Bad News

Bad News

 

Unfortunately, delivering “bad news” to patients and families is part of a clinician’s job. Even more unfortunate is the fact that many of us are really poor at the art of delivering bad news. The vast majority of us entered the medical profession to help care for people, but the act of delivering care can make it become more like a job.  Jobs can become arduous and mundane and do not engender caring.  It is important that we all remember that our profession is more than a job!

On many occasions, too many to recount, I have been the deliverer of bad news.  Some I recall, because the moments were poignant and powerful. Others I recall, because I allowed the other circumstances of the day/shift/case interfere with my ability to truly be present for the patient.  While I have learned a lot from the cases where I was the messenger, it has been eye-opening to be on the receiving end of the bad news.

What follows are some simple goals I have when I am responsible for delivering bad news. These are not rules, guidelines, or protocols and may, or may not, be supported by literature.  I welcome your perspectives.

 

Bad News is a Matter of Perspective

  • Particularly in the Emergency Department, our perspective of what is “bad” news can become distorted.
  • Just because life or limb doesn’t hang in the balance, the information you convey can still be rather devastating to a family.
    • Diagnosing diabetes may not alter your day greatly, but will substantially alter a family’s life.
    • Diagnosing appendicitis may be a daily routine for you; it is not routine for the family.
    • You may discuss the need for lumbar puncture in a febrile neonate 5 times per shift, but this particular family has never considered it before.
  • Some diagnoses and conditions seem to have universal weight (ex, traumatic injury, death), but do not assume every family will react the same.

 

Slow Down

  • We are busy. The clinical scenario may be demanding. Recognize that these situations may make you seem hurried.
  • Seeming to be hurried is easily interpreted as being too busy to care, so slow down when communicating.
    • Slow down the pace with which you ask questions.
    • Slow down the pace with which you answer questions.
  • Put yourself in their seat and realize that their minds will be occupied with a whirlwind of thoughts.
  • Their perception of time is altered, so slow down so that you can be heard.

 

Sit Down

  • Every medical student knows this and we preach it often… but I have witnessed astute medical professionals forget this.
  • Body language is powerful.
    • Sitting down goes along with slowing down.
    • It is a physical representation of your ability to be present in this moment with a patient or family.
    • While the words you say and intent may be clearly empathetic, standing by the door undermines your intent.
      • All a family sees is someone who is not comfortable in that space.
      • Worse yet, it can be interpreted as being too busy to be present.
  • Do not appear as if you have someplace better to be. Sit down and be present.

 

“Nothing for Us to Do” is a Terrible Phrase

  • There are occasions when the medical interventions that we have available will not help reverse the damage that has been done.
  • When these occasions occur, resist the urge to say that there is “nothing for us to do.”
    • The intent is appropriate – convey that injury/illness is at a point that our tools can no longer improve the clinical course.
    • What is conveyed however is painful – the connotation is one of “giving up” and the words often feel cold.
  • First of all, conveying medical futility does not need to convey lack of effort or continued care.
    • Just because you were not able to “cure” a patient, does not mean that you cannot “care” for that patient.
    • Additionally, you no longer only have the patient in the hospital bed, you have patients that are sitting next to the bed.
    • Family members can benefit from your care as well.
  • Secondly, there is always something to do.
    • Make the patient more comfortable.
    • Give the family time to be alone with their loved ones.
    • Hold a patient’s hand.

 

Silent Presence > Medical Nonsense

  • When people become uncomfortable, they make attempts to become comfortable.
  • For medial professionals, that often involves a lot of “fancy” words.
  • Become comfortable being uncomfortable.
    • Sit in silence.
    • Think of the words you may say and decide if they will be heard and interpreted appropriately.
    • If they will not be, think of another way to say what you mean… or say nothing.
  • Sometimes, words don’t mean as much as your presence.

 

Expect Not to Be Heard

  • Understandably, a lot of what you may need to say will not be truly received.
  • Expect that. Acknowledge the limitations of your ability to communicate effectively during these moments.
  • It is even appropriate to point this out to the family and say that everything can be repeated as needed… provided that you are not using “fancy” words.

 

Try to Not be Memorable

  • These poignant moments in patients’ and families’ lives are not about you.
  • Your goal should to be to remain on the periphery, not in the center of the attention.
  • By trying to achieve the goals above, I aim to achieve this last one.
    • I try to not appear callous and cold – that is memorable.
    • I try not to appear to be “bothered” by this moment and in a hurry – that is memorable.
    • I try not to stand awkwardly with my arms folded – that is memorable.
    • I try not to say ridiculous statements that are filled with medical words or can be emotionally provoking (i.e., “nothing for us to do”) – that is memorable.
    • I try to not hide from my own discomfort as this often makes me look more uncomfortable – that is memorable.
  • I try to not be memorable in the moment when the family’s memories should be occupied with more important memories of their loved ones.

 

References

Tobler K1, Grant E, Marczinski C. Evaluation of the impact of a simulation-enhanced breaking bad news workshop in pediatrics. Simul Healthc. 2014 Aug;9(4):213-9. PMID: 24787559. [PubMed] [Read by QxMD]

Abbaszadeh A1, Ehsani SR2, Begjani J3, Kaji MA4, Dopolani FN5, Nejati A6, Mohammadnejad E7. Nurses’ perspectives on breaking bad news to patients and their families: a qualitative content analysis. J Med Ethics Hist Med. 2014 Nov 12;7:18. PMID: 25512837. [PubMed] [Read by QxMD]

Gilmore T1. Reflections on giving bad news. Acad Emerg Med. 2012 Mar;19(3):356-8. PMID: 22360762. [PubMed] [Read by QxMD]

Fallowfield L1, Jenkins V. Communicating sad, bad, and difficult news in medicine. Lancet. 2004 Jan 24;363(9405):312-9. PMID: 14751707. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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4 Responses

  1. and please please always use the child’s name and this is NOT the time to call he a she or vice versa. It is the little things that they remember. Take the time to get them right.

  2. Jack Perkins says:

    Really well done pearl Sean. The quality of your pearls is routinely superb, but this one is sensational.

    hope you had great holidays,
    Jack

  1. December 27, 2015

    […] Fox gives his perspectives on delivering bad news to patients and families. […]

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