Delivering Bad News in the Emergency Department
December 1, 2025
By Paige Kompa, BS; Farha Khan, MD; Meryl Sudhakar, MD; and Hilary Stroud, DO
Executive Summary
- “Bad news” in the emergency department (ED) extends beyond death to include any diagnosis or outcome that threatens a patient’s functional future or personal values.
- Patient perception of bad news is individualized, and it is important to clarify what matters most rather than assuming.
- Possible communication barriers in the ED include crowding, hallway care, and rapid turnover. In addition, the high acuity, limited privacy, and lack of continuity make serious conversations uniquely challenging.
- Cultural differences affect autonomy, disclosure preferences, and the amount and preference for family involvement. It is crucial to avoid stereotypes and use open-ended questions to gain the most out of the patient encounter.
- Religious beliefs strongly influence preferences around suffering, resuscitation, and life-prolonging treatment. It is important to explore these beliefs with the patient and/or family.
- Unconscious bias can influence communication, particularly in the fast-paced setting of the ED. To mitigate this, emergency providers can take a moment to pause and use structured approaches.
- Identify the correct decision-maker early; capacity and Health Insurance Portability and Accountability Act (HIPAA) rules determine who receives information.
- Use shared decision-making to align ED interventions (e.g., intubation, pressors) with the patient’s goals and values.
- Apply the SPIKES (setting, perception, invitation, knowledge, empathy, strategy and summary) framework and adapt it to ED constraints by prioritizing privacy and minimizing interruptions.
- Warn that bad news is coming, and use clear language, small segments of information, and frequent pauses to check understanding.
- Name and validate emotions openly, since empathy strengthens trust during acute stress.
- For patients with limited English proficiency, the emergency providers should use professional interpreters.
- When delivering bad news by phone, ensure caller safety, speak slowly, use explicit empathy, and offer follow-up or in-person discussion.
- Clear, timely communication during critical events can significantly reduce long-term psychological distress in families (including grief, post-traumatic stress disorder, and complicated bereavement), underscoring that how providers communicate in the ED can be as impactful as the medical care delivered.
What Is Bad News?
Repetition in medical training is essential to the mastery of specific skills. Among these hard-sought skills is one that often is overlooked, although it is absolutely essential for every physician to acquire: the ability to deliver bad news to a patient or family. This is a necessary skill in medicine because of the inherent inevitability of unfortunate patient outcomes. Providers are tasked with treating patients in their most vulnerable states. A not insignificant number of people will spend their last moments in an emergency department (ED) bay. For some, the bustling ED is where they will hear the news that their loved one will not be coming home. These conversations, while already intrinsically difficult, are further complicated by a lack of privacy, the presence of several other sick patients in need of attention, and the overall chaos anyone who has spent even a few minutes in any ED has experienced. Conveying bad news in any environment is difficult, but ED providers must juggle extraneous circumstances to communicate effectively in an exceptionally emotionally charged state.
Explaining the loss of a patient to loved ones is not an uncommon practice in the ED. A total of 374,000 people (0.3%) die during or shortly after an ED visit each year (including patients presenting as dead-on-arrival), underscoring the frequency with which emergency clinicians deliver death notifications.1 However, bad news given in the ED is not limited to death. Researchers Jalilian et al state that bad news is “any health-related information that causes cognitive, behavioral, and emotional defects in the recipient of that news.”2 Other examples of commonly delivered bad news include debility, cancer, pregnancy loss, paralysis, poor prognosis, or amputation of a limb. Because of the variability of human values, each patient’s idea of what is considered bad news is different. Additionally, a provider’s definition of bad news will differ from that of the patient or family.
This concept is exemplified in defined terms, including the minimal acceptable outcome (MAO) and the minimal important difference (MID). When preparing to tell a patient bad news, the concept of an MAO is important to keep in mind. The MAO is defined as “the greatest level of disability perceived to be tolerable.”3 Depending on the type of bad news, the level of disability will vary, and this is important to keep in mind as a provider. An outcome that is tolerable for one patient may not be deemed tolerable for a different patient.
