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Giving Bad News
Giving Bad NewsGiving Bad NewsGregory J. Jurkovich, MDGregory J. Jurkovich, MD
Chief of Surgery, Denver Health Medical CenterChief of Surgery, Denver Health Medical CenterRockwell Distinguished Professor of Trauma SurgeryRockwell Distinguished Professor of Trauma SurgeryUniversity of Colorado School of MedicineUniversity of Colorado School of MedicineDenver, ColoradoDenver, Colorado
Giving Bad News
Giving Bad NewsGiving Bad News Giving such news can be difficult Previous work largely focused on
oncology and pediatric patients Little surgical literature
Oliver & Fallat: Grieving parents Rappaport & Witzke: Student education Vetto et al: Early clinical clerkship
Giving Bad News
LiteratureLiterature
Talking about Death with Children Who Talking about Death with Children Who Have Severe Malignant DiseaseHave Severe Malignant Disease
Ulrika Kreicbergs, R.N., Unnur Valdimarsdottir, Ulrika Kreicbergs, R.N., Unnur Valdimarsdottir, Ph.D., Erik Onelov, M.Sc., Jan-Inge Henter, M.D., Ph.D., Erik Onelov, M.Sc., Jan-Inge Henter, M.D.,
Ph.D., and Gunnar Steineck, M.D., Ph.D.Ph.D., and Gunnar Steineck, M.D., Ph.D.
NEJM, Sept. 16 , 2004 Vol.351 no.12NEJM, Sept. 16 , 2004 Vol.351 no.12
Giving Bad News
Specialized ObituariesSpecialized Obituaries
Giving Bad News
Death from injury Death from injury usually unexpectedusually unexpected
Giving Bad News
Literature reviewLiterature review Ptacek & Eberhardt, JAMA, 1996Ptacek & Eberhardt, JAMA, 1996
67 (181) pertinent articles since 198567 (181) pertinent articles since 1985 Nearly all articles written from physician Nearly all articles written from physician
perspective (2 exceptions)perspective (2 exceptions) Lack of empirical validation major limitation Lack of empirical validation major limitation
and needand need Does how the news is delivered make a Does how the news is delivered make a
difference?difference?
Giving Bad News
Oncologist concern: sit or stand?Oncologist concern: sit or stand?
“ Cancer patients (especially females) prefer physicians to sit when breaking bad news . . . . . However, sitting posture alone is unlikely to compensate for poor communication skills . . .”
Giving Bad News
BackgroundBackground Quality improvement process: to Quality improvement process: to
investigate our performance in the investigate our performance in the giving of the bad news of deathgiving of the bad news of death
To determine the most important or To determine the most important or significant features of the delivery of significant features of the delivery of bad news bad news from the perspective of from the perspective of surviving family memberssurviving family members
Giving Bad News
MethodsMethods Designed a survey toolDesigned a survey tool Administered tool to surviving family Administered tool to surviving family
members of patients who had diedmembers of patients who had died ED or Trauma ICU deaths onlyED or Trauma ICU deaths only Mail or phone response Mail or phone response Experienced ICU nurses administered phone Experienced ICU nurses administered phone
surveysurvey Becky Pierce, RN, Laura Pananen, RN, Becky Pierce, RN, Laura Pananen, RN,
Frederick P. Rivara, MD, MPHFrederick P. Rivara, MD, MPH
Giving Bad News
Survey toolSurvey tool What elements are important in the What elements are important in the
delivery of bad news?delivery of bad news? We gave them 14 options to chose fromWe gave them 14 options to chose from 1 = least important; 6 = most important1 = least important; 6 = most important Collapsed into three categoriesCollapsed into three categories
