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.

See Also

References
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