Dec 15, 2015
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
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.
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