Delivering bad news

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 and a structured approach).

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 what if any utility there would be to saying anything other than no.

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.