1. Delivering Bad News When Unanticipated Events Occur
Restoring Control in an uncontrolled moment
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All Rights Reserved. © 2005 Quality Medical Communications, LLC

2. This is how CNN describes us in the media.
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4. medical community knows
What the
medical community knows
Outcome measures
Length of stay
Infection rates
What the patient
and family understand
Parking issues
Quality of meals
Courtesy
Cleanliness
Problems lead to ANGER!
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5. What is so frightening is how easily communication can be
misinterpreted.
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7. A bridge to those we love
Where to start?
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8. Maintaining that bridge….
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9. Technology has elevated patient expectations
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10. Is this not a beautiful baby?
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11. And the journey begins…
The most
Important
Picture?
Say hello to Bobby!
And the journey begins…
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13. Like leaves floating down a stream, hearing bad news creates a sense of loss of control.
This is the origin of ANGER!
Effective communication restores that control and can reduce the anger.
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14. DELIVERING BAD NEWS Why am I so anxious? I did not do it. What will be
their response?
How will they react?
Silence?
Crying?
Anger?
No threat to me.
Did I miss something?
Will they be angry
at me?
Have I lost their trust?
I really feel guilty.
They could sue me!
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15. Do we shield ourselves at the expense of our patients?
Pre
Med
Medical School
Residency
Fellow
Practice
Coombs 1993
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16. 18 seconds Are We Good Listeners? Time from initial patient
statement of complaint
until interruption by
care provider—Are we our
own worst enemy?
Beckman 1984
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17. Are we appreciated by our patients? Sometimes
Patient – Are you a psychologist?
Me - No, I am an obstetrician. Why do you ask?
Patient – Because you are asking me all these things about my feelings.
Me – Why does that surprise you?
Patient – Because I thought all obstetricians just came in, did their thing, and went about their business.
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18. Conspiracy of Silence Lewis, 1979
If you, the patient, don’t talk about it, because I, the physician, don’t ask, you won’t think about it.
If you don’t think about it, you will forget.
Lewis, 1979
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21. Strategies for care during the initial hospitalization
See the patient twice a day. FIND THE TIME.
Use the baby’s name in the conversation.
Allow the family to create the “rules:”
Seeing and touching the baby.
A memory box.
Participation of sibs or grandparents.
Pictures, wrist bands, blanket.
Special requests (circumcision, time)
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22. “I’m sorry your family is going through such a hard time.”
The 10 minute chat
Letters say it all.
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23. Advise patients to be prepared for awkward moments once they get home.
The grocery store
Church
Their children’s school
The neighborhood gas station
Neighbors
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24. When an unanticipated adverse event occurs
in the hospital, always bring the patient and
her family back in the FIRST week after
discharge to review the details of the
event and the follow-up.
AVOID MEDICAL TALK. TALK TO THE ISSUES.
Later steps:
Review the autopsy when available.
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25. If anger reflects loss of control,
do you know the agenda?
The safe
target for anger!
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26. I’m her sister. Did someone make a mistake? DID I MISS ANYTHING?
She did not
take care of
herself!
I failed my
baby.
DID I MISS
ANYTHING?
I’m her mom. Who
will talk to me about my
feelings?
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27. Questions to Ask at First Office Visit
How did they treat you in the hospital?
Should more have been done to help you then?
How did it feel to go home?
What was the hardest part for you?
Have you had awkward encounters?
What were the responses of family members?
How did your husband’s co-workers react?
Have similar past events occurred? How did you respond to them?
Who is your main support person?
What do you think caused your baby’s death?
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28. A Strategy for Delivering Bad News
THE “FEARED” ACRONYM
A Strategy for Delivering Bad News
State the FACTS. Discuss the case.
Express EMPATHY.
Search for sources of ANGER. Tell the truth.
Have the patient REPEAT back your explanation.
Evaluate the EXTENDED family response.
DOCUMENT the conversation
and next steps.
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29. Physician/nurse certification of EFM TeamStepps Chain of Command
Chart/Tracing reviews
Ob rapid response team
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30. Patient-centered rounds
RESTORING
CONTROL.
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31. Where are the near misses?
Safety Walk-Rounds
Where are the near misses?
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32. The Debriefing Session
21 Year old has cardiac arrest
on OR table during CS.
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33. Simulated obstetric education
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34. Thank you
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35. I walked a mile with pleasure, She chattered all the way;
But left me none the wiser
For all she had to say.
I walked a mile with sorrow
And Ne’er a word said she;
But oh, the things I learned from her
When sorrow walked with me.
Robert Browning Hamilton
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36. Men
women
Hearing
bad news.
EDC
6 MONTHS
1 YEAR
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37. The Letter Starting the process of recovery Dear Jimmy,
I am writing this letter to
tell you of the hopes and
dreams that your dad and
I had for you, but were
never able to tell you.
We had made a lot of
plans . . .
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38. “The hour I spent with Nicholas before he died was a cherished gift I will never forget. During that hour, I dressed him in baby clothes I had made. And then as they took away the tubes, I said I love you. And then he died.”
M. Det., mother to a newborn male who died at one hour with Potter’s Syndrome.
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39. Sometimes it means hello, and sometimes, sadly, goodbye.
In normal life, “I LOVE YOU” is sometimes difficult to say. “I love you” can mean “don’t ever leave me” and also “I have to let you go now.”
Sometimes it means hello, and sometimes, sadly, goodbye.
Cox News Service. When words fail, simply say this: I love you. 9/17/01
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40. M.Det is a 32-year-old G2P1 who, at 28 weeks gestation, was found to carry a male fetus with renal agenesis. After several lengthy discussions, she and her husband chose to have a cesarean section, knowing full well that this condition is 100 percent lethal.
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41. A year ago today, my baby died.
A year ago today, around 9:15 in the morning, I held him in my arms, at home, and watched him stop breathing. And cried, and felt scared, and felt relief, and felt pain that is indescribable. I can’t believe it’s been a whole year since I last touched him, held him, heard his voice.
This day had to come. There’s no way around it. So far it’s not much more horrible than the 364 before it without Aaron. The worst part is the passage of time. It just gets farther and farther away from the time when Aaron was with us. It’s hard to remember how he *felt*.
I’ll, of course, never forget Aaron, my little Bubby. Life goes on, and so do his memories. He changed my life forever. He was a special, beautiful, sensitive, loving, wonderful child.
Thanks for listening.
On the Internet
3 June 1994
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45. Delivering Bad News When Unanticipated Events Occur
DISCLAIMER
The information contained in this presentation and accompanying materials is designed and intended for educational training purposes. It does not constitute risk management or legal advice. For such advice, consult with an institutional risk manager, general counsel, or individual legal advisor.
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All Rights Reserved. © 2005 Quality Medical Communications, LLC

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47. Pictures
are worth
a 1000
Words.
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48. Thank you.
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49. Which setting do
you use to
communicate
bad news?
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