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