EM Mindset: On the Bearing of Bad News

Author: Andrew M. Bazakis, MD (Assistant Clinical Professor of Emergency Medicine, Central Michigan University College of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

The room was filled with half a dozen women and two men. All seated, hands in their laps and wearing worried expressions. A man in a white coat and scrubs entered and introduced himself with one woman, well dressed and appearing in her early thirties announcing herself as the patient’s mother. A brief conversation ensued. All eyes in the room gazed expectantly upon the man in the white coat, appearing to hang on his every word. The doctor spoke quietly, leaning forward making eye contact with the well-dressed woman. Suddenly her hands cupped over her mouth as she stood and then almost fell back into the seat behind her. In doing so she let out a wail of grief.  It was the unmistakable sound that comes forth from that part deep within a mother’s soul when she hears the news that her child is gone and a part of her at that moment dies along with her baby.

Amidst the human condition’s propensity toward illness and death, modern society often lays the task of bearing of the announcement of such grim events at the feet of the physician. In 2013 over 300,000 Americans were pronounced dead in Emergency Departments across the United States (1) accounting for approximately 11.5% of the deaths in the US that year (2). More than 800 times per day in 2013 in America alone, someone was informed of the death of a loved one in the context of the Emergency Department. Consider also the additional notifications of the presence of disease with a poor prognosis and it is no surprise that the ability to bear bad news to patients and families in a manner that is empathetic, compassionate and professional remains an essential skill for the emergency physician.

In two decades of practice I have seen the result that the compassionate humanity of a physician can impart during a moment of grief. When each of us as physicians took up the mantle of medical practice, we assumed with it the responsibility for performing this much-needed task.  In these moments, every word, every expression, every action is indelibly etched into the minds of patients and families no matter how well or how little we ourselves will recall these events over time.  The physician has only one chance to “get it right” so to speak.  While there is no way to provide complete anesthesia from the pain of loss or anticipated loss, there are ways to bear bad news that are honest, compassionate, and professional. This skill is not only essential for the well-being of the patient and family but also for the well-being of the physician and health care staff as well.

Greek philosophers have often described the various entities one encounters in two ways: the apophatic (what something is not) and the cataphatic (what something is).  For example, a pen is a writing instrument.  It is not an animal.  It is small enough to fit in my hand.  It is not lighter than air, etc.  In this way we can describe by both counterexample as well as by affirmative example. One can describe the art of giving bad news in a way that is empathetic, humane and professional in much the same fashion.

We can illustrate with recounting the experience of a young woman in in her early twenties receiving a call from a local hospital reporting that her father was there and described him as in “critical condition”. He had collapsed while shopping at a local hardware store and was taken to a nearby hospital by ambulance. She arrived at this large academic medical center with a prestigious emergency medicine training program and was seated alone in a consultation room. A young man in a white coat, presumably a resident, entered the room and asked “Are you Mr. DeBono’s family?” When she nodded in affirmation, he replied while still standing in the doorway “I’m sorry ma’am but he expired.”  The man then quickly departed leaving the woman shocked and alone uncertain of what just happened let alone what to do next.

We would all easily agree that the above case example represents how not to break bad news. Sadly however, this case is not at all fictitious. That young woman later became my wife. That deceased man was my father-in-law. I have since apologized to her on behalf of my profession as this conversation should have gone much differently. This occurred at a well-known and well-funded hospital with a very prestigious residency training program located in a financially prosperous suburb of a major city.  How could this type of error have occurred there of all places? How could this type of error be avoided in the future? The following is in part my attempt to answer those questions and provide some thoughts as to a solution.

In the Emergency Department physicians often find themselves feeling prisoner to multiple competing interests. More patients every hour waiting to be seen, consultants that won’t call back promptly and are difficult when they do, demanding patients, demanding families, ever increasing required boxes to check and records to keep, overworked nurses stressed to the breaking point and in urgent need of your collaboration to address the latest crisis. All these and more weigh on one’s mind while navigating the intricacies of caring for a multitude of patients and families all in differing stages of vastly variant circumstances each along any one of a myriad of trajectories of care. In the mix of it all, the call to bear the bad news of an ominous diagnosis or the news of a death of someone’s loved one stops everything cold.  As it should. The doctor does so with part of him/her hoping that once emerging from that consultation room that the rest of the “plates are still spinning” so to speak.  We must resist the temptation to be quick about it and get out and back to our current active census as fast as possible. The memory of this shift will eventually fade for us, but the moments about to follow will remain forever in etched the minds of those with whom we are about to speak.  We must resist the temptation to put it off for too long, lest word of tragedy be brought to the family in some other way that is not so kind as we all know it should be.  We must always resist the temptation to delegate the task of bearing bad news to someone else as this is the physician’s duty specifically. The obligation to bear such news and to do so in a way that is compassionate and professional is a part of what we have each taken upon ourselves from the first time that white coat is cast upon our shoulders.