How well did the How well did the ““bad new giverbad new giver”” attend attend to these elements? to these elements? Good, adequate, or poorGood, adequate, or poor
Giving Bad News
Survey tool elementsSurvey tool elements AttireAttire KnowledgeKnowledge AttitudeAttitude LocationLocation AutopsyAutopsy Privacy Privacy ClarityClarity SenioritySeniority Clergy available Clergy available SympathySympathy DirectionsDirections Time for Time for
questionsquestions Follow-up contactFollow-up contact TimingTiming
Giving Bad News
Survey tool, msc. itemsSurvey tool, msc. items Perceived identity of news giverPerceived identity of news giver Relation of respondent to deceasedRelation of respondent to deceased Clinical detail desiredClinical detail desired Desirability of touching Desirability of touching Demographics, length of stay, injuryDemographics, length of stay, injury Clinical care service providersClinical care service providers CommentsComments
Giving Bad News
2000, Vol 48 (5), p867-872 59th AAST Annual Meeting, Boston, MA 1999
Giving Bad News
ResultsResults Conducted over 18 months; 119 deathsConducted over 18 months; 119 deaths Families contact 2 m - 6 m after deathFamilies contact 2 m - 6 m after death Poor mail response (25%) n=20Poor mail response (25%) n=20 Excellent phone response (87%) n=34Excellent phone response (87%) n=34 54 family members54 family members 48 deceased patients48 deceased patients
Giving Bad News
Results : Deceased patientsResults : Deceased patients
Mean age: 53 years (SD 24)Mean age: 53 years (SD 24) Age range: 12 - 91 yearsAge range: 12 - 91 years
2 < 18 yrs; 10 > 75 yrs; 2 > 85 yrs2 < 18 yrs; 10 > 75 yrs; 2 > 85 yrs 67% male; 33% female67% male; 33% female TICU deaths: 44 (49 surveys)TICU deaths: 44 (49 surveys) ED deaths: 4 (5 surveys)ED deaths: 4 (5 surveys)
Giving Bad News
Results: Cause of deathResults: Cause of death
Giving Bad News
Results: Cause of DeathResults: Cause of Death
Blunt traumaBlunt trauma 3636 75%75%
Penetrating traumaPenetrating trauma 22 4%4% Gen-Vasc. CatastropheGen-Vasc. Catastrophe 55 11%11% Subarch. BleedSubarch. Bleed 33 6%6% CardiacCardiac 22 4%4%
Giving Bad News
Results: Primary Care ServiceResults: Primary Care Service
Giving Bad News
Results: Primary Care ServiceResults: Primary Care Service
%Deaths%Deaths%Survey%Survey
GS /TraumaGS /Trauma 58%58% 56%56% NeurosurgeryNeurosurgery 29%29% 31%31% Emerg.Dept.Emerg.Dept. 8%8% 9%9% CardiologyCardiology 4%4% 4%4%
Giving Bad News
Results: Length of StayResults: Length of Stay
49% within 24 hours49% within 24 hours 69% within 2 days69% within 2 days 83% within 7 days83% within 7 days Longest stay: 5 weeksLongest stay: 5 weeks Length of stay did not correlate with Length of stay did not correlate with
results of surveyresults of survey
Giving Bad News
Results: When informedResults: When informed
Before deathBefore death 2424 44%44% While patient agonalWhile patient agonal 1414 26%26% After deathAfter death 1313 24%24% ““NeverNever”” 33 6%6%
Giving Bad News
Results: Who gave the news?Results: Who gave the news?
AttendingAttending 44 7%7% ResidentResident 99 17%17% ““DoctorDoctor”” 3131 57%57% NurseNurse 55 9%9% Family/FriendFamily/Friend 33 6%6% CanCan’’t recallt recall 22 4%4%
Giving Bad News
Results: Where was the news givenResults: Where was the news given
Conference roomConference room 1414 26%26% Waiting roomWaiting room 1010 19%19% PhonePhone 88 15%15% HallwayHallway 88 15%15% PatientPatient’’s rooms room 77 13%13% ICU/HospitalICU/Hospital 44 7%7% Other/no responseOther/no response 33 5%5%
Giving Bad News
Qualities ValuedQualities Valued
We asked the question:We asked the question:
What qualities of the giving of bad What qualities of the giving of bad news do you most value?news do you most value?
