Breaking Bad News
Question 1 from the first paper of 2004 asked the trainees to outline their principles for conveying bad news to family members. Since 2004, this topic seems to have become a viva station instead, as it is primarily an observable practical skill rather than a piece of purely theoretical knowledge. However, there is a purely theoretical component to it as well, and this is a well researched aspect of critical care psychology. Unfortunately, all of the literature on this topic is written by seasoned veteran givers of the news; people who are on the receiving end have not had the same opportunity to expand our understanding.
As far as resources go, one cannot go past the excellent Education Module for Critical Care Communication from the UCLA. Beyond that, the college answer to Question 1 quotes two articles : Ptacec et al (1996) and Fallowfield et al (2004). These resources have been recompiled to form the brief summary which follows.
Definition of "Bad News"
What exactly is "bad news", anyway? Ptacec et al (1996) quote from a 1993 paper by Bor et al, where councelling of HIV patients is discussed (in the bad old days, when HIV meant AIDS and death). They defined bad news as "situations where there is either a feeling of no hope, a threat to a person's mental or physical well-being, a risk of upsetting an established lifestyle, or where a message is given which conveys to an individual fewer choices in his or her life". Most of the time in medical literature "bad news" refers to conveying to a patient or their familty the diagnosis of some sort of objectively horrible condition, typically cancer. In the critical care environment, the patient is frequently a passive unconscious bystander to the events, and the brunt of the emotional stress is born by the family.
Practical guidelines for delivering bad news
Breaking bad news is an individalised and complex process which takes many different shapes and is dramatically different between different cultures, including both the culture of the clinican and the family. Given the amount of interpersonal difference, it would be difficult to standardise some sort of guidelines which would suit all situations.In spite of this, common sense dictates that there must be good ways and bad ways of delivering bad news.
Location and setting
You need to select a location where both you and the family can be comfortable. At the minimum, the family should be able to sit down (i.e. this should not be a conversation in the hospital corridor). There should ideally be enough space to accompdate everybody (and potentialy this could be a large number of people). The location should be private, well away from the clinical area. It should be quiet to allow for important words to sink in without interruptions by monitor alarms and yelling staff members. The person delivering all the bad news should be well protected from interruptions: one needs to give away one's telephone and pager.
The timing of the delivery needs to be right, both for the family and for the physician. The person who is delivering the news should dictate when the time is right. If the deliverer feels stressed, anxious, irritated or time-pressured - the conference will go poorly; nonverbal cues will be received and interpreted negatively by the family. One should make every attempt to not send any non-verbal cues which might undermine the main message. The family need to get the impression that what is being said is important and serious, and that an important and serious person is talking to them.
Preparation is important, particularly when problems are expected, ro when there is input from multiple medical teams. The major playes should organise to meet before the family conference in order to get their stories straight. The most effective family conferences are those where all team members stay "on message". The last thing one needs is a difference of medical opinion which is expressed for the first time in the conference, in front of the family.
The person doing the talking should ideally be somebody who has already met the family, and who has some rapport with them. The medical staff - wherever possible - should not outnumber the family members. The ICU should be represented by at least the medical team members, and also ideally the nursing staff (bedside nurse or nursing team leader). The social worker should be available for this discussion. Ideally, non-ICU medical team members should be available (for example, the surgical or medical team who were looking after the patient outside of the ICU).
Of the family, care must be taken to ensure that the person most affected by the bad news (spouse, child, etc) is surrounded by a pre-identified support structure. This may consist of other family members, friends, church members, or in desperate times the social worker and nobody else. The presence of other people also gives an abundance of extra ears and brains as storage and recording emdiafor the information. The more people hear your message, the more likely it is to be understood correctly. Support people who are less affected by gried owing to the distance of their relationship from he patient will retain their ability to ask incisive questions, and hearing the answers may be to everybody's benefit.