Another concept that can be applied to gauge a patient’s clinical care outcomes is the minimum clinically important difference (MCID), which is “the smallest difference in score in the domain of interest which patients perceive as beneficial and which would mandate, in the absence of troublesome side effects and excessive cost, a change in the patient’s management.”4 The MCID/MID has been used in the realm of clinical trials to better quantify a patient’s clinical relevance.4 Importantly, the MCID will vary from patient to patient “by the severity of their illness, their social status, their own concepts of health and improvement.”4 The authors give the example of two patients experiencing Guillain-Barré syndrome; one patient is an older adult woman who considers walking assisted a clinically relevant change, whereas the second patient considers not being able to compete in her professional sport again a relevant change. Because of the patient’s demographic, background, and values, the measurement of clinical relevance left an obscure pool of data. By using an MID, a patient’s well-being concerning their outcome can be more easily identified. In the acute setting of the ED, it is important to consider that bad news will have a tremendous effect on patients’ lives. Knowing that each patient has a different MAO and MIDs helps the provider in counseling the patient when delivering bad news.
Emergency Department Utilization and Outcomes
The Centers for Disease Control and Prevention (CDC) data from 2008 state that four in every 10 Americans visited an ED in the previous year.5 As ED usage and wait times continue to rise, the toll on emergency providers continues to mount. For many Americans, a visit to the nearest ED is not an unfamiliar occurrence. The ED functions as a catch-all environment that takes care of patients in acute life-threatening circumstances while balancing the overflow of patients who lack adequate preventive care.
The larger differences in usage are uncovered when comparing the rates of outpatient visits. Of the uninsured population, only 41.8% of patients had an outpatient visit compared to 76.6% of insured patients.6 This discrepancy highlights what those familiar with emergency medicine already recognize: that the ED is the repository not only for emergencies but also, often, for preventive care. In a retrospective study from 2011, it was clear that patients use the ED for non-emergent reasons, as 79.7% of patients chose the ED because of a lack of access to other providers. Only 54.5% of patients arrived at the ED because of the need for hospital resources.7
For many, the ED is their opportunity for life-saving care. In 2021, the CDC reported 139.8 million visits to the ED, with 2.8 million resulting in admission to intensive care units (ICUs). In a further breakdown of data, it was noted that 307,000 (0.2%) patients presented with acute myocardial infarctions, 23,647,000 (16.9%) patients presented with an injury or poisoning, and 5,018,000 (12.5%) were brought because of a motor vehicle accident.7
In an analysis of early and late causes of mortality in an ED in Bulgaria, a majority of early deaths were the result of cardiovascular disease. The highest proportion of deaths was derived from myocardial infarctions and precipitating events due to oncological issues. Contributing causes of mortality were poverty, travel time, and a lack of support for patients with terminal illness.8
The disposition of the patient and the time patients spend in the ED also can heavily affect their outcomes. When an ED is extremely busy and lacks private beds, it is not uncommon for some patients to be seen in a hallway bed until they are admitted to an inpatient bed or transferred to another department. Data from 90,000 ED visits were aggregated and analyzed from an academic hospital and showed a relationship that relates an increased boarding time to higher mortality rates.9 Additionally, researchers noted that the risk of medical error is higher when departments are overcrowded and use hallway beds. Patients who have respiratory compromise or signs of sepsis are at a higher risk of needing ICU care when the time-to-care increases.10 The boarding patient is not the only one affected. Admitted patients also are affected by increasing wait times for antibiotics, pain medication, computed tomography (CT) results, and increasing the risk of complications for trauma patients and acute coronary syndrome (ACS) and non-ACS-related chest pain.
It is clear that ED physicians treat a large percentage of patients with severe and acute conditions who need immediate life-saving care, along with providing chronic care medicine to subsets of populations. Care of these patients can result in life-altering morbidity or death. Clear and concise, yet empathetic communication to both the patient and their family members is a necessity. For each patient represented in the previous statistics, a physician is expected to deliver the news to the patient and the family. In the case of the death or permanent morbidity of a patient, additional special considerations must be taken.