Giving Bad News
Survey tool elementsSurvey tool elements AttireAttire KnowledgeKnowledge AttitudeAttitude LocationLocation AutopsyAutopsy Privacy Privacy ClarityClarity SenioritySeniority Clergy available Clergy available SympathySympathy DirectionsDirections Time for Time for
questionsquestions Follow-up contactFollow-up contact TimingTiming
Giving Bad News
Results: Qualities valuedResults: Qualities valued
HighHigh MediumMediumLowLow AttitudeAttitude 72%72%19%19% 2%2% ClarityClarity 70%70%9%9% 4%4% PrivacyPrivacy 65%65%11%11% 7%7% KnowledgeKnowledge 57%57%13%13% 7%7%
Giving Bad News
Results: Qualities valuedResults: Qualities valued HighHigh MediumMedium LowLow SympathySympathy 48%48% 24%24% 7%7% Time for ?Time for ? 48%48% 15%15% 15%15% Autopsy infoAutopsy info 47%47% 15%15% 12%12% ClergyClergy 39%39% 13%13% 9%9%
39% did not even rank availability of clergy as an 39% did not even rank availability of clergy as an important element of giving bad newsimportant element of giving bad news
Giving Bad News
Results: Qualities valuedResults: Qualities valued HighHigh MediumMedium LowLow Rank/SeniorityRank/Seniority 24%24% 22%22% 19%19% Follow-upFollow-up 20%20% 26%26% 13%13% AttireAttire 4%4% 15%15% 44%44%
35%-41% of respondents did not even rank these 3 35%-41% of respondents did not even rank these 3 elements in importance in the giving of bad newselements in importance in the giving of bad news
Giving Bad News
Results: Clinical detailResults: Clinical detail Amount of clinical details desiredAmount of clinical details desired
In-depth detailIn-depth detail 1616 30%30% Progress from generalProgress from general information to detailed information to detailed
1111 20%20% General terms onlyGeneral terms only 77 13%13% No commentNo comment 2020 37%37%
Giving Bad News
Results: Physical contactResults: Physical contact
Touching during news deliveryTouching during news delivery Do not touchDo not touch 1616 30%30% Touch desiredTouch desired 99 17%17% Hand-shake onlyHand-shake only 44 7%7% No commentNo comment 2525 46%46%
Giving Bad News
Attention GivenAttention Given
We asked the question:We asked the question:
How much attention was give to this How much attention was give to this particular issue by the bad news particular issue by the bad news
giver?giver?
Giving Bad News
Results: Good Attention GivenResults: Good Attention Given
%Respondent%Respondent Appropriate attitudeAppropriate attitude 44%44% Clarity of messageClarity of message 52%52% PrivacyPrivacy 17%17% Answer questionsAnswer questions 48%48%
Giving Bad News
Results: Poor Attention GivenResults: Poor Attention Given
% Respondents% Respondents Likelihood of autopsyLikelihood of autopsy 26%26% Clergy availableClergy available 20%20% Timing of conversationTiming of conversation 17%17% LocationLocation 17%17%
Giving Bad News
Results: Attention GivenResults: Attention Given Nearly every respondent commented on Nearly every respondent commented on
these four elementsthese four elements Empathy of the news giverEmpathy of the news giver Clarity of the messageClarity of the message Attitude of the news giverAttitude of the news giver Ability to answer questionsAbility to answer questions
Giving Bad News
Results: “poor attitude”Results: “poor attitude” 6 news givers judged 6 news givers judged ““poor attitudepoor attitude””
6 lacked sympathy (empathy)6 lacked sympathy (empathy) 5 unable to effectively answer 5 unable to effectively answer
questionsquestions 4 lacked clarity of messages4 lacked clarity of messages 5 on one clinical service5 on one clinical service
Giving Bad News
Results: “poor attention given to”key areasResults: “poor attention given to”key areas
96 total 96 total ““Poor Attention GivenPoor Attention Given”” ratingsratings
Neurosurgery: 55%Neurosurgery: 55%General-Trauma: 32%General-Trauma: 32%ED: 13%ED: 13%
Giving Bad News
Results: CommentsResults: Comments
87% had a positive comment87% had a positive comment 51% were about nurses or hospital staff51% were about nurses or hospital staff 19% remarked on skilled and professional care19% remarked on skilled and professional care 11% specified physicians11% specified physicians 11% detailed specific kindness, single act11% detailed specific kindness, single act
74% had a negative comment74% had a negative comment 12% about physicians12% about physicians 12% parking and housing12% parking and housing
Giving Bad News
CommentsComments
““Be kind, direct and to the point. Be kind, direct and to the point. Look them directly in the eye Look them directly in the eye
and briefly share the pain.and briefly share the pain.””
