNR. I caught some flak from his daughter, but protected my patient's rights and dignity. Also, no one should be able to make that decision for another mentally competent person - it's not ethicaly or morally right. Regardless of professional approval, it's the patient's life and their choice.