It’s every health professional’s most dreaded task to have to communicate difficult news to desperate patients, friends and relatives; particularly when someone has died.
Think about this clinical case and ask yourself what you would do.
A 46 year old man is involved in a motor vehicle accident arrives via the paramedics into the Emergency department. Despite the team working well together and everything being done perfectly the man dies. You have been asked to go and inform his wife and three children who are waiting anxiously in the busy waiting room. A junior member of staff asks if they can come and observe for their own learning. You agree, and surreptitiously wonder whether you are good at this? Are you really the person to show best practice in this most important task. You doubt your abilities and wonder if it is something that you do well.
It may come as a surprise to many readers, but such feelings of doubt, an imposter syndrome of sorts, haunt many clinicians in emergency medicine. Such doubts persist and irrespective of whether you are brand new to the speciality, or whether you have been doing this for many years doubts persists. Perhaps it is a good thing that we don’t reach a state of complacency as we would argue that such conversations should never become routine. Arguably we should all continue to reflect and review how we can tackle such terrible conversations. What would we have become should we find such a task a blank, unemotional and routine task? The paradox lies in finding a place where the ability to deliver such terrible news becomes professional without losing the empathy and emotion that must surely pervade every second of the interaction.
At St.Emlyn’s we recognise that these are tough conversations and that they really matter. We want you to do the best you can for patient and so we present our thoughts on how to approach and interact during a conversation that will forever be a terrible moment for all involved. This is based on years of experience and reflection and accompanies the podcast below. We’d love to hear your thoughts and wisdom from your perspective. Please consider and comment below.
The Importance of Self: You take a moment to check in with yourself, and catch your breath. You check in with the team and do a quick debrief. Then you gather your thoughts, you want this to be compassionate, you want to be present for the family and to demonstrate that the man was important, received excellent care but that his injuries were not compatible with life. You feel a mixture of sadness, frustration and reflect on the care the man got and assure yourself everything was done. Sometimes in these moments you think of your own family but you know that’s normal and remind yourself that they are safe at home. One of the junior staff members ask if they can observe you talking to the family and this makes you feel a little anxious but you know it’s importan to mentor and agree. You let the junior staff person know that if tears come they are of comfort to the family however you warn that families should never need to comfort you. You advise the junior that if you were feeling really out of control you would ask another colleague to speak to the family? On the way to see the family you tell the junior staff member how you are feeling and your plan of communication, as you recognise this is also valuable learning. In your mind you have a series of things you want to ensure happen.
Space: Before you go to see the family you are mindful to find a suitable space that is private, safe and confidential. You don’t want the family hearing this news in a busy waiting room or in earshot of the whole department. You ensure there are enough chairs and check to see if there are tissues.
Body Language: Before you approach the family you check in with your body language and facial expressions, talk with the junior staff member about what you want to convey before you speak. The goal is a sincere and sombre face of compassion so that the family know the news is not good but also can see that there is someone who can lead and guide them through what needs to happen next.
Introduction: Very briefly introduce yourself and the junior member of staff to the man’s wife. Let her know the news is difficult and ask if she wants to bring the children in to talk. Remind yourself that there will be no protecting the children from this news; they will have to hear it sooner or later. Let the wife decide what she wants to do and support her in that decision. As you walk to the room stay close to the wife in case she is unsteady on her feet, guide her to the room.
Communicating the news: The only news his wife is interested in is whether her husband is dead or alive so be careful to say this in the first sentence. “I am very sorry but your husband has sustained horrendous injuries in the accident and has died”. Be very careful not to use medical terminology and jargon. Even words like abdomen, cyanosis, respiratory can be foreign to the general public. People in crisis have less capacity to understand words that are not part of their everyday vocabulary. The woman becomes very distressed, crying and wailing loudly. You feel really confronted but recognise this is just grief and you can’t do anything for her husband but you can for her and the children so you remain engaged with your body language but you do not speak. You look over to the junior staff member and with your eyes assure them this is normal and it is okay to allow this level of emotion. After a period of time, tell her how sorry you are. After a period of time when her grief subsides respond gently respond to her questions if she has any. Stay very concise; keep your voice low and steady If she is really overwhelmed by her grief ask if she can identify someone you can call to come and be with her. Assure her that you are available for questions later. Ask if she would like to see her husband? Your primary goal at this point is about connection and safety for the man’s family. Even though the grief may make you feel uncomfortable allowing space for grief and to pause and allow silence will be very powerfully received.
Do we ask “what do you already understand?”:This is an incredibly powerful tool in communication when someone has a chronic illness, or has been in the ED or ICU for duration of time seeing multiple colleagues. It is not as useful when someone has died. It gives relatives the confusing message that they may have something to contribute to help their loved one. If after informing them their loved one has died they ask ‘how?’, you may use this phrase then.