The senior clinican who will do the talking should identify themselves and introduce the other staff members who are present. Wherever possible, the patient and their family members need to be referred to by their actual names.
The main objective is to deliver the serious news clearly and unambiguously without exacerbating the associated discomfort. Most authors agree that one needs to fire a "warning shot", i.e. a statement to warn the family that bad news are coming ("I am afraid I have some bad news for you, Mrs Brown"). The pace of delivery needs to be appropriate, and that can be assessed from the responses of the family (i.e. assess whether they are ready to recieve the next piece of information). This may mean waiting until the family ask leading questions. The deliverer needs to be comfortable with silence, allowing periods to pass for the family to process the last piece of information. The deliverer needs to be prepared to repeat themselves, as much of what is said may go unheard by the grieving family members. It is generally expected that much of what is said after the "crux" is delivered will be either unheard or poorly understood.
The news need to be conveyed "in a way that conveys respect and empathy". In fact, to cynically manipulate the college examiners, the savvy candiate will use words like "warmth", "caring" "empathy" and "respect" in their SAQ answer.
Sitting close to family members makes it easier to detect nonverbal cues from them. Eye contact is important: it is interpreted as sincerity. It is important to eliminate physical barriers; do not conduct the conversation from behind a desk or from across the room. Facing the person whom you are talking to is very important.
Non-verbal message must be consistent with the verbal message. Do not keep your arms crossed or folded; do not put your hands in your pockets. Ensure an open posture, leaning towards the person you are speaking to.
Do you want to touch them? Do they want you to touch them? Use of touch may be appropriate in some circumstances. It will not always be appropriate. Not everybody is going to like you enough to respond positively to your hug or hand-hold - some people will be offended (i.e. "who the hell do you think you are?", etc). It is important to read the situation carefully. If you are like the author and have a touch of Aspergers, you can confidently assume that your reading of the situation is always going to be wrong, and abjure the use of touch altogether.
Importance of content: the medical details
This, we are suprisingly bad at. According to some studies, up to 50% of family members claim they have no idea about the diagnosis or progress of their loved ones after 48 hours of ICU stay. Anxiety and depression are magnified when they are kept in the dark and left out of the decisionmaking.
It does not need to be said, but truthful information must be conveyed.The details must be correct. The language should be clear, simple and unabiguous. One should not use complex metaphors and euphemisms. Avoid jargon and only use specific medical terminology if it is appropriate to the family's level of medical knowledge or if clarification of simpler terminology is specifically asked for. One needs to be careful not to take away all hope; at the very least the family need to be reassured that comfort and dignity remain medical priorities in the management of their loved ones.
Follow-up discussions need to be organised. The social worter will frequently remain in the room following the discussion, in order to "mop up" any questions which the family may have thought of after the medical staff had left, and to offer counselling or psychological support. Spiritual support should be offered, if the family have specific religious needs or if there the expectation that the patient would have wanted such involvement. If a quiet private space has been designated for the discussion, that space should be made available to the family for some time forllowing the discussion, with the expectation that they will wish to spend some time in there, discussing the issues among themselves and coming to terms with the information they have just received.
Documentation of the end of life discussion needs to be completed shortly after the discussion had taken oplace so that it is clear in the mind of the person doing the writing. The people who were present need to be idenfied in the medical record; the content of the discussion and the decisions which were reached need to be documented carefully. The opinions voiced regarding these decisions must be recorded (i.e. that the family agreed with the end of life plan, or that they had objections, and specifically what those objections were).
Welfare of the deliverer
Delivery of bad news is a stressful situation for medical staff, and this stress needs to be acknowledged. Fortunately, this stress seems to dissopate quite quickly. Unless the family conference was a complete disaster, the deliverer of bad news will lilely carry little baggage into the next scenario. For the disasters, post-conversation debriefing is valuable to maintain the energy of the deliverer and to allow them space for self-reflection. Feedback is important. Social workers, nursing staff and senior medical mentors should be used as sources of feedback for the trainees.