Delivering Bad News in the Pediatric Emergency Department

Delivering Bad News in the Pediatric Emergency Department.

So it is Friday the 13th in the year 2020… and I awoke in a cold sweat concerned. Concerned about what you ask? (I mean it is still 2020, isn’t that enough to be concerned about on its own?) Concerned that we have yet to address one of the most critical aspect of our roles. Sure we have discussed the need for us to be ever vigilant for the subtly sick (ex, Heart Failure) and how the unusual can become even more complex (ex, Kawasaki Shock Syndrome). The question, though, remains: what do we do when we actually discover one of those life-altering conditions? Do we simply say, “We are going to keep your child in the hospital,” and let our friends with “Hematology & Oncology” on their white coats inform the family that their child has leukemia? Let’s take a minute review Delivering Bad News in the Pediatric Emergency Department:

Delivering Bad News: Parental Perspective

  • Clearly, an important aspect of caring for humans, is communication… and communication of difficult / bad news is a critical point in the patient-physician relationship.
  • Sadly, it is known that we perform this duty poorly.
    • We providers often feel uncomfortable with the conversation.
    • We likely have had little, if any, formal training on how to do this.
    • Commonly we rely on the “see one, do one, teach one method,” but only have seen this done poorly.
  • While our intentions may be noble and empathetic, what is received / conveyed is often not.
  • With respect to what parents perceive, several themes have been highlighted recently… and while these are not specific to the Emergency Department environment, their tale is universal [Brouwer, 2020]:
    • Lack of TIMELY communication
      • There is no perfect time to learn of bad news, but too late is always the worst time.
      • In the ED, we can start the conversation at least.
    • Failure to ask parents for input
      • While we are protective of patient autonomy, we should also respect parental autonomy when possible.
    • Parents felt unprepared during and after the conversation
      • Obviously, this one is much difficult to get around in the ED…. but…
      • When you start an evaluation, inform the family what it is you are worried about… you don’t have to announce everything on your Ddx, but if you were worried that the weight loss, fevers, and odd lymphadenopathy was due to cancer, at least hint at that being on your mind to begin with… if you find a ton of Blasts on that CBC’s Differential, then you need to go back to point #1.
    • Lack of clarity about future treatment / options
      • Yes… you thought you were clear… but if that information was not received, you were not clear.
      • Even if you don’t know the all of the specifics, at least information about which other providers may be consulted is imperative.
    • Physicians’ failure to voice uncertainties
      • “I Don’t Know.”
      • It is ok to say. The older I get, the more I say it.
    • Failure to schedule follow-up conversations
    • Presence of too many / unknown healthcare professionals
      • We are all guilty of this… I feel more comfortable with my friends beside me… but a wall of white coats may not be very empathetic appearing.
    • Concerns about how bad news should be conveyed to their child
      • Again, respect parental autonomy to any degree that you are able.
      • Speaking to a family member out of hearing range of the child to discuss the results/issues first will help empower the parent to still be the child’s source of truth.
    • Clues / indications of bad news in non-conversational context
      • Again… we need to be careful of what we say in the hallway!
      • We also shouldn’t have the consultant tell the patient why they are being seen … very poor form.
    • Parents’ misunderstanding of medical terminology
      • Communication is difficult enough when anxiety and fear is in the room…
      • Do not use medical jargon as your safety blanket.

Delivering Bad News: My Humble Perspective

  • Bad News is in the eye of the patient.
    • The literature likes to focus on life-threatening issues… because, they are clearly severe, but…
    • While diabetes may be commonly encountered in your daily job, it may be devastating to the patient/family.
    • Do not presume to know the weight you are placing on the family by the diagnosis that you are giving them.
  • Set the Stage
    • As soon as you know that a poor outcome or bad news is on the horizon, do not conceal that.
    • You do not have to explain it all at first, but allowing the family to know that you are seeing clues that warrant your concern (trust me, they likely can tell from your facial expressions anyway) will help them hear you more clearly in the next conversation.
  • Do your own dirty work
    • Do not punt the difficult conversation to the next team or the hospitalist or the consultant.
    • We are all responsible and this is part of our duty to care.
  • Do not become memorable
    • The conversation is meant to be about the patient and the family and their needs and their healing.
    • Do not say anything that may become more memorable than that moment… again, silly phrases meant to diffuse tension (more specifically, your discomfort) can really stand out.
  • Be comfortable being quiet
    • Say what you need to say… succinctlyconcisely… and then shut up.
    • Sit there.
    • Wait.
    • Listen.
    • And be present.

Moral of the Morsel

  • We all deliver bad news in our roles as providers every shift. We need to treat it like a skill that needs to be refined and honed.
  • What you say matters.

References

Sean M. 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 renowned 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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