Telling patients bad news: A dozen tips
The technique you use to deliver bad news to families can have an effect on their grieving process, emphasizes Kathy Nichols, RN, CFRN, CEN, EMT-P, a flight nurse at West Michigan Air Care in Kalamazoo. "Nurses can make or break a family's perception of a traumatic situation," she explains. "They will focus on certain words or phrases, how the news was presented, the tone of voice you used, and remember that forever."
Here are a dozen ideas to consider when giving patients or family members bad news:
Give bad news gradually. "If someone comes to the ED and immediately hears that a family member died, it is much more difficult than if you tell them gradually," says Gail Pisarcik Lenehan, RN, EdD, CS, a former psychiatric clinical nurse specialist in the ED at Massachusetts General Hospital and Boston City Hospital and editor of The Journal of Emergency Nursing.
Depending on how much time you have, give families a chance to digest the news by providing information in increments. "First, tell the family that they are doing everything they can but nothing seems to be helping, and even though it looks very bleak, it might take a miracle at this point," says Lenehan. "That is better than having them in the waiting room while the resuscitation is going on, and not saying anything, then coming out and saying the patient is dead, when the family member might assume they just have some indigestion."
Even if you don't have time to make repeated trips to the waiting room, news can be given in increments. "Even in the space of one conversation, you can gradually tell them, by first going over what transpired since the patient came in, and then, how the patient became sicker," says Lenehan.
Still, give every indication the news is not good, stresses Lenehan. "But if you warn people in advance, they are able to mount their defenses and start coping in some way. If you tell somebody their husband might die, they can start thinking, who would I turn to, what would I do?"
Allow family members a last contact with dying patient. "When you are leaving to take a patient to surgery, stop for a second and have the family give them a chance for some type of physical contact even if they are intubated," says Nichols. "Try not to use the word goodbye. Instead, tell them, 'If you want to give them a message, this is your chance right here.'"
If a trauma patient is being rushed to the OR, you can bring a family member to wait at an elevator that will be used. "In the few seconds that it takes to turn into the elevator, a relative can quickly say, 'I'm here,'" Lenehan suggests.
The contact can help the family member deal with bad news, says Nichols. "It may well be the last time they will get to talk to that person when they are still alive, and having a final contact is so important to the grieving process."
Consider your appearance. "If you're bloody, sweaty, or dirty, take a minute to collect yourself and clean up before you go talk to the family," says Nichols.
Find a safe place. "Consider the environment you're going to deliver the bad news in," says Nichols. "Attempt to have a private area, and try to have another nurse or family member present to help support them."
Identify family members. "Before you walk into a roomful of people, find out who you are talking to," says Nichols. "You want to know who the next of kin is, and who has the right to the information."
Doing this can avoid awkward misunderstandings. "You may assume a person is the patient's spouse, but that may not be the case," says Nichols. "For example, if a woman comes to the hospital after a man died of a heart attack, she may not be his wife. She may be upset and demand to know what happened, but she is not the appropriate person to give the information to."
Sit down. "If you remain standing, you give the signal that you just want to take a brief moment to tell the news and leave," says Nichols. "You want to give the impression you are there for them and will take time to answer their questions, instead of standing with your hand on the doorknob."
Give belongings to a more distant relative. "Particularly if it is a trauma patient with bloody clothes, it's very traumatic for family members," says Lenehan. "I always put things in a bag and give to a family member who wasn't as close, so they can decide if they feel it's necessary to give them to the relative who is closer to the patient. If that's not possible, I explain to the family member that the patient's clothes are soiled or cut, and ask if they would still like to have them."
Ascertain prior knowledge. "Find out how much the family member knows," says Nichols. "If they are the person who called the ambulance, they will know more about the seriousness of the situation, but maybe someone else took the patient to the hospital. Say, 'I understand you were with your husband when he collapsed, can you tell me what led up to that?'"
Family members may know more than you are aware. "You may be trying to soft pedal something, only to find out that, at the scene, paramedics have already told the family that the patient is not likely to survive," says Lenehan. "Ask what they understand about what has happened so far."
Use simple terms. "It's important to use the word 'died,'" says Nichols. "If you use the word 'passed away' or 'gone,' it may mean different things to people. Medical people are comfortable with terminology and tend to use terms the family may not understand. Instead of using the term 'cardiopulmonary arrest,' telling someone 'your loved one had a heart attack and his breathing stopped' is easier for people to understand."
