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Outline  Breaking bad news  Conflict resolution  Telephone advice.

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Presentation on theme: "Outline  Breaking bad news  Conflict resolution  Telephone advice."— Presentation transcript:

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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 § * Dosanjh et al. Medical education 2001;35:197 § Girgis et al. Behavioural medicine 1998;7:53

5 Is this important?  Bad news, conveyed in an inappropriate, incomplete, or uncaring manner may have long-lasting psychological effects on the family * * Parkes CM. BMJ 1964;2: “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.

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…

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 * * 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” 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 * 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

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

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 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

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