Breaking Bad News to Families of Hospitalized Patients
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Abstract
Breaking bad news to families of hospitalized patients is one of the most difficult tasks facing health care professionals, yet subsequent family decision making may depend on the adequacy of this type of communication. Strategies that facilitate effective communication are presented, including: preparation, environment, time, clarity, empathy, acceptance, and follow-up.
Key Words: family, health care professionals, communication, bad news
Margaret L. Campbell, R.N., M.S.N., C.S., is Clinical Nurse Specialist, Comprehensive Supportive Care Team, Detroit Receiving Hospital, Nursing Administration, 4201 St. Antoine St., Detroit, Michigan, 48201.
Breaking bad news to families In the hospital setting is one of the most difficult tasks facing health care professionals (HCP). Although HCPs face the delivery of bad news regularly, few have had formal training in this experience (Quill & Townsend, 1991). Distress for both the HCP and the recipient can result when bad news is communicated ineffectively. Families who have a distressing experience receiving bad news may have negative long-term consequences (McLaughlan, 1990). Difficulty with this type of news delivery may be a throwback to the ancient custom of killing the messenger of bad news; HCPs may fear being blamed for the news. Decision making about treatment options and future planning depend on the adequacy of this communication. There are a number of useful strategies that can be employed by HCPs in the hospital which will enhance the delivery of bad news.
Prepare in Advance
Full preparations should be made in advance of meeting with the family. Determine what information the family already knows and how they have been coping. Other members of the health care team may have insight into the family's knowledge and reactions. Determine if there is a support person who should be available during the discussion. This indivdual could be another family member, clergy, or a hospital resource person, such as a nurse, social worker or chaplain. When multiple health care team members will be participating in the news delivery, a decision should be made in advance about who will break the news. An optimal setting for the news delivery needs to be planned before the family is convened.
Establish a Therapeutic Environment
A therapeutic environment within the hospital needs to be established for the communication of bad news. Discussing confidential information about patients must be conducted using a "face to face" approach in a private location. This practice permits exposure of both parties to the non-verbal aspects of the communication. This environment will enhance the HCP's ability to demonstrate empathy, compassion, and sincerity. Additionally, the HCP can determine the family's response to the news more directly and provide additional information or support. Telephone interactions may be useful for follow-up discussions.
Families will be more likely to respond openly and naturally to the news if their privacy can be assured, which will strengthen the comprehensiveness of the discussion. The ideal environment for this type of discussion is a room that can be made private by closing the door, and which has sufficient seating for all parties involved. Attempt to have all parties at the same level; for example, all sitting or everyone standing. Avoid artificial barriers, such as desks or tables. This arrangement establishes a balanced atmosphere making all concerned more comfortable and minimizing psychological distance. In addition, HCPs must give attention to their appearance if the discussion follows an acute resuscitative effort. A disheveled or bloody appearance will be distracting and make the family uncomfortable.
Allow Sufficient Time
A comprehensive discussion of the patient's test results, diagnosis, and prognosis may be time-consuming—requiring 45 minutes or more, depending on the complexity of the news and on the preparedness of the family. Choose a mutually convenient time of day that allows for sufficient time without interruptions, especially by electronic pages. Consider handing a beeper over to a colleague or storing messages during the family meeting.
Deliver the Information Clearly
The information given to the family must be honest, reliable and comprehensible. HCPs must be "bilingual" with regard to communicating technical information to families who may be unsophisticated in the use of medical terminology. Euphemisms, jargon, and acronyms should be avoided; families may be too intimidated or polite to ask for clarification. Table 1 illustrates some examples of lay equivalents for common medical terms used in the hospital.
| Medical Term | Medical Acronym/Jargon | Lay Equivalent |
|---|---|---|
| Cardiac arrest | Code |
Heart stopped
Patient died
|
| Anoxic encephalopathy | Brain damage | |
| Cardiopulmonary resuscitation | CPR | Resuscitation/Reviving |
| Cardiovascular Accident | CVA | Stroke |
| Intracranial Bleed | IC Bleed | Stroke |
| Subarachnoid hemorrhage | SAH | Stroke |
| Myocardial infarction | MI | Heart attack |
| Cancer/Malignancy | CA | Cancer |
| Renal failure | ARF | Kidney failure |
| Dialysis | Kidney machine | |
| Respiratory failure | Breathing failure | |
| Ventilator | Vent |
Breathing machine
Life support
|
The following is an example of unclear communication of bad news and the corrected response:
UNCLEAR
"Your mother has had a severe IC bleed. She is in the ICU and has been intubated and ventilated. Neurosurgery has placed a ventriculostomy to reduce the pressure in her brain. We do not anticipate a good prognosis."
MORE CLEAR
"Your mother has had a severe stroke. She is in the intensive care unit and has been placed on life support. The brain surgeons have inserted a tube to reduce the pressure in her brain. We do not think she will survive."
Euphemisms for dying are used to make the communication more comfortable for the person breaking the bad news. However, these ambiguities will block effective understanding on the part of the family and additional discussions and decisions will be impaired. For example:
HCP: "Your mother's condition is deteriorating and her prognosis is very poor."
Family: "Thank you, doctor, we know you are trying your best."
Family to each other after physician leaves: "Thank goodness, he didn't say she's dying."
If the patient is dying, an explicit statement must be made; euphemisms merely avoid direct communication. Families may have specific needs or patient directives which will not be brought forward if there is no clear understanding of the patient's condition.
It may be easier for the HCP to confirm bad news that the family already knows or suspects than to break unforeseen news. For example:
HCP: "What do you already know about your father's condition?"
Family: "We've been told that he has had a severe stroke and will probably not wake up."
HCP: "Your information is correct: I'm sad to have to confirm this news.
