As a cardiac electrophysiologist, I have had to discuss bad news with patients and families more times than I would like during my career. How a physician goes about this process can make an enormous impact in the lives of those affected by the news that must be delivered. Precious little time is devoted to teaching this essential communication skill in the training of physicians today. I can remember back to the early days of my internship at the University of Virginia when I had my first patient death. I had been a “real doctor” for less than a week. I was caring for a gentleman in the CCU who had suffered an anterior MI and was in cardiogenic shock. He was on multiple pressors and his BP remained dangerously low. He had lots of tubes and lines and was supported by an intra-aortic balloon pump. When my supervising attending and cardiology fellow went home that evening (leaving me in charge) they informed me that we had “done everything we could” and they did not expect the patient to live through the night. Several hours later, the patient coded. VF arrest, multiple electrical shocks, tons of drugs and ridiculous doses of Epinephrine were all to no avail. The patient died. I had to go and tell the family that their husband and father was not coming home. Walking to the quiet family conference room, I tried to compose myself. Be factual, be clear, be compassionate–I repeated to myself over and over again. When I sat in front of the family, my eyes gave me away. The family began to sob. I told them of the heroic efforts that were used in an attempt to save a life. I told them that he had died. As I recounted the insurmountable medical problems and the multiple interventions and attempts at treatment, I became tearful. I cried with the family. I began to feel the pain that was so apparent and real to the folks who had known this man for a lifetime.
Later that year, I received a call from my Chief Resident. He had received a letter from the family of the patient who had died with cardiogenic shock. They had written to express their appreciation for our care. They commented on the fact that I had grieved with them and that I had helped them feel good about the care their loved one had received. Even though I was ill-prepared to deliver bad news of such magnitude so early in my career, I defaulted to providing care and compassion and I allowed my emotions to be seen and felt by the family. I was fortunate, sheer instinct (and Devine intervention) had allowed me to help the family through a difficult time. However, blind luck aside, I wish that I had been provided formal training in communicating bad news during my medical education. Most medical schools and post graduate residency programs still do not do an adequate job teaching emerging physicians this critical communication skill. However, some programs are finally beginning to emphasize this aspect of training and creating seminars as part of the curriculum. We must do more. We must prepare doctors to be effective communicators-even when the news is bad.
Much has been written about how to deliver bad news in the medical literature. Buckman et al from the University of Ontario is very well published in this area. In his book published in 1989, Dr Buckman advocates a 6 step plan (SPIKES). It involves the following process:
1. Setting-DO NOT give bad news over the phone. Deliver bad news in person in a quiet place and always have the family member bring others with them. When families are given bad news, they do not always “hear”. An extra set of ears may be important. Do not launch directly into the bad news. LISTEN and develop a rapport.
2. Perception-Get an idea of how much the family knows already so that when you discuss the pertinent facts, you are starting at the right place. You must understand that some families may have absolutely no idea that the loved one is truly very sick and this may come as a huge surprise. Conversely, others may have been preparing for the moment of bad news for months if not years.
3. Invitation- Levels of medical sophistication and education vary widely among patients and families. You must get an idea of where a particular family stands and how much detail the family may or may not want. The ability to assess this level of detail comes with experience.
4. Knowledge-As you begin discussions, give the family a warning of what is to come. Attempt to prepare them for the news with statements such as “I wish I had better news… or Things have not gone very well…” Take time revealing the news and provide the news in small bits. Repeat and review througout the discussion. Often, families may shut down and be unable to process the news if given too quickly. Give families a chance to cry. Take a break for tears.
5. Empathy-Let the family know you care. It is OK to cry with the family but make sure you have delivered the news clearly. In my opinion, this is the most important step to developing effective communication when delivering bad news.
6. Summary and Strategy-Take a moment to ensure the family understands what you have told them. Make sure they have a support system and a way to get back in touch with you for follow up questions and support.
How we deliver bad news is critical to how families deal with grief and process loss. As medical professionals we must accept death as a reality. Unfortunately, we must help families to deal with this acceptance as well. Successful communication and a structured process for delivering bad news must be mastered early in training. It is essential that training programs teach these skills. More importantly, physicians who are involved in training programs must model effective behaviors. Promote a team based communication strategy and always involve trainees in family meetings and end of life discussions. The “See one, do one, teach one principle” is important in learning effective communication skills just as it is in learning procedures.
Most of all, remember it is ok to cry. It is ok to feel pain and grieve with families experiencing loss. Even though death often cannot be forestalled, effective communication during these events can help families begin to heal.