Death Telling

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?

References

Baile, W, Buckman, R, Lenzi, R, et al.  SPIKES–A Six Step Protocol for Delivering Bad News:  Application To the Patient With Cancer.  The Oncologist 2005; 5:302-311.

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One thought on “Death Telling

  1. All great tips. I’ll throw in some additional pointers that are especially useful in unexpected deaths (young people and trauma patients are typical examples) because these are more likely to turn bad than when chronically ill old folks die.

    1. Keep yourself between the family and the door. I usually sit/kneel just inside the door. If you need to get out of a dangerous situation, you don’t want an angry family member in your way.

    2. Use the social worker/chaplain/nurse to get a sense of the situation before you go in. Is the family relatively calm? Do they seem to get along with each other? Are there a lot of them? If any of these things make you uneasy, refer to #3.

    3. Don’t be afraid to ask security to come with you. They don’t necessarily need to be in the room, but can be outside the door in case things turn violent (which they can…quickly). This is especially true in the case of violent deaths (shootings/stabbings/etc), or deaths with unusual circumstances (very young patients, possible drug involvement). A good tip here is that if there are detectives in the ED, take security with you.

    4. Always take someone with you that can stay with the family when you’re done. Not only will it help answer the family’s “logistical” questions (next steps, etc) but it will also give you a friend in the room if things go south. That way you’re not leaving the family hanging when you’re finished. And always end by saying that you’re available if they have additional questions. Again, it prevents them from feeling like you’re leaving them hanging.

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