Avoid misleading loved ones. When a 5-year old boy suffered a traumatic head injury from being hit by a car, Nichols clarified the seriousness of the situation. "He had dilated pupils and no response, and the mother was at bedside. I looked at her and said, 'do you understand this is a very serious head injury?' I told her that we'll do everything we can to get him to the other hospital safely. You want to allow some hope, but you don't want to give false hope."
Find the right emotional balance. "You can have tears in your eyes, but you don't want to give the impression that it affects your ability to give care," says Nichols. "Families will almost always allow caregivers to show emotion, such as hugging them or putting an arm around their shoulder. But, you have to learn what the boundaries are and be aware of the different responses that families may have."
Regardless of whether tears are shed, it's important that the family member perceives you as someone who genuinely cares. "I think the thing that matters most is that a staff member isn't just sympathetic, but empathic," says Lenehan. "Put yourselves in their shoes and convey the fact that the patient is special in some way. If you just remember the golden rule-how would you want to be told something if it was your loved one?"
Assess family's need for privacy. While some families may appreciate the silent presence of a nurse sitting quietly with them, others may become uncomfortable. "With some families, particularly those who don't have a verbal tradition, it may make people uncomfortable to have somebody sitting there and not talking," says Lenehan. "Sometimes, it might be better to give them time to digest the news and come back in a few minutes to give an update or to find out if they're doing okay, rather than sitting in silence."
Increase comfort level
Giving bad news is never easy, but there are ways to increase the comfort level. "Some people are naturally good at it, and some people are just not comfortable with it," says Maureen Harrahill, RN, MS, CEN, trauma coordinator at Oregon Health Sciences University in Portland.
Still, it's imperative for every nurse to be his or her best they can be at it. "You need to recognize your own limitations, but there are going to be times when everyone is forced to do it," says Harrahill. "Be prepared to step up to the plate if you have to."
Role playing. Participating in role-playing scenarios can be a "safe" way to get experience giving bad news. "In our ED, someone comes in and acts as a survivor and a physician is asked to give them bad news, such as telling a woman her husband has been critically injured in a car crash," says Harrahill. "If you do it once in a safe environment, it's easier to try it again."
The "survivors" give immediate feedback to the clinicians. "For example, some people have a hard time getting to the point, beat around the bush, and say every word but died," Harrahill says. "Afterward, the survivor will tell them, you scared me to death because you wouldn't get to the point. Having heard that once, you can learn from that very quickly."
Be exposed indirectly. "If there is a physician in the ED who is experienced at this, you can be present when the bad news has to be delivered and learn from what they do," says Harrahill. "It can also work the other way. If you know physicians who aren't particularly good at it, nurses should get up there and help them, acting as a team."
Watch videotapes. In Oregon Health Sciences University's ED, a videotape was created to help clinicians give bad news. Scenarios included calling a woman out of state to inform her that her husband had died of a heart attack, and telling a frantic mother her child was critically injured. "By watching the tapes, you can pick up some tricks of the trade," says Harrahill.
Don't get discouraged by negative reactions. "You're giving bad news, so you're not going to have happy people at the end of it," notes Harrahill. "But, you have to focus on the fact that people may have more comfort or can look back and have a good feeling about the way they learned the news."
Develop a training tape. If your ED doesn't have a training tape, consider creating one. "It's important that the actors who play the role of the family members be convincing," advises Harrahill. "If you do it poorly, it just turns into a farce and will seemed canned."
At Oregon Health Sciences University, a local actor and ED physician who acts in local plays took on the roles. "We also had hospice workers and volunteers come in and play survivors. That worked out well since they are very used to dealing with all kinds of similar situations," says Harrahill.
Know what patients want. Understanding the needs of family members can be helpful. Research showed that family members who experience sudden bereavement appreciate emotional support, reassurance regarding medical treatment, having an opportunity to view the body, and telephone follow-up.1,2 "The least helpful interventions were when the family wasn't given personal items, were notified by telephone, and lack of explanation of the role of the medical examiner," notes Kathy Nichols, RN, CFRN, CEN, EMT-P, a flight nurse at West Michigan Air Care in Kalamazoo.
References
1. Fraser S, Atkins J. Survivors recollections of helpful and unhelpful emergency nurse activities surrounding sudden death of a loved one. J Emerg Nurs 1990;16:13-17.
2. Mian, P. Sudden bereavement nursing interventions in the ED. Crit Care Nurs 1989;10:30-40.
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