The literature is replete with all manner of excellent mnemonics on how to effectively and compassionately relate bad news, most of these focusing on revealing the death of a loved one to the family and friends of a patient pronounced dead in the emergency department. (3,4,5). In teaching my own residents I have traditionally employed the following guidelines using the mnemonic ASHES based in part of the work of Dr. Robert Buckman of the University of Toronto (6). The mnemonic is mine, but its basis is found in his work on the topic.

First Assemble the team. So much as is at all possible, allow for a private accommodation for the family such as a consultation room. The team always includes the physician and at least one other staff member. Ideally a member of the nursing staff should be a part of this team, along with a chaplain and/or a social worker to provide additional support and stay with the family once the initial notification has taken place.  Notifying security personnel is also at times an appropriate part of assembling the team, often present just outside the consultation room door, in the event further logistic assistance is required or if safety concerns arise. I almost never break bad news alone.  This is more for the sake of the patient in the unlikely event I am urgently called from the room so as not to leave the family alone not knowing what to do next. Make your coworkers aware that you are stepping “off the floor” of the department so to speak. It is appropriate to allot to this duty of breaking bad news the same degree of attention and priority as running a resuscitation. Announce who you are and who the members of the team are when entering the room. I find that even if one does not wear a white coat on shift that this type of event is one where having a clean, pressed white coat hung somewhere to wear during such events is helpful as it provides a cultural signature that you are the doctor and often provides a comforting sense of authority for the family. Affirm the identity of the patient’s family by using the patient’s name to be certain that you are entering the correct room and speaking to the appropriate people.  Nobody wants to break bad news to the wrong family members.

Sit if at all possible. Time is often at a premium as it is in the emergency department, and in the breaking of bad news time is particularly sacred. When we sit, this communicates compassion and gives the message to the patient, or in the case of a death the family, that those to whom you speak represent a priority. (7,8). At times, it may be best to sit near a door to safely allow for a quick exit should a volatile response to the bad news occur. Speak plainly (3). Often a group will have one person who acts as a spokesperson. Even if that family person has a medical background and can understand the jargon of medical practice, use language understandable by the lay public so that all in the room may understand. Say the patient’s name and as stated above confirm who is in the room. So as to not sound clinically distant, avoid the use of phrases like “the patient” as the use of the patient’s name shows a certain recognition of and respect for the patient’s humanity and individuality.  Stay; that is be sure not to appear at all rushed. This can be particularly challenging in a busy department. Be certain however that the fifteen minutes you spend with this grieving patient or family will have far more impact over time than the extra fifteen minutes of waiting on the part of anyone else on your census.

History is best obtained right away.  There are some words in medicine that produce what in modern colloquial parlance is described as a “mic drop”. The news of death almost always changes the tone of the room permanently. That is, once these words are uttered, everything changes and the family may be in no state to provide historical details.  Start by ascertaining what the family members know up until that point to allow clarity of communication and avoidance of misunderstandings and misconceptions. I have found it most helpful to inquire up front as to events surrounding the patient’s presentation, medical and surgical history, and who the primary care physician is prior to breaking the actual news of death or a grave prognosis. That said, if the physician is asked point blank if the patient is alive or not, an immediate and clear answer is necessary.

Express the news clearly. Be certain to use clear language including words such as “I’m sorry sir, but he is dead,” or “We did everything we could but she died.”  Euphemisms such as “passed away”, “gone”, or “fallen asleep” should be avoided in this situation. Jargon such as “expired” or “remained in asystole” should similarly not be used for the same reason. The former are perfectly appropriate for chaplain staff, pastors, and other spiritual leaders, but in the communicating the news of death the physician has a certain duty of clarity and in this word choice is key.

Sympathy should be expressed once the initial grief reaction has abated. The teams’ patient silence through the initial grief reaction is necessary and is often the greatest possible show of respect and sympathy we can offer. Stay through the emotion that ensues after the bearing of the news. Show availability to guide the family through the next steps in the process.  This will involve the use of nursing staff and chaplain or social work staff if available. Be certain to assure your availability for any further questions or concerns. An expression of condolence to the family for their loss is always appropriate and reflects the doctor’s own humanity.

