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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, May 30, 2016

Breaking bad news in the ED: Who is going to bell the cat?

As Emergency Physicians, declaring unexpected bad news is a part and parcel of our job. On one of the most stressful shifts that I have had so far, I remember declaring 3 people dead over a span of 8-10 hours. This can be an extremely challenging task which if not done appropriately can have long standing consequences, not only on the family members of the deceased but also on the physician who breaks the news. Unfortunately, not much attention is paid on how to address this issue in many fields of medicine and only a few specialties receive the right kind of training of doing do such as Emergency Medicine, Critical Care, Palliative Medicine and Oncology. Moreover, even in various life support courses, this particular skill is seldom taught. 


Declaring a sudden unexpected death in Emergency Department is quite different from what happens in the Oncology/Palliative Care wards or even in the ICU. In case of a sudden death in the ED, families have a tough time in absorbing the news whereas settings like ICU/Oncology/Palliation wards often provide enough time for the family to adapt the situation. 

Here is a framework on how can we do this in the ED:

1. Setting the scene
To begin with, we need to set the stage right, ensuring privacy and giving respect to the family members. Introduce yourself, confirm their identity/relationships and most importantly know the name of the deceased. You have 1-2 minutes to set this right, connect with them, making them feel important and creating a rapport. To accomplish these, look professional, demonstrate empathy, watch you body language, voice tone and expressions. Also turn your phones on silent modes. 

I am sorry to meet you in these circumstances. This is going to be a tough conversation for us. 

I would also recommend to involve a social worker/nurse right, a chaplain and a medical student or resident with you. They can take control of the situation and provide continued support if you need to leave the room urgently for some reason and for a med student, this is the best opportunity to learn this skill.


This is not like a 1980-90s Bollywood flick, where typically a doctor exits from the operation theatre, shakes his head and says "I am sorry, he is no more" and then walks away. Declaring death is one of the hardest jobs that emergency physicians do and this can be very exhausting if done without apt training.

I believe that the most senior physician present in the ED should take the responsibility of doing this task. The gives a sense of reassurance to the family. A med student or a fresh trainee should never do this alone unless he has been appropriately trained. 


2. Breaking the News - Crux of the matter

After a quick introduction, avoid beating around the bush and building unnecessary tension. Come to the point fast and be succinct. You might consider them asking their view point and understanding of the circumstances so far, but avoid asking too many details. Try and deliver the news 2-3 minutes into the encounter. And remember, once you say the work "Death" or "Dead", just stay quiet and let them break the silence. Don't be afraid of silence and allow time for people to imbibe the event. If they break down, give them time and offer tissues or water. 


The less you say, the better it is. As physicians, we tend to mention minute details such as:

During resuscitation, we did chest compressions, administered adrenaline and delivered 300J shock but could not bring him back. It seems like he suffered from a refractory cardiac arrhythmia

Using medical jargon along with providing these minute details might sound a bit defensive and it is best to avoid doing this. It only adds to the confusion. Keep the conversation simple, clear and to the point. If the family witnessed the resuscitation, then they would already know the kind of efforts that you made, which helps them in understanding things better. 

3. Continuation of support
At the first place, try to give them uninterrupted time but if there is an emergency and you need to leave, excuse yourself and let the nurse and the social work over take over. 

I am going to excuse myself for a while. We have Sister XYZ and our social worker (XYZ) here to help you out further. I will be available in a few minutes to answer any questions that you might have. 



Social Workers play a vital role here in terms of helping the family understand about the next steps such as documentation, issuing of a death certificate and preparation of funeral.  They can also provide assistance if the relatives want to call and speak to someone.



As a physician, you need to visit them again to ask if they have any questions or concerns or if they would like to see the deceased person or perform some religious rituals. And if they want to see or touch the the dead body, take a few minutes to make the body look presentable and warn them for any disfigurement that they might see.  

Follow the local organ donation policies, involve the organ donation co-ordinator for this. I personally think you need not speak about organ donation with the family in a case of sudden unexpected death. This is best left to the organ transplant co-ordinator. 



But if your institute has a stringent policy that states emergency docs need to initiate this discussion, then start with something like this:

I am sorry for asking this Mr. XYZ, but have you ever had any discussions about organ donation ?
OR
Does  (Name of the deceased)  has an organ donation card?



In addition, you also need to mention the need to perform an autopsy if it is a medico-legal case. The brunt of doing this falls on the emergency physicians. The family (regardless of the cause of death) is never in favour of a post-mortem examination. If you think autopsy is required, be assertive on that and consider saying something like this:

Since this is an medically unexplained death/Road Traffic Accident. I am bound to fill a medico-legal form which is then passed on to the police department. Unfortunately, I don't have a say in this and things are going to move as per the law of the land.

Many hospitals also give follow up calls to the families to ask about their well-being 2-3 weeks after the event. 

Breaking a bad news might be an everyday thing for you, but for a family, this is possibly the most stressful day in the lives or probably a life changing event. Therefore, we need to keep everything aside and give them uninterrupted attention for a few minutes. They are going to remember what you say for the rest of their lives, so be sensitive and considerate. 


References:
  1. https://www.acep.org/content.aspx?id=26468
  2. https://edcentral.net/2013/12/21/im-sorry-we-did-everything-we-could-breaking-bad-news-in-the-ed/
  3. http://theoncologist.alphamedpress.org/content/5/4/302.long

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