Giving Bad News
CommentsComments
““The ER doctor realized my mother The ER doctor realized my mother was alone. He arranged for a was alone. He arranged for a
neighbor and I to come be with her neighbor and I to come be with her before telling her. I appreciate that before telling her. I appreciate that
more than you know.more than you know.””
Giving Bad News
CommentsComments
““The doctor who spoke with us The doctor who spoke with us asked us what kind of man dad asked us what kind of man dad was. It gave us a chance to talk was. It gave us a chance to talk
about him. It was a very positive about him. It was a very positive memory.memory.””
Giving Bad News
CommentsComments
““Be very clear but not too graphic. Be very clear but not too graphic. The doctor said he couldnThe doctor said he couldn’’t save t save
my sonmy son’’s legs. My husband s legs. My husband thought, and still does, that you thought, and still does, that you
had to cut his legs off.had to cut his legs off.””
Giving Bad News
CommentsComments
““When we arrived in the When we arrived in the Emergency Room, we were told Emergency Room, we were told our son was our son was ““D.O.E. It was very D.O.E. It was very scary until they explained he was scary until they explained he was
a John Doe.a John Doe.””
Giving Bad News
CommentsComments
““He told us in the hallway.He told us in the hallway.””
Giving Bad News
CommentsComments
““SheShe’’s going to die and yous going to die and you’’re just re just going to have to deal with it.going to have to deal with it.””
Giving Bad News
How you say it matters !How you say it matters !
SurgeonsSurgeons’’ tone of voice: A clue to malpractice history. tone of voice: A clue to malpractice history. Ambady et al, Surgery, 2002.Ambady et al, Surgery, 2002.
• Psychologists; AHCPR fundedPsychologists; AHCPR funded• Audiotaped 65 surgeons (ortho and GS) clinic visits Audiotaped 65 surgeons (ortho and GS) clinic visits
in Portland, Denver, Salemin Portland, Denver, Salem• 10 sec. clips, 2 patients each, begin and end of visit10 sec. clips, 2 patients each, begin and end of visit• 12 blinded raters, Harvard psychology undergrads12 blinded raters, Harvard psychology undergrads• Scale 1-7 these areas: warmth, anxiety/concern, Scale 1-7 these areas: warmth, anxiety/concern,
interested, hostile, sympathetic, professional, interested, hostile, sympathetic, professional, competent, dominant, satisfied, and genuine. competent, dominant, satisfied, and genuine.
Giving Bad News
How you say it matters !How you say it matters !SurgeonsSurgeons’’ tone of voice: A clue to malpractice history. tone of voice: A clue to malpractice history.
Ambady et al, Surgery, 2002.Ambady et al, Surgery, 2002.• Interjudge reliability: 0.54Interjudge reliability: 0.54• 4 key variables: 4 key variables:
• 1. Warm/professional 2. Concerned/anxious1. Warm/professional 2. Concerned/anxious• 3. Hostile 4. Dominant 3. Hostile 4. Dominant
• Surgeons with a tone of voice that was more Surgeons with a tone of voice that was more dominant and less concerned = surgeons more dominant and less concerned = surgeons more likely to have been sued. likely to have been sued.
• Dominance OR 2.74; Concern OR 0.46Dominance OR 2.74; Concern OR 0.46
Giving Bad News
Table 1Table 1
Table 1. Tasks of mourning.Table 1. Tasks of mourning.
Copyright © 2011 The Journal of Trauma. Published by Lippincott Williams & Wilkins. 49
Traumatic Childhood Death: How Well Do Parents Cope?Oliver, Ronald C.; Fallat, Mary E.Oliver, Ronald C.; Fallat, Mary E.The Journal of Trauma. 39(2):303-308, August 1995The Journal of Trauma. 39(2):303-308, August 1995. .