Effects of Patient Culture and Demographics on Care
Physicians have a unique and pivotal role in discussing bad news with a patient and/or family. Regardless of the specific patient and family structure, delivering bad news is inherently a difficult conversation, which provokes strong emotions. The training physicians receive in medical school and residency typically is minimal, and this can directly affect the patient’s and family’s understanding of these critical situations.11 In an already emotionally heightened situation, a physician must be able to clearly communicate to ensure patient and family comprehension. Communicating with the patient or the family can add another layer of complexity when the patient is of a different culture than the provider relaying the bad news.
Authors Hernandez and Gibb describe culture as “a socially transmitted system of shared knowledge, beliefs and/or practices that varies across groups, and individuals within those groups.”12 Anthropologists believe that culture is a broader concept that affects every part of an individual’s experience and cannot be separated from factors of daily life like politics, the environment, and genetics.13
Traditional cultural competency approaches often relied on group-specific “dos and don’ts,” which risk encouraging assumptions about patient values based on perceived cultural norms. Contemporary research shows that cultural background can influence preferences for autonomy, disclosure of serious diagnoses, and family involvement.14 For example, some communities tend to favor direct disclosure to the patient, while others prioritize family-centered decision-making and may prefer to shield the patient from distressing information.15 In certain societies, discussing a terminal diagnosis is believed to cause psychological harm or worsen a patient’s condition, shaping the preference for family-managed communication.15 While these patterns can provide context, they must not be applied rigidly. Individual variation is substantial, and the most effective approach is to ask patients and families directly how they prefer information to be shared and who they want involved in decision-making.
In the last decade, there has been a shift in opinion in the medical literature that steers away from tailoring the conversation to specific cultures. This is because of the emerging data that suggest a cross-cultural approach. Researchers Epner and Baile noted that the word “culture” is largely misused in the field of medicine.13 Currently, most healthcare providers operate from a multicultural approach, which assumes that people from the same culture share similar experiences of daily life and values.13 Patients inside the same culture can have vastly different personal experiences, values, traits, and personalities. Think of two Muslim females who both present with modest clothing, including a hijab, but patient A recently immigrated from Kuwait, and patient B is Kuwaiti, but is a first-generation American who grew up in suburban Ohio. On a surface level, these patients may seem very similar. They share a common language and have family present speaking Arabic. However, the values, personalities, and opinions of patients A and B can differ significantly because of the environment in which they were raised, despite their shared culture. This is an example of categorical thinking.
Categorical thinking can lead to stereotypes about patients, which can lead to assumptions regarding their values and ultimately can affect how a provider would convey information or bad news. Epner and Baile believe that the superior approach is the “cross-cultural” and patient-centered model that “focuses on foundational communication skills, awareness of cross-cutting cultural and social issues, and health beliefs.”13 Effort by the provider is needed to discern each patient’s role inside their family circle and to have the awareness that other disparities like racism, gender inequalities, and patient mistrust may affect communication.13 America is becoming increasingly diverse, which means the use of a cross-cultural and empathetic base approach should be fundamental in engineering these types of conversations.16
The effect of unconscious bias is a societal construct that healthcare workers must analyze. When a physician first sees a patient or their family, a first impression is quickly formed by all parties. Unconscious bias is defined as “the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner” that occurs naturally, without awareness or control.17 Patient demographics or social cues can contribute to premature diagnostic closure, increasing the risk of misdiagnosis and poorer outcomes.18
The ED is an incredibly fast-paced environment. Data from the CDC suggests that 22% of ED visits lasted only 15 minutes.5 While it remains difficult for unconscious bias to be completely eliminated, clinicians can reduce its effect by increasing awareness, slowing down during critical decisions, using structured diagnostic processes, and consciously checking assumptions to ensure that bias does not affect care.
Effects of Religion, Attitudes, and Families on Care Decisions
Religion can significantly influence the outlook families and patients have about their conditions and affect the amount and type of life-saving care patients find acceptable. It is not unusual for people of certain religions or faiths to transfer control of their situation from the physician to God. They often cite prayer and the belief in miracles.15 Studies have shown that religious people choose more aggressive measures during end-of-life care.15 Epner and Baile recounted a story of one American Jewish woman and her husband who were determined to continue chemotherapy even when the doctor recommended palliative care as the next step because they saw death as a sort of failure.13 In another case, a daughter convinced her father to change from a “no-code” status to a “full-code” status because of her strong faith in the saving miracles of God.13 These are examples of how the interplay of religion and family units can influence the care plan, many times toward more aggressive measures.