After family notification, the tasks of the emergency physician are far from over. In many cases, the medical examiner may need to be notified to clear the patient’s body for release to the funeral home versus reservation for autopsy. In some states physicians are required to notify Child Protective Services and law enforcement of any unexpected pediatric death (e.g. SIDS deaths).  Each provider should be aware of state and local statute as well as local standards of care regarding these circumstances. In addition to these notifications, it is our duty to immediately notify the patient’s primary care physician.  It is the duty of the emergency physician to make due diligence in this professional courtesy to our primary care colleagues. This is not only a show of respect for their relationship with our shared patient, but also a show of care and respect for the patient and family themselves.

The case at the beginning of this article involved a six-year old little girl shot in a drive by shooting while walking off her grandmother’s porch holding her father’s hand. She gasped her last breaths in her grandmother’s car en route to the emergency department.  Her father was wounded and transported urgently to another hospital, and her mother and other family members did not expect the news that her chest wound was fatal. That was several years ago, and to this day I still carry with me a picture from the newspaper of that little girl who I only saw once. I remember her face; it is forever engraved in my memory. I remember her name; it is permanently inscribed in a part of my heart.  I remember her mother and the shock of her family’s grief; that shared experience has for eternity become a piece of my own soul as well.

We must also never disregard the impact of this aspect of our practice on our own well-being. The impact on the emotional and even physical health of the entire health care team is one requiring particular consideration (9,10). An opportunity for the health care team to debrief is especially helpful, and I dare say even necessary. This often can be a brief few moments in the resuscitation bay once death has been declared. Resident physicians in particular are at times encountering these scenarios for the first time in their professional role. Careful mentorship by experienced attending physicians is essential. The attending physician also would do well to remain cognizant of the impact such events have on his or her own soul and not neglect to address the permanent changes in one’s own heart and mind that occur as a result of the necessary sharing in the grief of our patients and their families. Should we disregard our own humanity, then the price insidiously paid over time may be very great indeed. Kim, et. al noted the correlation between bearing bad news and physician anxiety, emotional exhaustion, and burnout. (9)

The emergency physician has, as part of expected practice, the duty of bearing bad news to patients and families in a way that is compassionate, thoughtfu,l and reflective of a respect and even I dare say a love for humanity, including one’s own.  We must ever recall the wise words of Hippocrates:

“Wherever the art of medicine is loved, there is also a love of humanity.”

References / Further Reading

(1) National Hospital Ambulatory Medical Care Survey: 2013. Emergency Department Summary Tables. Centers for Disease Control.

Click to access 2013_ed_web_tables.pdf

(2) Kochanek, K, Murphy S, Xu J, Arias E. Mortality in the United States, 2013. NCHS Data Brief No. 178 December 2014. Centers for Disease Control https://www.cdc.gov/nchs/data/databriefs/db178.pdf

(3) Nardi T, Keefe-Cooperman K. Communicating Bad News: A Model for Emergency Mental Health Helpers. International Journal of Emergency Mental Health. 2006; 8(3): 203-7.

(4) Baile WF, Buckman R, Lenzi R, et al: SPIKES–A six-step protocol for delivering bad news: application to the patient with cancer, Oncologist 5:302-311, 2000.

(5) Lowry F. Think GRIEV_ING When Giving Bad News to Loved Ones. ACEP News. April 2007.

(6) Buckman R. How to break bad news. A guide for health care professionals. Baltimore: JHU Press; 1992.

(7) Swayden KJ, Anderson KK, Connelly LM, Moran JS, McMahon JK and Arnold PM. Effect of sitting vs. standing on perception of provider time at bedside: A pilot study. Patient Education and Counseling, 1Feb 2012; 86 (2):166-17.

(8) Johnson RL, Sadosty AT, Weaver AL, Goyal DG. To Sit or Not to Sit? Annals of Emergency Medicine, 01 Feb 2008; 51 (2):188-193.

(9) Gordon GH (2017). Breaking Bad News. The Medical Interview. Elsevier. Chapter 27, 216-225.

(10) Kim L, et.al. Simulating Reflective Practice Using Collaborative Reflective Training in Breaking Bad News Simulations. Families, Systems and Health. 2016; 34(2): 83-91.