Giving Bad News
Table 2Table 2
Table 2. Indices of pathologic and normal Table 2. Indices of pathologic and normal outcomes of mourning.outcomes of mourning.
Copyright © 2011 The Journal of Trauma. Published by Lippincott Williams & Wilkins. 50
Giving Bad News
Beneficial Effects of a Hospital Beneficial Effects of a Hospital Bereavement Intervention Program Bereavement Intervention Program after Traumatic Childhood Deathafter Traumatic Childhood Death
Oliver, Ronald C. PhD; Sturtevant, Joel P. DMin; Oliver, Ronald C. PhD; Sturtevant, Joel P. DMin; Scheetz, James P. PhD, and; Fallat, Mary E. MDScheetz, James P. PhD, and; Fallat, Mary E. MD
J Trauma, 2001 Volume 50 (3) pp 440-448J Trauma, 2001 Volume 50 (3) pp 440-448
Giving Bad News
Beneficial Effects of Hospital Bereavment ProgramBeneficial Effects of Hospital Bereavment Program 59 of 77 families participated59 of 77 families participated 81 deaths (3501 admissions, children only)81 deaths (3501 admissions, children only) Family contact at hospital, home visit within Family contact at hospital, home visit within
1 month, educational meeting within 2 1 month, educational meeting within 2 months, follow – up surveymonths, follow – up survey
Key comments: Poor conceptualization of Key comments: Poor conceptualization of medical care, brain death, and delayed regret medical care, brain death, and delayed regret for missed organ donationfor missed organ donation
Giving Bad News
Table 4Table 4
Table 4. How Are Parents Doing?Table 4. How Are Parents Doing?
Copyright © 2011 The Journal of Trauma. Published by Lippincott Williams & Wilkins. 53
Giving Bad News
Table 2Table 2
Table 2. Supporters Survey after Educational Table 2. Supporters Survey after Educational Meeting (245 Individual Responses)Meeting (245 Individual Responses)
Copyright © 2011 The Journal of Trauma. Published by Lippincott Williams & Wilkins. 54
Giving Bad News
Table 1Table 1
Table 1. Parent Survey after Educational Table 1. Parent Survey after Educational Meeting (44 Individual Responses)Meeting (44 Individual Responses)
Copyright © 2011 The Journal of Trauma. Published by Lippincott Williams & Wilkins. 55
Giving Bad NewsTable 5Table 5
Parents view of lasting effectiveness of the Parents view of lasting effectiveness of the dinner meeting and the role of their dinner meeting and the role of their support network of family and friendssupport network of family and friends
Copyright © 2011 The Journal of Trauma. Published by Lippincott Williams & Wilkins. 56
Giving Bad News
Table 3Table 3
Table 3. Communicating with parents.Table 3. Communicating with parents.
Copyright © 2011 The Journal of Trauma. Published by Lippincott Williams & Wilkins. 57
• Clergy and Mother-in-laws help the most– for both moms and dads
• 8% divorce rate attributed to child death
Giving Bad News
SummarySummary The manner in which bad news is given The manner in which bad news is given
has a long-lasting impacthas a long-lasting impact Most comforting behaviorMost comforting behavior::
AttitudeAttitude: Caring and empathetic ClarityClarity of the message KnowledgeableKnowledgeable: well informed and
able to answer questions PrivacyPrivacy
Giving Bad News
CQI-PI RecommendationsCQI-PI Recommendations
Educate hospital staff Physicians Students and residents Allied health care
Develop a system for initial visit Create a “news team” model
Giving Bad News
Successful news teamSuccessful news team Physician
Well informed, able to answer questions Unrushed, focused, calm Empathetic behavior, gestures
Nurses Ensure privacy Communication liaison
Giving Bad News
Successful news teamSuccessful news team Nurse (cont.)