These stories are not anomalies; in fact, each major religion has teachings surrounding death. These guidelines frame patients’ outlook on the meaning of death and their opinions on transitioning to end-of-life care, organ donation, and euthanasia.19 The Roman Catholic religion allows transitioning to comfort measures only if it is considered “dangerous, extraordinary, or disproportionate.” While palliative care and alleviation of pain in the dying are supported, active euthanasia is contrary to their belief system.19 Protestants have similar beliefs, with the understanding that patient comfort is superior to perceived futile care.19
Greek Orthodox followers differ in that they believe that “withholding and withdrawing therapy is not allowed” and if a patient denies a life-saving treatment, they think the physician should “persuade [them] to consent.”19 They think alleviating pain is important, but only if it does not cause the “double effect,” which in this case equates to the unintentional hastening of death due to palliative care treatment.19 However, the Jewish religion differs, and the belief is that the double effect is permissible and all palliative care treatments should be given.19 Jewish patients and families follow Halacha, or the Jewish Legal System, which aims to balance patient autonomy and “the sanctity of life.”20 Caring for Jewish patients may consist of ensuring the patient’s comfort is sustained because there is a moral obligation written into the Halacha that requires alleviating pain.19
The Muslim religious code is based on the Qur’an and Sunna. When caring for Muslim patients, it is possible to see a resistance to the idea of death and the acceptance of aggressive measures.19 Transitioning to comfort-focused care is allowed, but only if there is no chance for a return to an acceptable quality of life and if there has been thorough counseling and consent by the family.19 Notably, Islam is not a monolithic religion, and patients may refer to the “opinion of their own recognized religious scholars.”19
In the Hindu and Sikh religions, karma is the sacred belief that there are “good deaths” that consist of spending time with loved ones and saying a formal goodbye and a “bad death” that is met with uncomfortable circumstances and categorized as “violent, premature, in the wrong place.”20 It is important to note that death in a hospital setting, like the ED or ICU, would be considered a “bad death.”19 The Hindu and Sikh religions see death as a path to a new life (with the type of life, good or bad, determined by the mechanism of death), but still share the human experience of mourning death.19
Patients awaiting bad news are in a vulnerable state. Generally, a person’s reliance on a higher power is greater with an increased level of stress.13 Few situations elicit as much stress as a loved one in a state of sickness or at the end of life. Religion can be a tool to help understand the context in which families make decisions and comprehend information. Religion can help inform a healthcare provider, but the provider should avoid assumptions of opinions based on a labeled religion. For example, seeing a Muslim patient and assuming that they will want to elect for aggressive care and providing all possible measures would fall under the out-of-favor categorical thinking. Religious affiliation is something to account for, but careful consideration of family-specific values is even more important.
A large part of delivering bad news is working alongside families to come to an understanding and a path forward. As the authors Epner and Baile state, “nurses, doctors, and all providers suffer when patients suffer.” Epner and Baile describe two paths that providers can take when explaining the severity of a situation to patients and their families with their religious background in mind. One option is to make a logical explanation using facts and statistics, and another option uses empathy, validation, and exploration into what matters most at the end of life.13 When patients are highly emotional, Epner and Baile suggest the latter approach because delivering factual information will not reach this type of family or patient.13 Because of the high-stress situation, religion plays a larger role; therefore, Epner and Baile suggest validating their point of view first. Epner and Baile describe the goal of this conversation as feeling fluid and collaborative, and to avoid persuading a patient or family.13
Logistics of Delivering Bad News to Families
Health Insurance Portability and Accountability Act (HIPAA)
In the fast-paced ED environment, it is vital to respect patient privacy and autonomy while communicating effectively with families. Patients may have different preferences regarding how, when, and with whom bad news is shared. Some patients may want to receive information privately, then disseminate information to their families; other patients may want family presence at the initiation of the discussion. Patients who have decision-making capacity should be asked who they want to be present for the delivery of bad news and the treatment discussions thereafter.
