Saturday, October 14, 2006

Breaking Bad News

Yesterday I had the unfortunate task of informing a patient's family that he had passed away suddenly. He had died of (what I presume) was a ruptured abdominal aortic aneurysm (or AAA). This is where, over many years, the main artery carrying blood from the heart dilates and swells, getting weaker over time. In most people this is a very slow process, but for some people it can happen over a few short years, especially if they have high blood pressure, high cholesterol, and smoke. It can continue to dilate like a balloon until it bursts, at which point the patient has a 1 in 2 chance of making it to hospital alive, and a 1 in 4 chance of surviving surgery. Most patients have no idea that they have this problem, especially if they rarely see a doctor.

In any case, my patient had been previously well, but suddenly complained of back pain, collapsed, and had a cardiac arrest at home (a bad sign). He was transported to hospital by an ambulance crew and his rhythm restored, but things were not good. By the time he reached the operating theatre he had died and his belly was so full of blood it looked like a giant watermelon. All of this happened over the course of 2 hours, and there was hardly any time for the family to understand what was happening.

It is tragic enough breaking bad news to anybody, whether it be cancer or any other serious illness, the need to perform any operation to save life or limb, or a death. It is even worse when there is no time or opportunity for the patient or family members to realise that bad news might be coming.

Sadly I have to do this on a regular basis, and perhaps I have not learnt how to do it with grace, but rarely is there a meeting where at least one family member is not crying or asking "How could this have happened?". I have come to accept that no matter how empathic or caring I am, it is always distressing. I have learnt to carry on with my job after breaking the news (there is always paperwork), but make sure that a nurse or somebody else remains with the family to talk things over further and make sure nobody passes out.

So, my (limited) tips for breaking bad news:
  1. Always sit down. Do this whether you are breaking bad news or not. It is a good habit for you, and encourages the family member to sit down. It also avoids many fainting episodes.
  2. Introduce yourself, then ask the family what they know. This lets the family talk first so you can get a gauge to how they will respond. Often they know what you are going to say.
  3. Get to the point. Family members know when you are beating about the bush, and it only gets worse if you put it off. That doesn't mean make it the first thing you say, just be tactful.
  4. Always have tissues handy. Nobody ever says no to tissues.
  5. Maintain eye contact until you have finished what you are saying. Staring at the wall or floor are bad no matter who you are talking to. It makes you look insincere.
  6. Don't try to say too much. They will not remember. It is silly to blabber on while people are crying. Blah blah blah, blah blah blah blah ...
  7. Don't get drawn into discussions about "What if?". Theories are theories, and given the selective memory of family members in grief, your conjectures may come back to haunt you. Usually in the Coroner's Court. This is especially true if you have strong opinions about what happened. You are probably upset too (and sometimes wrong).
  8. Always check if they have any questions, and offer to discuss and explain what happened at a later stage if they wish. This avoids many complaints.
  9. Tell them what will happen next. They do not want to make difficult decisions straight away, but they will want to know if the Coroner or Police will be involved, if an autopsy will be requested, when the body will be removed and to where.
  10. If they wish to see the body warn them of what they will see, especially if there are any tubes, wounds or deformities.
  11. Always make sure that somebody else is there with you to make sure you are not talking gibberish.

1 comment:

Kal said...

I wrote about this recently, but in a pre-hospital environment. You might like to read my thoughts and feelings after my first "Please sit down, I'm afraid I have some very bad news."