Arranges visits Provides means to get questions answered Coordinate family information to
bereavement counselors/clergy Social Services
After death procedures Obtain belongings Long term support information
Giving Bad News
Thank youThank you
Giving Bad News
Trauma ICU Staff SurveyTrauma ICU Staff Survey
Loss of control Need to feel connected to the family Unable to answer the family’s
questions Protect the family from the patient’s
appearance
Giving Bad News
One year later . . . Nurses report One year later . . . Nurses report Hard, but worth it Easier with experience Preparation important for both the care givers and
the family Define the parameters and expectations of the
initial, very brief, visit Special connection between family and liaison Less family conflict, more trust
Giving Bad News
Initial VisitInitial Visit Get the family in for a brief (sighting)
visit in the first 10 minutes One resuscitation team member
assigned to be the family liaison Key to family visitation Makes initial contact Prepares the family for subsequent visits
Giving Bad News
Liaison Liaison
Introduces family to the patient’s nurses and doctors
Supports the family during a visit Shepherds the family through a visit Helps keep the family informed
Giving Bad News
One year later . . . One year later . . . Physicians report
Few (2) initially resistant Key to success is liaison who understands
the physician’s perspective ICU is OK, ER is shaky, OR is out of the
question
Giving Bad News
Emergency Nurses AssociationEmergency Nurses Association ENA supports the option of family presence
during invasive procedures and/or resuscitation efforts.
ENA supports Research related to family presence Educational resources for ED personnel Collaboration with others ….to develop multidisciplinary
guidelines for family presence
Giving Bad News
Should Patients be in the Should Patients be in the Resuscitation Room ?Resuscitation Room ?Should Patients be in the Should Patients be in the Resuscitation Room ?Resuscitation Room ? ““Rights” of the patient v. Rights of the Rights” of the patient v. Rights of the
physicians v. Rights of the familyphysicians v. Rights of the family Whose rights are you infringing upon?
PerspectivePerspective Let the family members know the perspective of
the caregivers/physicians. If distracting, do they really want to be there?
Giving Bad News
ED Visitor Policy & ProcedureED Visitor Policy & ProcedureED Visitor Policy & ProcedureED Visitor Policy & Procedure
Objective: To protect patient privacy Objective: To protect patient privacy and enhance patient careand enhance patient care
Policy:Policy:All visitors must wait in the designated waiting All visitors must wait in the designated waiting areas until allowed in the treatment area, at areas until allowed in the treatment area, at the discretion of the zone/charge nurse.the discretion of the zone/charge nurse.
Giving Bad News
Should Patients be in the Resuscitation Room ?Should Patients be in the Resuscitation Room ? LiaisonLiaison
Bring the family in; stay with them, escort Bring the family in; stay with them, escort them out, answer questions; get stuff; tell them out, answer questions; get stuff; tell them what to dothem what to do
RulesRules How long, how often, how many, what they How long, how often, how many, what they
can and cancan and can’’t dot do
Giving Bad News
ED Visitor Policy & ProcedureED Visitor Policy & Procedure Visitors must check with the triage nurse Visitors must check with the triage nurse One visitor at a timeOne visitor at a time Physicians and medical students must clear a Physicians and medical students must clear a
visitor with the zone nursevisitor with the zone nurse No food or drinkNo food or drink No visitors in hallwaysNo visitors in hallways Verbally of physically abusive visitors will be Verbally of physically abusive visitors will be
escorted outescorted out
Giving Bad News
Stress of Giving Bad NewsStress of Giving Bad News ““Losing itLosing it””
Not the correct term. Your are actually Not the correct term. Your are actually getting something.getting something.
Post-Traumatic StressPost-Traumatic Stress Debriefing after major stress often very Debriefing after major stress often very
helpful and effective in resolving and moving helpful and effective in resolving and moving on -- but not always and not a givenon -- but not always and not a given
Giving Bad News
ConclusionsConclusions Developed new hospital policies for the Developed new hospital policies for the
most critically ill or injured patientsmost critically ill or injured patients Two nurses: one for the patient, and one Two nurses: one for the patient, and one
for the familyfor the family Liaison nurse facilitates visitation and Liaison nurse facilitates visitation and
flow of informationflow of information Staff educationStaff education
