Bad news has been defined as “any information which adversely and seriously affects an individual’s view of his or her future” (Baille et al, 2000)
- Effective communication doesn’t happen by chance, it requires a systematic, considered approach
- Breaking bad news to relatives effectively can help minimise the distress of relatives and maintain therapeutic relationships
- The approach described here uses the PLIIE mnemonic;
- who needs to be there? (family and support for them, other disciplines)
- plan the meeting: people and correct names, content of message, know details well, what do I want to get across and how
- talk to other staff members prior
- seek advice if required
- trainees: need to be taught
- appropriate layout
- no disturbances (phones, pagers)
- set aside sufficient time
- support people (if required)
- my name and role
- other staff members
- ask family to introduce self (so names can be used)
- use appropriate language and body language
- start out by finding out what the family already knows
- warn about bad news before the bad news is broken
- use understandable language (clear and simple)
- deliver information in small bites
- no jargon
- tailor information
- give as much information as required by family
- monitor pace of information
- allow time for reflection
- silence is good
- allow time for discussion
- convey respect and empathy
- check understanding
- elicit concerns
- open disclosure
- answer all questions
- offer support
- arrange a follow up meeting
- document meeting in clinical notes
BREAKING BAD NEWS ON THE TELEPHONE
The first rule of breaking bad news is: do not do it over the phone. However, in some situations – such as family being overseas – it is unavoidable.
Here is an approach:
- Rehearse before making the call (e.g. with a social worker, or someone else skilled in difficult conversations)
- Although this needs to be done in a timely fashion, delay the phone call until you are psychologically prepared if at all possible
- Check the identity of the patient and the identity of the NOK, including contacts details
- Introduce yourself clearly (Name, Role, Hospital)
- Check that you are speaking to the right person and they are an adult
- Be direct and compassionate, use the “D-word” – for example, say “I’m sorry that I have to tell you the worst possible news. Your son, Mike, died in a car crash tonight.”
- Check if they have support… if they don’t, offer to call someone for them)
- Provide follow up (e.g. social worker contact number)
TIPS AND TRICKS
Hot tip (courtesy of Vera Sistenich):
- The person involved in an emotionally draining resuscitation doesn’t have to be the person who breaks bad news to the family.
- A senior colleague who was not emotionally involved in the case may be better placed to have the discussion.
Debrief after a family meeting with the other staff present (e.g. nurse, social worker) and seek feedback on ways to improve.
References and Links
- Baile WF, Buckman R, Lenzi R, et al. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5:(4)302-11. [pubmed] (free full text)
- Iverson KV. Notifying survivors about sudden, unexpected deaths. West J Med. 2000;173:261-5. [pubmed]
- Marrow J. Telling relatives that a family member has died suddenly. Postgrad Med J. 1996;72:(849)413-8. [pubmed] (free full text)
- McEwan A, Silverberg JZ. Palliative Care in the Emergency Department. Emergency medicine clinics of North America. 34(3):667-85. 2016. [pubmed]
- VandeKieft GK. Breaking bad news. Am Fam Physician. 2001;64:(12)1975-8. [pubmed]
FOAM and web resources
- 99% Invisible — Breaking Bad News (2018)
- ED Central — I’m Sorry… we did everything we could. Breaking bad news in the ED (2013)
- INTENSIVE — Breaking Bad (News) by David Anderson (2015)
- Justin Morgenstern, “Breaking bad news: Notifying family members of a death in the emergency department“, First10EM blog, July 6, 2015.
- Vital Talk (excellent website for developing communication skills about serious illness)
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.