1. Administration Series 1: Communication Skills
Dr. Bruce MacLeod Jay Green
Emergency Medicine Resident, PGY-3
September 11, 2008

2. Outline
Breaking bad news
Conflict resolution
Telephone advice

3. Breaking Bad News
We are required to communicate bad news to patients, family members, and caregivers
Method is important
Shapes the course of subsequent grief and coping
Strengthens trust
Fosters collaboration in planning
In the ED, often sudden and unexpected

4. Are we ready to do this? We receive little formal training
Many residents are afraid to do this*
Only 35% of medical residents felt competent§
§Girgis et al. Behavioural medicine 1998;7:53
*Dosanjh et al. Medical education 2001;35:197

5. Is this important?
Bad news, conveyed in an inappropriate, incomplete, or uncaring manner may have long-lasting psychological effects on the family*
“Give necessary orders with cheerfulness and serenity...revealing nothing of the patient's future or present condition”
- Hippocrates§
§Hippocrates. Decorum, XVI. In: Jones WH, Hippocrates with an English Translation. Vol 2. London: Heinemann, 1923.
*Parkes CM. BMJ 1964;2:

6. BBN – What they want Privacy when receiving news
The ability to express emotions safely
Information free of unclear language or medical jargon
Empathetic and caring attitude
Allowance for hope
Ability to ask and receive good medical information
Rosen

7. BBN – Some key points Listen Pause Be guided by the patient and family
Pace, amount of information, style
“It's a solemn ceremony to preside over a death and a grim one to announce it, a morbid unveiling, a confirmation.”
Neilson. Can J Emerg Med 2007;9(5):389

8. An approach to breaking bad news…
Chalk talk

9. BBN – SPIKES approach Setup: Preparation
Perception: What does the family know?
Invitation: How much do they want to know?
Knowledge: Sharing the information
Emotions/Empathy: Responding to feelings
Summary/Strategy: Planning & F/U
The Oncologist 2000;5:

10. Step 1: Set-up Know the patient’s name! Confirming medical facts
±Mental rehearsal
Environment/support staff
Which family members are present
Introductions
Body language
Sitting MD’s perceived as more compassionate*
Body language – sit down, eye contact
*Bruera et al. Palliative medicine 2007;21:501

11. Step 2: Perception What does the patient/family know?
Were they with pt prior to ED arrival?
What have they been told so far?
Can help adjust the way you deliver bad news
Don’t prolong this part
Perceived as delaying
74% prefer immediate notification of death*
*EM Reports 2005;26(7)

12. Step 3: Invitation How much do they want to know?
Cultural differences
Sometimes age-dependent

13. Step 4: Knowledge Sharing the information
Address the closest family member
Simple, non-medical language
Preparatory warning
If pt died, not a long preamble
Use “died” or “dead”, not “passed away”, “gone”, “passed on”
If pt dying, reassure that pt not being abandoned
Pause
Answer questions, ensure understanding
Be careful with “I’m sorry”
I’m sorry = empathy or apology?
(break news of death within 30sec - 2min after dialogue begins)
Bloch. Social Work. 1996;23(4):91

14. Step 4: Knowledge Sharing the information
May want to explain EMS/ED details of care
Ensure family that their response was appropriate
Ensure family that pt did not experience unnecessary suffering
Offer viewing of deceased
Some warnings
More family members regret not viewing than viewing the body*
Organ/tissue donation conversation
±Autopsy/ME
Survivor guilt is likely the only aspect of the grief response that EP’s can alter
Warnings – tubes, lines, colour/temp changes
Tissues (corneas, eyes, skin, bone, veins, and heart valves ) that are ischemia resistant can be retrieved 10-24h after death (if body refridgerated within 4hrs of death)
Organ donation – pts >80, HIV, severe HTN not eligible
*Parish et al. Annals of EM. 1987:16;1792

15. Step 5: Emotions/Empathy Responding to feelings
Variety of responses (sadness, rage, blame, etc)
Allow them to express this response
SW, Chaplain can help

16. Step 6: Summary/Strategy Planning & F/U
Can use “hope for the best, prepare for the worst”
May discuss future actions if pt deteriorates
Outline next steps
Outline support staff availability
±Inform pts family physician
Support staff – may offer to contact religious resource person

17. BBN – SPIKES approach Setup: Preparation
Perception: What does the family know?
Invitation: How much do they want to know?
Knowledge: Sharing the information
Emotions/Empathy: Responding to feelings
Summary/Strategy: Planning & F/U
Anyone use a different approach? Anything to add to any of the steps that works for you?

18. Complaints Not being kept informed
Not speaking with a physician (or not realizing they had)
Being unclear of the details of care by EMS/ED
Patient belongings being handled improperly
Parrish et al. Annals EM 1987;16:792

19. Dealing with anger Will feel like an attack aimed at you
Empathy is the most effective response
Pause
Recognize the anger (vs sadness, fear, etc)
Name the affect
“Sounds like…”, “If I’m hearing you right…”
If you’re baffled admit it
Express understanding
Understanding is not necessarily agreeing or forgiving
Platt & Gordon. Field guide to the difficult patient interview. Lippincott Williams & Wilkins, Baltimore 1999.

20. Questions so far?

21. Family presence at resuscitation
94% of families said they would participate again
76% felt this facilitated their adjustment to death
64% felt their presence helped the deceased
80% who were not present wanted to be
96% believe they have the right to be present
EM Reports 2005;26(7)

22. Family presence at resuscitation
Up to 30% of staff members report increased stress
What experience have you had with this?
Tsai E. NEJM. 2002;346:1019