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

Outline Breaking bad news Conflict resolution Telephone advice

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

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

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;2:274-279

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

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

An approach to breaking bad news… Chalk talk

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;5:302-311

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

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)

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

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

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

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

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

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?

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

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.

Questions so far?

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)

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