Delivering bad news

Background

• Physicians must disclose bad news to family members - often times unexpected notification of death can be difficult for family.
• The process can be challenging for providers.
• Using a structured approach can help alleviate the emotional challenging of delivering the bad news.
• Think of delivering bad news as a procedure (with a pre-procedure time out, a structured approach to the delivery of bad news, and requesting a colleague in the ED to hold your phone or take any runs that come in while you are in your critical five minutes of breaking the news.

Types

• Notification of death
• Informing of poor prognosis e.g. "It's not my job to take away all hope, but I am very worried about _ and he/she is very sick"

Procedure

• Time Out Before the Procedure (Mandatory)
  • Confirm identity of patient and family specifically that family is TRULY the family of the patient. Can be difficult when the patient arrives as a "Joe Doe" without family. Before having meeting, identification processes (social work can assist) with confirming age, demographic, location that patient came from (can be found on the EMS run sheet).
  • Confirm that you known the name of the patient so that way you can refer to him/her by his/her name. Ask social work if they know the names of the family and/or their relation to the patient.

Approaches

GRIEVING

• Gather ‐ Get SW in room,
• Resources ‐ +/‐ security, tell attending will have to be gone, get pager/trauma coverage
• Identify person we are talking about, myself and all people in room, identify level of understanding of what has happened already
• Educated ‐ warning shot "I have some bad news." Don't wait too long before saying "___ has died."
• Verify understanding
• Inquire ‐ questions
• Nuts/Bolts Give contact info
• Give the family space to process; Be silent

SPIKES

• SETTING UP the Interview
  • Arrange for some privacy, Involve significant others, Sit down.
  • Make connection with the patient.
  • Manage time constraints and interruptions.
• PERCEPTION
  • "What have you been told so far?”
  • Assess receiver's level of health literacy.
• INFORM
  • Briefly explain chronology of events leading up to death (or bad news)
  • Avoid euphemisms
• Knowledge
  • Allow receiver to ask questions.
• Empathy
  • Say "I'm sorry."
  • Repsond and validate the emotions of grieving: NURSE
    • Name the emotion
      • "It sounds like this has been overwhelming."
    • Understand the emotion (empathize)
      • "I cannot imagine how hard this must be for you."
      • "I wish I had better news."
    • Respect the patient or family
      • "You are asking all of the right questions."
      • "You are being such a strong advocate for your [family member]."
    • Support the patient or family
      • "We will be here for you."
    • Explore the emotion
      • "What other things are you worried about?"
      • "Tell me more about what you're thinking."
• Summary and Strategy
  • Acknowledge questions may arise after processing, establish your availability to be reached by social work in they have questions that come up when they see their loved one.
  • Leave receiver with social work. "I'm going to step out and let (the social worker) help you with the next steps"

Tips

• If family asks if they suffered, consider (assuming it would not be obviously a lie) what if any utility there would be to saying anything other than: "No, he/passed peacefully." After all, our patients are also the family of the deceased.

External Links

• https://www.acep.org/clinical---practice-management/think-griev_ing-when-giving-bad-news-to-loved-ones/

See Also

• Brain death