Outline your principles for conveying bad news to family members.

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College Answer

There are many published studies (including multiple reviews) addressing this area. Most information relates to non-critical care areas, and the majority are written from a medical perspective,  and  relate  to  conveying new  to  a  conscious  patient.  Few  studies  address  actual outcomes of the process. The welfare of the deliverer of the news should also be considered (eg. preparedness, training). The general principles espoused include: the importance of knowledge (content) of the medical details; delivery in a comfortable location offering privacy and relative quiet; setting aside sufficient time; identifying support network for the family members and having them present; delivery by or with a staff member who knows the family; sitting close to family members without physical barriers in between; non-verbal messages consistent with the verbal message; consider warning of bad news before news actually broken; awareness of what family know/have been told; present information in a way that conveys respect and empathy, use of touch may be appropriate in some circumstances; deliver at a pace appropriate to the family, allowing time for discussion; use clear & simple language to avoid confusion, though specific medical terminology may be referred to; convey some hope, even if in terms of minimising discomfort; provide  for  follow  up  meetings;  document  information regarding meeting in  medical  record. (Ptacek JT. Breaking bad news. JAMA 1996 26(6):496-502; Fallowfield L. Communicating sad, bad, and difficult news in medicine. Lancet 2004 363:312-9)

Discussion

As far as resources go, one cannot go past the excellent Education Module for Critical Care Communication from the UCLA. The college answer also quotes two articles : Ptacec et al (1996) and Fallowfield et al (2004). These resources have been recompiled to form the answer offered below:

Basic premise

  • 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.
  • In the absence of a firm definition (what exactly is "bad news", anyway?) or empirical standarads, we rely on psychological literature on stress and coping to inform our approach to breaking bad news. 

Location and setting

  • Comfortable - at the minimum, the family should be able to sit down (i.e. this should not be a conversation in the hospital corridor).
  • Private, away from the clinical area. 
  • Quiet- allowing for important words to sink in without interruptions by monitor alarms and yelling staff members.
  • Insulated from interruptions: one needs to ensure that this time is "protected" by giving away one's telephone and pager.

Personnel present

  • 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 eb available (for example, the surgical or medical team who were looking after the patient outside of the ICU).

Essentials of the verbal communication

  • The senior clinican who will do the talking should identify themselves and introduce the other staff members who are present.
  • One may wish to warn the family that bad news are coming before actually delivering the bad news.
  • 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 answer.
  • The pace of delivery needs to be appropriate, and that can be assessed from the responses of the family (i.e. assess whether hey are ready to recieve the next piece of information)
  • 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.
  • Wherever possible, the patient and their family members need to be referred to by their actual names. 

Non-verbal communication

  • Sitting close to family members
  • Eye contact is important
  • 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.
  • 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.
  • Use of touch may be appropriate in some circumstances.

Importance of content: the medical details

  • Needless to say, 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

  • 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

  • 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 needs to be documented carefully
  • The decisions which were reached need to be documented carefully, as well as the opinions voiced regarding these decisions (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

  • Training in delivering bad news is important. 
  • Delivery of bad news is a stressful situation for medical staff, and this stress needs to be acknowledged. 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.

References

References

Arnold et al; "Educational Modules for the Critical Care Communication (C3) Course - A Communication Skills Training Program for Intensive Care Fellows"

Ptacek, J. T., and Tara L. Eberhardt. "Breaking bad news: a review of the literature." Jama 276.6 (1996): 496-502.

Fallowfield, Lesley, and Valerie Jenkins. "Communicating sad, bad, and difficult news in medicine." The Lancet 363.9405 (2004): 312-319.