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"Dying is not just this taboo or dirty topic. We can make it so beautiful by doing simple things, by just being there, by having presence." —Dr. Sonia Malhotra
Dr. Sonia Malhotra is an Associate Professor of Internal Medicine and Pediatrics at Tulane University. She completed Med-Peds residency training and an Adult and Pediatric Hospice and Palliative Medicine Fellowship at the University of Pittsburgh where she also did a Master’s in Medical Education. Dr. Malhotra is board certified in Internal Medicine, Pediatrics and Hospice and Palliative medicine. She previously served as Medical Director of Ochsner’s Palliative Medicine program where she created the first Pediatric Palliative Medicine program in the state of Louisiana.
Currently she is the Director of Palliative Medicine services at University Medical Center in New Orleans, Louisiana and holds faculty appointments at Tulane University School of Medicine, LSU School of Medicine, and the joint program between University of Queensland/Ochsner Clinical School. She teaches for the Center to Advance Palliative Care (CAPC) and in 2022 will Chair the Equity, Diversity & Inclusion Council for the American Academy of Hospice & Palliative Medicine.
Megan Snyder is a 4th year medical student at Tulane. She first studied aging and dementia in college. Afterward, she worked at Charles House, a neighborhood eldercare home in North Carolina, as a personal care aide for older adults with dementia. It was here that she had her first experiences with end of life care from the caregivers’ side, working closely with hospice nurses. She is looking forward to pursuing a residency in OBGYN and hopefully a future fellowship in Gynecology Oncology.
Episode Pearls
“The Relentlessness of Black Grief” by Marissa Evans in The Atlantic
SPIKES Protocol for Delivering Bad News
A peer-reviewed protocol outlining six steps for disclosing unfavorable information that meet the requirements defined by published research on the topic.
S Setting
P Patient's perception
I Invitation
K Knowledge
E Exploring/ Empathy*
S Strategy/ Summary
*Examples below
Empathetic Statements
"I can see how upsetting this is to you."
"I can tell you weren't expecting to hear this."
"I know this is not good news for you."
"I'm sorry to have to tell you this."
"This is very difficult for me also."
"I was also hoping for a better result."
Exploratory Questions
"How do you mean?"
"Tell me more about it."
"Could you please explain what you mean?"
"You said it frightened you?"
"Could you tell me what you're worried about?"
"Now you said you were concerned about your children. Tell me more."
Validating responses
"I can understand how you felt that way."
"I guess anyone might have that same reaction."
"You were perfectly correct to think that way."
"Yes, your understanding of the reason for the tests is very good."
"It appears that you've thought things through very well."
"Many other patients have had a similar experience."
Click here to read the full protocol.
Walter F. Baile, Robert Buckman, Renato Lenzi, Gary Glober, Estela A. Beale, Andrzej P. Kudelka, SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer, The Oncologist, Volume 5, Issue 4, August 2000, Pages 302–311.
Elisabeth Kübler-Ross's Stages of Grief
As we discuss in the episode, each individual experiences these stages in a different order, at a different pace.
Denial
Anger
Bargaining
Depression
Acceptance
Five Wishes: (free) Widely-used by health care professionals & the public. Advance Care Planning resource kit, guide and sample documents.
We Croak App: (free) Find happiness by contemplating your mortality (five times a day the app will send you a quote about death).
Delivering Bad or Life-Altering News: (free) article by AAFP
What is palliative medicine? What is hospice? What is the difference? Were you surprised to learn about the difference between palliative medicine and hospice?
Have you experienced loss? How does our own experience of loss impact patient care?
How can we, as providers, tailor the delivery of bad or life-altering news to a patient's needs? What questions can you ask to determine how much and what patients want to know? How does this differ if your patient is a pediatric patient?
What is empathy? a) What is an empathetic statement that you use in your daily life (with a patient, loved ones, etc)? b) What questions do you ask to find out more in a challenging conversation? c) What is a validating statement that makes a patient or loved one feel heard? (See below for examples from SPIKES protocol).
How has your training equipped you to provide the support dying patients need?
Do you have a living will or advanced care directive? Have you discussed your goals of care with a trusted loved one?
GOAL: Pick an empathetic or validating statement or exploratory question. Incorporate into your practice, and notice how it feels.
Host: Dr. Rebekah Byrne, MD
Guest: Dr. Sonia Malhotra, MD, MS, FAAP
Student Interviewer: Megan Snyder
Producer: Erika Bennett, Dara Bramson
Sound Design: Timothy Knowlton
Original Music (Composed & Performed): Timothy Knowlton