Saturday, January 24, 2009

Week Four Online Challenge

Last week we talked mostly about the difference between withdrawing and withholding life-sustaining treatments, and touched a bit on surrogate decision makers, the challenge of interacting with families and what to do when it becomes clear that some medical approaches are futile. These are each topics that could consume an entire class, if not a whole quarter. It's reasonable that you feel like there are some loose ends!

This week's challenge offers a chance for each of you to do a little teaching about some of these difficult issues.

How do you break bad news? Write about one strategy you use (or could use) to talk with patients or families about death or a terminal diagnosis.

Update Jan 27, 2009: If this is an issue you are particularly interested in, there's a good article available about grief in the ER available on eMedicine. You may need to register for a free login with MedScape to read it.


  1. Obviously this is an important part of practice. I question whether doctors are either good at this or bad just by seems that way. Perhaps it's something one can learn to be good at. Just from my limited clinical experience, it seems like some physicians are inherently good at breaking bad news while even I a second year student, noticed how badly others discuss the situation at hand with their patients.

    I guess for me the most critical part of the discussion is the beginning. I would think a good way to start the conversation is to ask the patient what they already know about their condition if any and how much information they would like to find out. I remember having patients come talk to our classes reiterating to us how important this was for them. Some simply don't want to know all the 5-year survival data and prognostic details that may depress their hope while others want to know EVERYTHING. Neither way is right or wrong but just simply identifying what each individual patient wants and tailoring the conversation around that is a good starting point....just a thought.

  2. I agree with some of the previous comments from MNM. One of the most important things, I’ve found, is the beginning of the encounter. Assessing their level of awareness is paramount. There are individuals who are very aware of what’s going on, and can tell you “I think I’m going to die.” Then there are others who have no grasp of the enormity of their situation and think, for example, their progressive muscle weakness is just deconditioning or an acute viral illness as opposed to Lou Gehrig’s disease. How you approach these two patients might be totally different.

    I think another important part is to really keep the details to a minimum. The first time someone hears bad news they retain very little of the conversation afterwards. Just listen, answer their questions, but really give them a chance to talk. That is the reverse tactic from one I’ve unfortunately seen in some cases in which a nervous doc/resident speaks endlessly and gives the patient very little time to talk and ask questions.

  3. I agree with what Bryce said, that I think patients or family members retain very little of what you say after they hear the initial bad news. I remember a talk from my EMT training that dealt with how to break bad news to people that mentioned this, and stressed the importance of not saying too much and giving the patient time to process the information. You use cues from the patient and the surroundings to figure out how to go from there.

    One other thing they said in that talk was not to gloss over anything in the interest of "breaking the news gently." That's not to say that we should give bad news without any regard for how the person will react or feel. Rather, we shouldn't use euphemisms or trite phrases. They told us to say someone "died" rather than "passed on." That sounded callous to us, we were being told to speak so bluntly. But speaking bluntly isn't the same as speaking disrespectfully or without empathy, and it's better for the person you're talking to because it has less risk of giving false hope or confusion.

  4. MNM, Bryce, & Dave_student have summed up a lot of things I was thinking when I read the question.

    The biggest thing I can think to add, is be completely honest. If you know a patient is going to die, don't give words of hope to the family or the patient - Speak frankly. Remembering that no one wants to hear this news, and people will react very differently. Some will yell, scream, or sob, others shut down and act like nothing happened. Be patient and give them time to absorb the information. If there is time to spend with their love one and they want to be with them - give them that time, don't fill it with conversation.

    Additionally, stay away from comments we use to comfort, like "Everything is going to be OK" - instead let them know you are there and make sure SW is there to help with further resources.

  5. Thanks for your comments. So far, there is a common theme of controlling the flow of conversation. Start off right, don't speak too fast, don't give too much information, no euphemisms... It seems to me like it could be difficult to enter into this space having just been in the fast pace of the ED. What do you think some practical things might be to help me get from the fishbowl to the family conference room?

    (The fishbowl is often the central workspace of the ED.)

