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 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/

References

1. Emergency Medicine Conference at Boston Medical Center 2015. Contributions by multiple facutly (including Dr Jeffrey Schneider and BMC EM residents
2. Lowry, Fran. Think GRIEV_ING When Giving Bad News to Loved Ones. ACEP News

April 2007

1. 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)
2. Shoenberger, Jan MD et al. Death Notification in the Emergency Department. Western J Emerg Med. 2013;14(2):181-185.