If the family has no knowledge of the patient's condition, then a direct approach will prepare them without misleading them. Prefacing your remarks with "I'm afraid I have bad news" is an effective way to introduce the subject. Notification that death has occurred may be done in-person or by telephone. Telephone notification can be appropriate in the case of an expected death, but in-person notification is best when the death is unexpected. If the family is asked to come to the hospital so that the HCP can make an in-person notification that death has occurred, then most people prefer an immediate announcement of the news upon their arrival (Viswanathan, Clark, & Viswanathan, 1986). The HCP should avoid telling the family that the patient has expired because this term is used in a different context by laypersons and may not clearly communicate the death. For example:
HCP: "Mrs. Jones, your husband collapsed at work and our efforts to resuscitate him were not successful. I'm very sorry.
Wife: "So how is he doing?"
HCP: "I thought I explained,... Mrs. Jones your husband expired."
Wife: "But, doctor... How is he doing?"
HCP: "Mrs. Jones, your husband died."
Wife: "Oh no, no, no...(weeping)."
Demonstrate Compassion and Empathy
The easiest way to demonstrate empathy for the family, is to tell them how the delivery of the bad news is making you feel. For example, "It makes me sad to give you this bad news," or "I am uncomfortable because I know this news is causing you to be unhappy." Compassion can be demonstrated through the extension of a comforting touch to the family member's hand or shoulder.
Accept the Family Responses to the News
A number of types of responses to the bad news can be expected from the family. Some families may demonstrate a "fight/flight" stress response which is generally characterized by the family member pacing vigorously or even running from the room. Family flight suggests an inability to absorb additional information, therefore, additional imparting of news must be postponed until readiness is demonstrated. The "fight" aspect of the stress response may be displayed through aggression directed at walls, furniture and other inanimate objects. Rarely, this aggression is aimed at the HCP. The family member must be protected from self-harm and from harming others which can generally be left to the other family members. The HCP should remain nearby until calm is restored.
Characteristics of the grief response may be demonstrated by the family after hearing the bad news. These characteristics may include: somatic distress, feelings of guilt, expressions of hostility, and preoccupation with the image of the patient (Lindemann, 1944).
Families may verbalize doubt or seem to be challenging or questioning the news. This is a normal response and is a manifestation of an inability to accept the news and to hope for a different or positive response from the HCP. It is important not to argue or to personalize the family's doubt. Answer all questions with honesty and remain consistent. Check the family's understanding periodically and invite them to ask questions which demonstrates willingness to provide comprehensive information.
Finally, some families will respond to bad news in a calm, quiet fashion that appears like acceptance. The family may be accepting the news as delivered, or they may be too shocked to respond. It may be helpful to acknowledge their calm, and ascertain their understanding.
Some HCPs will attempt to soften bad news by offering something positive. Statements like "He'll soon be at peace," or "He lived a good, long life" are not welcome: These type of statements trivialize the family's impending loss. Additionally, care should be taken to avoid offering false hope.
Families may need some time alone to talk or grieve openly after the delivery of bad news, while others may prefer to have the HCP remain to give support. If additional discussion is required for decision making, then the HCP needs to determine the family's readiness before proceeding.
Discuss Treatment Options
A discussion of treatment options, or organ/tissue donation, may follow the delivery of bad news. Garrisons (1991) believe it is essential to allow a temporal separation between the explanation of brain death and the request for organ donation to maximize family consent. Families need time to absorb the news and fully understand brain death before they can participate in decision making. Brain death is a difficult concept for families, therefore, HCPs should avoid using potentially contradictory phrases when discussing the patient's condition. For example, a suggestion that the organs are alive while the brain is dead is misleading. It may be better to indicate that the organs are functioning as a result of machines and drugs, and avoid a suggestion that life is continuing. When families ask what happens when the machines are stopped it is best to state that the organs cease to function. It is incorrect to say that the patient will die, since death was previously pronounced by brain criteria.
A discussion of treatment options following delivery of bad news for a living patient may also need to be postponed until the family demonstrates readiness. As in the delivery of the bad news, the HCP must provide relevant treatment options in language that is comprehensible. Furthermore, options need to be explained with regard to risks, benefits and burdens. If the HCP makes a treatment recommendation, then the rationale for that recommendation should be provided to the family.
Follow-up
Other members of the health care team must be told that bad news was given to the patient's family to ensure consistency in subsequent interactions by others. Additionally, supportive and empathetic behaviors can be demonstrated. Additional discussions may be required. Information may need to be repeated since stress can interfere with comprehension and understanding. Other family members may seek individual or group meetings in order to validate the previous discussions or to address other decisions. Avoidance of further meetings may signal a non-caring attitude to the family, or even a sense of abandonment.
Summary
The delivery of poor prognostic news can be one of the most difficult discussions a health care professional will face. A number of strategies have been suggested to facilitate a comprehensive, sensitive exchange with patient's families. Subsequent health care decision making will be enhanced if the initial delivery of bad news is well conducted by the health care team, and well understood by the patient/family.
References
Garrison, R. N., (1991). There is an answer to the shortage of donor organs. Surgery, Gynecology and Obstetrics, 173, 391-396.
Lindemann, E. (1944). Symptomatology and management of acute grief. American Journal of Psychiatry, 101, 141-149.
Quill, T. E., & Townsend, P. (1991). Bad news: Delivery, dialogue, and dilemmas. Archives of Internal Medicine, 151, 463-468.
McLaughlan, C. A. J. (1990). Handling distressed relatives and breaking bad news. British Medical Journal, 301, 1145-1149.
Viswanathan, R., Clark,J.J., & Viswanathan, K. (1986). Physicians' and the public's attitudes on communication about death. Archives of Internal Medicine, 146, 2029-2033.