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

• GRIEV_ING: (Pnuemonic)

• • • 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

• • • _ Be silent, give the family space to process

• • • Inquire ‐ questions
    • Nuts/Bolts Give contact info

• SPIKES

• • S - SETTING UP the Interview
    • Arrange for some privacy,

Involve significant others, Sit down. Make connection with the patient. Manage time constraints and interruptions.

• • P - PERCEPTION
    • "What have you been told so far?”
    • Assess receiver's level of health literacy.

• • I - INFORM
    • Briefly explain chronology of events leading up to death (or bad news)
    • Avoid euphemisms

• • K - Knowledge
    • Allow receiver to ask questions.

• • E - Empathy
    • Validate emotions of grieving.
    • Say "I'm sorry."

• • Summary and Strategy
    • Acknowledge questions may arrise 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/

References

Emergency Medicine Conference at Boston Medical Center 2015. Contributions by multiple facutly (including Dr Jeffrey Schneider and BMC EM residents

Lowry, Fran. Think GRIEV_ING When Giving Bad News to Loved Ones. ACEP News April 2007 SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer, Baile, et al. The Oncologist. Jun 2000. (http://theoncologist.alphamedpress.org/content/5/4/302.full)

Shoenberger, Jan MD et al. Death Notification in the Emergency Department. Western J Emerg Med. 2013;14(2):181-185.