  6. Getting out of the "fishbowl" is a different story (having someone take your phone calls, pages, medic calls), but at times you have to force yourself out. When you need to talk you need to talk.
    Bad news in the ED is different than bad news in other parts of the hospital. I think Thomas' new question is trying to make us think about those times where we don't have a table and chairs to sit around.
    Some of my "family conferences" have been while I have been coding a patient. Especially with new ACLS algorithms that require 2 minutes of CPR between interventions and pulse checks, brief discussions about prognosis can be had in the presence of the patient. Similarly, bringing the family to the patient's bedside to see how they are doing, can provide context and show how much you are doing.
    I agree with Nutrire Valetudo that you need to be honest and direct. And, although frequently used, the phrase, "I am sorry. We tried everything but we couldn't save your _______" works well. But be prepared for tears.

  7. As a physician we have to realize what effects our actions have. There are times when the discussion does not need to or can't take place at the bedside. Ex. when the patient is in surgery.
    We should be able to be "in tune" enough to sense when staying in the ED will work and when you can step out of that environment for a couple minutes. After all this encounter can be quite life-altering for those involved. Take a moment to consider whether staying in the ED is an excuse to hide in some way or a help.

  8. This is a difficult situation that doesn't have one correct answer. The keys include talking slowly, factually and in short phrases. The family will remember less of what you say and more how you present it. By using simple language it will allow them to focus on themselves/ thier loved one. Silence is also a tool that can be used. After saying something giving some time for them to ask questions. Showing that you are there for them includes putting in the time of being available. By not rushing and answering questions shows that you care. It is also important to show empathy for their loss. The key is to treat them as you would want to be treated. This being said it is much easier to talk about on this blog than in person. Practice and compassion will aid in this process.

  9. Great comments. My 2 cents: our own hardest places to visit emotionally will be the places where it is hardest to stay present with our patients. The more familiar we are with our own grief, anger, the insanity of losing control or whatever we struggle with, the more present we're able to be for others.

    Compassionate silence and a hand on someone's shoulder have been some of the most powerful support I think I've been able to give, after delivering bad news.

  10. I haven't had any experience delivering bad news myself, but I've seen it done a few times. A particularly difficult situation was when I was shadowing an ortho surgeon who told his patient for the 1st time that she had metastatic bone cancer. She began to cry and demanded to know how long she had to live. The doc refrained from giving an estimate, telling her that it depends on exactly how far its advanced and the type of cancer, etc etc. She persisted however, and when he gave in and told her an estimate of 6 to 9 months she lost it. To make things even worse, after we left and she was taking her gown off to put her shirt back on, her humerus broke at the site of the tumor... This is a good example of why communication skills and breaking bad news is so important to bedside manner and our skills as physicians.

  11. Since the previous posts included everything I could think of, I had a look at the article Thomas linked above to see what it recommends. It had a couple of suggestions that I wondered about, including one that seems to contradict a bit of what we're saying. One of the first suggestions the article makes is to take a few minutes to write down all that happened to the patient in a chronological order and then be able to walk the family through the events leading up to the loved one's death. I wonder about taking the time to write down what you want to share. Does anyone have thoughts about or experience with that? Also, the article seems to suggest that the physician walk the family through the events leading up to the death with some detail in order to help them understand what happened. It states that some of the dissatisfaction families express with their experiences in the ED have to do with not being given enough detail about what happened. This seems somewhat different than what the previous posts suggest about minimizing detail.

    The other suggestion the article makes which is echoed in the posts is to be silent after delivering the news that the patient is dead. It suggests waiting a minimum of 30-60 seconds in silence. I imagine that a minute in silence would be extremely difficult to do!

  12. In response to Barb's comment, I'll add simply that I think it's important to look beyond our own comfort in these situations, as difficult as that may be, and try to do what's best for the patient and family.

    I agree with previous posts that it's very important to listen and tell the patient/family the amount of detail that they want to hear. Some people want all the details and percentages, others not at all.

  13. I'd also like to add that the physical setting is extremely important. if it's in the hospital, the conversation may be in the patient's room or the doctor's office, but the environment also extends to the patient's support group. The patient may want family or friends present for the discussion.