How to deliver horrible news

I've gotten a lot of compliments on how I deliver horrible news. I've had to give the talk so many times now that it's more or less routine to me. It's a skill I learned in med school, but I've since honed in residency. I thought I might at least share my technique. Like all things though, it takes practice. One thing to remember is that it's always better to set the stage. You can actually use this very technique to deliver bad news over the course of a few days, which can help soften the blow a little.

(1) Set the time and place. Get everyone together. At a minimum, you should have the patient's next of kin, if not the patient himself. All available family should be there. It's also good to have the nurse, the social worker, a palliative care nurse, any relevant consultants, and of course the treating physician (that's you). Make sure everyone is comfortable and can hear you.

(2) Appoint someone to run the meeting. It doesn't have to be the doctor. In fact, it's better if someone else runs the meeting. Usually, the nurse is the best candidate. That way, the family can easily separate curative and palliative options. But hey, I've run tons of these meetings, so it's just a matter of someone doing it.

(3) Be prepared. Have the chart, review it beforehand, make sure the care team members are all aware of the agenda for the meeting (such as trying to get the family to consider DNR or Hospice, etc). Make sure you know or meet all the principal players.

(4) ALWAYS start by designating a family spokesperson.

(5) Have the family tell you what they already know. This way, you can get the family involved in the talk, and you can figure out exactly where they are in terms of dealing with their loved one's illness. If they already know everything, then why waste everyone's time and skip to the end.

(6) Now, starting from the BEGINNING, fill in any holes the family may have. Avoid all jargon. Your speech should be at a 5th grade level. Stop frequently to make sure that everyone is still following you. If you can't answer something, refer to the chart.

(7) Tell them what you are doing RIGHT NOW, and what effect that is having.

(8) Tell the family what other curative options are available, and the chance that those interventions would affect survival. Also note if there would be associated complications or effects to the patient's quality of living.

(9) Tell the family IN NO UNCERTAIN TERMS that your medical opinion is that the patient is dying.

(10) Give the family time to grieve. Offer tissues. Don't say anything for 5 minutes unless directly asked a question. Don't answer rhetorical questions.

(11) Now it is time to discuss code status. The family meeting cannot end until the family has at least thought about code status. I discuss code status by explaining what a code is, and then noting that in the ICU (as most talks are on ICU patients), we are already doing extremely aggressive measures, and that if the patient coded, there's little to no hope he's live through it, but it would be a very traumatic experience to the patient and to the family to witness.

(12) Now, let palliative care services discuss what they can offer to the patient, regardless of whether there was a change in code status. There's always a place for palliative care. Leave the room at this time if the family has no more questions for you. It's important to let the palliative care people proceed without your interference. Make yourself available to family if they have more questions.

Of course, it's different to see it in practice. This is just a framework. Following the same format, I've given amazing talks and I've given horrible ones. It's a matter of finesse.

But one thing you should take home with you. After you tell the family that their loved one is dying, they won't remember anything else you have to say for at least 10 minutes. You've got to let them grieve a little and regain their composure. When you start discussing code status and withdrawal of care, keep it simple. In the family's mind, withdrawing care is withdrawing care. Think of it this way. When you take your car in for a tune up, the mechanic doesn't explain the whole tune up procedure to you.

What I usually say is something like, "Currently, [patient] is a full code. That means if his heart stops beating, we'll do CPR and shock him and give him special emergency meds. But right now, we're already doing very aggressive things, and even using some of those emergency meds right now. I think if his heart stops, the shocks and the CPR won't help. The best we could hope for is to prolong the inevitable. I think the best idea is that if his heart stops, we let him go and make him comfortable."

Then, it depends on whether you think withdrawal of care is appropriate. If I think withdrawal of care is appropriate, then I'd say, "We are giving him very dangerous meds, things we can only give in the ICU, and instead of getting better, he's only gotten worse. And at this point, I don't see that these things are helping him at all. I think we should get rid of these meds and instead try to make him as comfortable as we can, and let him die peacefully." Let palliative care talk about the details.

Now, I'm sure some out there will find faults with my method, but honestly, it gets me results. And as long as it works, and families are happy with me, and patients die peacefully (when we can't save them...), then I'm going to keep doing it my way, thanks. And you may disagree with how I do things, but I've had families hug me and thank me, and it always blows my mind, that they would hug the person they will forever point to as the doctor that couldn't save their loved one.

2 comments:

DrMidlife said...

How do you designate a family spokesperson? Does it work? I can't picture the "who wants to talk for the family?" question actually being successful, and I can't picture the individuals actually respecting the designated speaker.

incidental findings said...

Often, I say, "We'll be communicating frequently, and in order to avoid confusion, we like to have one person that can be the spokesperson for the family. Can someone do that?" When someone volunteers, the follow up question is "And are you the person responsible for making decisions?"

It may sound awkward, but I've never had trouble.