Providing assurance: There are important key messages that families often need to hear. If you think the person die not suffer and was not aware let her know this as it will be a source of comfort. If you are unsure this was the case do not offer the sentence. if you are aware that someone has attempted CPR or first aid on the scene it is incredibly powerful and can soften guilt and regret to have a health professional acknowledge that they did a great job under difficult circumstances. That they gave their loved one a chance by getting them to hospital and that there was nothing more they could have done. We often say something like “we know you did CPR on the scene. You did a really good job, that’s what got them here and gave them a fighting chance”
See the family more than once: After you have assisted the family to be with their relative’s body you are tempted to just throw yourself back into your work or hide in the team room. State this out loud to the junior staff member so they know emotional fatigue is normal after this sort of interaction. However, you know that families often need the chance to reconnect and ask questions so you go back in, even if only briefly, reintroduce yourself and ask if the family have any questions. This is a good time to inform them about the Coroner and/or autopsies. If the person who has died is a child think about genetic implications when discussing autopsies, you may save the family the heart ache of going through this again. Giving the family your card or email is very empowering for the family just so they have a name of the person that was with their loved one when he died. Very few families make further contact but this gives the clear message that they were important and communication is open. Before you say goodbye to the family just pause for a moment and ask yourself if you have informed them of everything they need to know.
Self-Care: After the family have left and you have a moment take the junior staff member aside, maybe to the tea room and reflect over what just happened. Let them know that with every conversation you learn something new. Ask them what they thought about the conversation and the resuscitation. What they thought went well and what didn’t go so well. Remind yourself and them that we cannot cure everyone but we always have the opportunity to care and connect and that is what makes the job meaningful. This is a self-care strategy in itself.
I suspect every clinician has had teaching on ‘breaking bad news’ at some point. What’s different in the ED you might ask? Arguably the unexpected nature and sadly the finality of the news that we must share in the event of a sudden death is a world away from the out patient setting of a cancer diagnosis (a common scenario in teaching). Few clinicians ever experience the moment that we describe here and maybe that’s a good thing. However, as ED clinicians it’s not something that we can avoid and we owe it to our patients and their families to reflect and review how we can do it as best we can.
In summary we ask you to pause and reflect on those conversation that you have had, and those that you are yet to have. They will be difficult for you, though far more terrible for the families involved. They will be sentinel moments for the families you speak with so please, do your best for them, for your colleagues and for yourself.
Liz
Great blog and sage advice. The self care aspect is frequently neglected and I’m guilty of this – I’ll tend to wait to the end of the shift before reflecting on those events and crack on regardless. Sometimes, I don’t reflect at all. I make sure the team is OK but not myself – something to reflect on.
With so many different presentations of death in EM, one size does not fit all and I don’t do it the same way every time but if I’m going to the relatives room I always have the same opening: “Hello, my name is David Hartin (never Dr Hartin)… I’m the A&E consultant (and I still use A&E, not EM, this is not the time to educate); identify who’s in the room, identify NOK, seat directly in front of them, at eye level or lower and within arms length of their shoulder (it’s OK to touch) and say “I’m terribly sorry, x died a few minutes ago.” and stop. Stop talking. For as long as it takes. No point in you saying anything more right now, no-ones listening. Until someone says something or looks at you for help. And then ask if they would like to know what happened. Answer their questions honestly. Uncertainty is OK, it’s OK to say “I don’t know”. Make sure you have someone with you who can make tea. And as Liz points out, give an opportunity for a further conversation or questions later. And then I say again how sorry I am. And I mean it. Because I am.
We practice open resuscitation so frequently relatives are present when we are coming to the end of an unsuccessful resuscitation attempt. This is almost easier for a clinician than the relative room scenario as the loved ones can see the effort, the lack of response and come to terms with futility on their own terms. I’ve never had hysteria or protest from relatives when ceasing active resuscitation: just appropriate grief, distress or quiet acceptance of what has happened. The subsequent conversation then takes place in a more reflective atmosphere rather than the shocked, distressed scene described above and can be a more informative, comforting and rewarding interaction.
We offer bereavement follow-up for relatives of anyone who has died. An invitation usually goes out a few weeks after the event. It gives a chance for relatives to ask us questions about process, post-mortem results etc and I think it’s important to get relatives back to the scene. Chances are, they’ll need to access the EM service again and while they’ll never forget their loved one dying and where it happened, it may make coming into the ED again just slightly easier. Of course if they would prefer to meet outside of the ED, that’s fine too.
Lastly from a departmental perspective one other thing we do is the “blue butterfly”. When someone dies in the department, we put up laminated blue butterflies in prominent places, on doors etc to let the team know that someone has died. Hopefully the noise decreases by a few decibels, a more sombre mood, maybe one less audible wisecrack about a speciality registrar so that there is a more thoughtful and respectful atmosphere through the department while this sudden bereavement is managed. The relatives won’t notice but they might have noticed “business as usual” in a negative way. As with much of Emergency Medicine, it’s the little things that make the difference.
I’m not sure any of this is wisdom as requested in the preamble, more a reiteration of what Liz & Iain have so eloquently described on the podcast. I would advise colleagues to remember to be human. Leave your scientist defence mechanism somewhere else. Embrace your human vulnerability and emotion. Too many colleagues use professional detachment as an excuse for coldness or lack of empathy or fear. Be human.
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I’m reviewing blogs & podcasts that I’ve learned from over the past few years – having listened to this again today I would say it is an exemplar of good practice. It should be on the undergraduate curriculum as “the way it should be done” or considered. I’m glad to say that it’s the way I do it and we should be teaching it this way.
One thing I would advise – if you’re busy, it’s not if you ‘have time’ to do this properly – ‘make time’ i.e. the only thing more important than this is if someone is actively dying in your department and you may be able to prevent it. If it takes an hour or more, so be it.
We’ve only got one shot at this. We’ll do it a lot. Get good at it.
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