Breaking bad news is probably the most miserable aspect of our job in Emergency Medicine. I’d rather go to an infection control committee meeting than tell someone I’ve never met before that their loved one has just died. However, just like working to cut down on nosocomial infections is really important work, so is breaking bad news, and doing it well at least leaves you with a sense that you have done something really important. Strangely, you will receive a lot more thanks and appreciation from the community for the work you do telling them their loved ones are dead than you will saving them from untreatable staph sepsis.
Read on for a look at how to do it and how to teach it.
Like a lot of really important skills in medicine it has not ever really been taught very explicitly (at least not when I went to school). When I reflect on how I learnt to do it the following memories come to me:
- Being told by a palliative care nurse as a student that I wasn’t ever to use the words “passed away” or “he’s gone” or “he didn’t make it” but to come out with the concrete truth “I’m sorry, Peter was very sick when he arrived here and despite everything we could do Peter has died”.
- TV, movies, books: police at the door, white-coated handsome doctors shaking their heads sadly, offering a box of tissues, someone making a cup of tea.
- My father telling me as an 8 year old that my good friend had been killed by a car, or my mother telling me when I was 17 that two of my school mates had wiped themselves out on the road, and then me going to another friend’s house later that morning to pass the news on to him.
- Sitting in with Joe Epstein at the Western as he told two parents that their young adult son had died crashing his motorcycle or with Fred Mori at The Alfred as he told a young man and his daughters that his wife, their mother, was dead- the thrill of the trauma resus now dissolving into vicarious grief.
Some philosophical background
Death is not a medical event.
This may seem shocking to critical care docs but death, like birth, belongs to lots of people other than us. It is inevitable, like puberty and wrinkles and sleep and hunger. It is a social event and a personal one and a biological one (and for many a spiritual or religious one) but it is not (or not necessarily) a medical event. The consequence of the medicalisation of death is illustrated by the modern death certificate which will not allow “old age” as a cause of death; death becomes immediately a contested notion, something that needn’t have happened, the result of a reversible cause, rather than an inevitable stage of living.
Acute care hospitals are ill equipped to manage death.
60% of today’s adults will die in an acute care setting BUT only 2% of people in acute care settings at any time will die there. That means that most people go to die in a place with comparatively little focus on dying. This makes sense only if death is seen as something which must be avoided at all costs, a last resort, a final failure. However the well described failure of all the wonders of the modern world to reduce the lifetime incidence of death below 100% would suggest that that is a foolish approach.
More on the topic
Dr Peter Saul, intensivist from Newcastle Hospital in NSW, has spoken and written extensively on the topic of modern death and has given a TED talk here which is a good starting point for people interested in exploring further. The inspiration for a lot of this post comes from a panel discussion at the AMA national conference in Sydney this year in which Peter Saul, Professor Michal Ashby (Head of Pall Care at Royal Hobart) and Dr Kate Robins-Browne (GP and medical ethics researcher) spoke around end of life care and advance care planning. A talk on the topic from Michael Ashby is available here.
How is it best done?
When a resident needs to stitch up a traumatic facial wound they are often reluctant to do so for fear of causing a scar. I always try to make them see that they are not causing the scar, the punch in the face caused the scar. They might be able to minimise the scar with good technique but they are not responsible for it being there. The same applies when you walk into the relatives room to bring news of death. The terrible thing has happened already. You have the potential to make the whole experience slightly less awful but you are not the cause of the grief.
- Know the name of the deceased and use it often. Whenever you think you might use a personal pronoun (he/she) use the name instead. Whenever you might think of saying “the body” use the person’s name instead (or say “Peter’s body” “Judy’s body”).
- Know as clearly as you can what has happened. You will know what happened in the resus room but try to clarify from the Ambos what happened pre-hospital. Was it obvious that the patient was in trouble before they left the scene? Did the family see CPR going on at home? Did the Ambos give the family any idea of what was likely coming? Who else was involved (police/fire/etc). Any confusion or inconsistency in your account may lead some people to grasp desperately at the hope that there has been a mistake, that you are talking about a different person, that someone else is dead.
- Try to know who you are talking too before you go in and how many people you are going to be meeting. The triage clerk or triage nurse who let them into the department will likely know who is who so go and ask. If you are going into a room with 20 people in it you might want to take someone with you. You don’t want to go and start the “Your husband is dead” conversation with someone who then says “No, no I’m his workmate”.
- Plan who you want with you. When it is a really tragic and sudden death, like a child or young parent for example, I always to to take an experienced nurse with me. Remember that your own emotions can get hold of you unexpectedly; you might walk in and see three kids that look just like yours, or something might suddenly remind you of the time you lost your Dad and all of a sudden you might be much less use than you thought you were going to be. Having someone who can take over is invaluable. Having someone who can go get a phone or some tissues while you just sit with the bereaved can be a big help. And, lets face it, sometimes nurses can present a more human face of the health care system than physicians.
