OutlineOutline

Breaking bad news Conflict resolution Telephone advice

Breaking Bad NewsBreaking Bad News

We are required to communicate bad news to patients, family members, and caregivers

Method is important Shapes the course of subsequent grief and

coping Strengthens trust Fosters collaboration in planning

In the ED, often sudden and unexpected

Are we ready to do Are we ready to do this?this?

We receive little formal training

Many residents are afraid to do this*

Only 35% of medical residents felt competent§

*Dosanjh et al. Medical education 2001;35:197§Girgis et al. Behavioural medicine 1998;7:53

Is this important?Is this important?

Bad news, conveyed in an inappropriate, incomplete, or uncaring manner may have long-lasting psychological effects on the family*

*Parkes CM. BMJ 1964;2:274-279

“Give necessary orders with cheerfulness and serenity...revealing nothing of the patient's future or present condition” - Hippocrates§

§Hippocrates. Decorum, XVI. In: Jones WH, Hippocrates with an English Translation. Vol 2. London: Heinemann, 1923.

BBN – What they wantBBN – What they want

Privacy when receiving news The ability to express emotions safely Information free of unclear language or medical

jargon Empathetic and caring attitude Allowance for hope Ability to ask and receive good medical information

Rosen

BBN – Some key pointsBBN – Some key points

Listen Pause Be guided by the patient and family

Pace, amount of information, style

“It's a solemn ceremony to preside over a death and a grim one to announce it, a morbid unveiling, a confirmation.”

Neilson. Can J Emerg Med 2007;9(5):389

An approach to breaking bad news…

BBN – SPIKES approachBBN – SPIKES approach

Setup: Preparation Perception: What does the family know? Invitation: How much do they want to know? Knowledge: Sharing the information Emotions/Empathy: Responding to feelings Summary/Strategy: Planning & F/U

The Oncologist 2000;5:302-311

Step 1: Set-upStep 1: Set-up

Know the patient’s name! Confirming medical facts ±Mental rehearsal Environment/support staff Which family members are present Introductions Body language

Sitting MD’s perceived as more compassionate*

*Bruera et al. Palliative medicine 2007;21:501

Step 2: PerceptionStep 2: PerceptionWhat does the patient/family What does the patient/family

know?know? Were they with pt prior to ED arrival? What have they been told so far? Can help adjust the way you deliver bad news Don’t prolong this part

Perceived as delaying 74% prefer immediate notification of death*

*EM Reports 2005;26(7)

Step 3: InvitationStep 3: InvitationHow much do they want to How much do they want to

know?know? Cultural differences Sometimes age-dependent

Step 4: KnowledgeStep 4: KnowledgeSharing the informationSharing the information Address the closest family member

Simple, non-medical language

Preparatory warning

If pt died, not a long preamble Use “died” or “dead”, not “passed away”, “gone”, “passed on”

If pt dying, reassure that pt not being abandoned

Pause

Answer questions, ensure understanding

Be careful with “I’m sorry”

Bloch. Social Work. 1996;23(4):91

Step 4: KnowledgeStep 4: KnowledgeSharing the informationSharing the information May want to explain EMS/ED details of care Ensure family that their response was appropriate Ensure family that pt did not experience unnecessary

suffering Offer viewing of deceased

Some warnings More family members regret not viewing than viewing the

body*

Organ/tissue donation conversation ±Autopsy/ME

*Parish et al. Annals of EM. 1987:16;1792

Step 5: Step 5: Emotions/EmpathyEmotions/Empathy

Responding to feelingsResponding to feelings Variety of responses (sadness, rage, blame,

etc) Allow them to express this response SW, Chaplain can help

Step 6: Step 6: Summary/StrategySummary/Strategy

Planning & F/UPlanning & F/U Can use “hope for the best, prepare for the

worst” May discuss future actions if pt deteriorates Outline next steps Outline support staff availability ±Inform pts family physician

BBN – SPIKES approachBBN – SPIKES approach

Setup: Preparation Perception: What does the family know? Invitation: How much do they want to know? Knowledge: Sharing the information Emotions/Empathy: Responding to feelings Summary/Strategy: Planning & F/U

ComplaintsComplaints

Not being kept informed Not speaking with a physician (or not realizing

they had) Being unclear of the details of care by EMS/ED Patient belongings being handled improperly

Parrish et al. Annals EM 1987;16:792

Dealing with angerDealing with anger

Will feel like an attack aimed at you Empathy is the most effective response

Pause Recognize the anger (vs sadness, fear, etc) Name the affect

“Sounds like…”, “If I’m hearing you right…” If you’re baffled admit it Express understanding

Platt & Gordon. Field guide to the difficult patient interview. Lippincott Williams & Wilkins, Baltimore 1999.

Questions so far?Questions so far?

Family presence at Family presence at resuscitationresuscitation

94% of families said they would participate again

76% felt this facilitated their adjustment to death

64% felt their presence helped the deceased 80% who were not present wanted to be 96% believe they have the right to be present

EM Reports 2005;26(7)

Family presence at Family presence at resuscitationresuscitation

Up to 30% of staff members report increased stress

What experience have you had with this?

Tsai E. NEJM. 2002;346:1019