This is something I wrote last year, but I think its relevant to what was presented in conference today. I wasn’t able to attend, but here’s my thoughts on the subject.
I remember the first time I ever told a family that their loved one had died. It was my first year of residency. The patient arrived in cardiac arrest. Despite multiple rounds of ACLS we couldn’t get a pulse back. At the end, my attending asked me if I wanted to talk to the family. I confidently said “sure” and nervously walked back to the family room where pastoral care had taken them family.
As I walked in, I was surprised to find about 20 people all squeezed into the tiny room. I remembered how I was “told” to tell the family. I started with the condition of their family member when they arrived (full arrest) then explained that despite our best efforts, we could not get him back. “He died.”
At that moment the entire room burst into tears, started yelling, jumping, falling…….I was pretty shocked! It was at that point that my rule of no more than 2 or 3 family members when I talk to family was made.
Death telling is difficult no matter how many times you’ve done it. I was not prepared well by my medical school or my residency. I had heard that is was important not to say that their family member had died until the end because if you do, they will not hear anything you say after. Other than that, I had no guidance. My attending didn’t offer to go in with me or ask me if I had done it before. With this entry I hope to give you some guidance.
Perhaps the best article I’ve discovered on this topic was published in The Oncologist in 2005. It is entitled SPIKES–A six step protocol for delivering bad news. Application to the patient with cancer. This article is worth reading, and I will link to the paper at the bottom of this post. The steps are as follows:
SETTING UP the interview
Assessing the patient’s PERCEPTION
Obtaining the patient’s INVITATION
Giving KNOWLEDGE and information
Assessing the patients EMOTIONS with EMPATHETIC responses
STRATEGY and SUMMARY
The above is applicable to death telling or giving bad news in the ED with perhaps the exception of obtaining invitation. It is clear that with my encounter above I failed at setting up the interview. Given the near riot that ensued, I would say I failed also at assessing emotions and summary.
So how do I do it now? I really do use the SPIKES protocol. One of the most important things is the setup…..quiet room….only close family, pastoral care/social work back up. I always start with asking them what they know about their family members condition. Then i segue into what has happened since they last saw their family member. I end with the pts current condition avoiding phrases like “passed away” and “no longer with us.” At that point I will answer questions and usually have the social worker or pastoral care transition into the conversation.
Is my way the right way to do it? I’m not completely sure. It has worked for me . How do others do it?