- Consider whether you want to take a resident or registrar with you. As the senior person on I have always felt I should shoulder the responsibility of these talks but you wouldn’t expect at trainee to put in a CVC alone without first watching someone else do it and then doing it supervised. This is no different. Just remember that you may need to support the trainee through and after the process. There is nothing wrong with that. In fact, it may be the trainee who ends up supporting you!
Whenever possible try to deliver bad news in a dedicated private space for the purpose. Most EDs should have some sort of family room or distressed relatives room. Do whatever you can to avoid giving this news in a corridor. There are occasions where you will meet the relative in the corridor as you both are heading to the room. On most of these occasions you ail be able to guide the person on to the room as you introduce yourself “I’m Mark Putland, I’m the doctor who has been caring for Graham, please, come with me so we can talk.”
There are a few occasions where the relative will refuse to take a step further. It is an extraordinary feature of humans’ capacity for non-verbal communication that people so often know what you are going to tell them in theses situations before you open your mouth. When the reaction is one of angry defiance and a refusal to cooperate with requests it can be very difficult to move a person out of the public eye and perhaps it isn’t necessary. There have been times when I have been drawn in to telling someone in the corridor between the ambulance bay and resus. It hasn’t been pretty and unless you are prepared to sit on the floor of the ED with a wailing person I do not recommend it.
Introduce your self and identify who you are talking to.
When you are addressing a room full of people try to identify the primary person. The body language of the crowd will usually do this for you.
People who have ever been told this sort of news, and people who have had to tell it a few times, will know that human beings have an extraordinary ability to read faces and situations. I think that by the time you utter the words “I’m sorry, Susan has died” the person you are telling already knows.
This is the crucial thing to remember when you are feeling like hesitating at this moment. The person knows and they are deperately trying not to know and it is a horrible feeling. It is your job to put an end to it so get the words out cleanly and clearly and get it over and done with.
Sometimes I add some context quickly- “You saw Susan collapse at home, when the ambulance got there her heart was barely beating and in spite of everything that we have done Susan has died” or “Peter was in a car accident, he was very badly injured and was already unconscious at the scene and despite everything that the team could do Peter died”. The reason for the context is that people may need some event to attach the news to in order for it to make sense. Remember that once you tell them that the person has died they will take nothing more in for some time so keep it short and once you have told them you need to STOP TALKING.
Silence is golden: just sit and allow whatever comes to come. A box of tissue, a gentle hand, a quiet “I’m sorry” can help but most of all you need to just sit quiet and say nothing. This is hard to do, especially after you have just taken time out from running the floor to run a resus. The good news is, it can be good for you too. One study has shown that the average Emergency Physician spends around 24 seconds an hour in quiet contemplation while at work and if ever there is a moment in medicine that deserves some quiet contemplation it is this so sit and contemplate for a moment.
Remember to give yourself some time afterwards to deal with your own emotional response to the situation. Sometimes it will be easy but don’t count on it. Look out for each other a these times and allow your colleagues to look out for you. You will last a lot longer in the job. When the death is of a child or young person or there is some complicating factor that is likely to make it harder on staff it can be worthwhile getting everyone together for a moment in the fishbowl or somewhere away from patients, to thank everyone for their efforts and to acknowledge that the while thing was pretty awful.
How can it be taught?
Like a lot of medical skills teaching, breaking bad news can be taught by a combination of explicit didactic instruction, modelling and observation, reflective discussion and role playing. Don’t underestimate the importance of example. Junior doctors should take the opportunity to go with their consultants when they go to break bad news, just the same way they would take the opportunity to watch a central line being placed. Senior doctors should remember to take their resident or registrar in with them for the converse reason.
Some helpful resources
A lot of the material out there is aimed at breaking bad news to people before death. The “It’s Cancer” talk. With a bit of sense though, a lot of lessons can be extracted for our situation. By our situation, I refer to the common ED job of meeting someone for the first time in the distressed relatives room to tell them that their loved one has died. That is not to say that there are not other situations in which we need to give bad news, it is just that this is the archetypal scenario for ED.
This post on a geriatric medicine blog collates a series of youtube clips from various films where bad news is delivered well or not well and offers some teaching points from each. I actually really enjoyed watching these, especially John Wayne and Jimmy Stewart in The Shootist.
There is a short post on LITFL here that summarises the key points.
The Medical College Wisconsin End of Life and Palliative Care Education Resource Centre has a set of “fast facts” on various topics including breaking bad news here.
For app junkies, the Vitaltalk app is a great resource for the bad news chat. Again, it is aimed not at the catastrophic event but at having a talk at the time of diagnosis, or when treatment has become hopeless. It breaks the process up into stages, offers tips and pitfalls on each stage and even offers a “debrief me” function. There are little videos for each section making it a really good educational tool.
This is one of the most important tasks you can perform in EM, and one of the hardest.
To do it well, be prepared and be straight to the point. Leave no room for confusion and make sure you say the dreaded word “dead” or “died” clearly.
Silence and just being there is very valuable. You can’t make things better with words.
Online resources exist to help with learning and teaching this skill.
Direct example and supervised practice is terribly important. Trainees and consultants should do this together whenever possible.