When a patient lacks decision-making capacity, whether because of illness severity, altered mental status, or baseline cognitive impairment, the responsibility falls to the treating physician to identify the appropriate surrogate decision-maker. The order of priority is as follows:
1. Legal guardian;
2. Designated medical power of attorney;
3. Legal next of kin.
ED social workers are instrumental in identifying the correct contact to serve as surrogate decision-maker. Once the appropriate surrogate has been identified, that individual may choose to include other loved ones in the conversation.
Shared Decision-Making
Difficult decisions often need to be made quickly in the ED, especially when determining whether to pursue aggressive next steps, such as intubation, pressor support, and line placement. For patients who have decision-making capacity, their wishes guide care planning.
If the patient lacks decision-making capacity, decisions should be made by their surrogate decision-maker. In situations where there are multiple surrogates — such as when there are multiple adult children — the ideal approach is to reach a consensus. If a consensus is unable to be reached and the decision is time-critical, decisions can be made based on a majority opinion.
Delivering Bad News to Families
Delivering bad news to families in the ED can be emotionally challenging. Acute grief in patients’ families can manifest in various ways and can be highly charged. It is crucial to have the appropriate supportive personnel present to assist with managing emotions.21
ED physicians face multiple challenges when delivering bad news to families. There is a consensus that numerous barriers exist in communication between families and physicians, leading to a general lack of satisfaction among families. Review articles indicate that one of the main barriers is the “presence of unknown healthcare workers” during the process of delivering bad news.21 In emergency medicine, physicians are required to quickly establish relationships with patients and their families to provide care. Emergency medicine physicians often are unfamiliar to patients and their family members who have been seeing specific physicians for months or even years. An ED visit usually is the first interaction a patient and their family have with this physician, creating a barrier that emergency physicians must regularly overcome when delivering bad news. Vital Talks, a website dedicated to helping clinicians communicate effectively with patients with serious illnesses, provides resources to guide clinicians through the aspects of giving bad news.
Preparation is crucial, and ensuring all relevant information is obtained can be challenging in the ED. There are key elements to delivering bad news that can be applied even in the acute setting of the ED. The SPIKES strategy (setting, perception, invitation, knowledge, empathy, strategy and summary) offers an easy protocol and template for communicating bad news, helping physicians guide the direction of the conversation based on the family’s responses. The SPIKES strategy emphasizes empathy toward emotions, and the following sections will discuss the different aspects of the approach.22
Setting
The setting for giving bad news is crucial and should be done privately. Although privacy can be challenging to achieve in the ED, it is essential to deliver bad news in the patient’s room with the door closed or in a family counseling room. Physicians should be mindful of the relationships among family members involved and seek permission to discuss important medical information. Sitting down without any physical barriers can make the discussion less intimidating, allowing families to feel like they are part of a conversation.
Maintaining an attentive and calm demeanor is important, and using the psychotherapy “neutral position”— sitting with ankles together, palms downward on the lap, and making eye contact — can help families feel that physicians are giving them adequate attention. Listening and repeating back communications made by the family sends a message that the physician is actively listening to them.23
Perception
Before delivering bad news to a patient’s family, it is crucial to ask the family about their understanding of the medical situation. This helps gauge their perception of the news and identify any gaps in their understanding of the seriousness of the condition and their expectations. If the family is in denial, it is recommended not to confront this denial during the first interview, since it could cause tension in the new physician-family relationship.24
Invitation
It is not appropriate to assume that a family wants to know all the details about their loved one’s medical condition. It is recommended to ask permission to determine the extent of information a patient or family would like to know about their medical condition.25
Knowledge
Before communicating bad news, it is important to provide the patient’s family members with a warning that bad news is coming. This can help families have more time to collect themselves psychologically during this emotionally charged conversation. An example of a warning is explicitly stating, “I am sorry, but I unfortunately have bad news about your family member.” This gives families a couple of seconds to mentally prepare for the news they are about to receive.20
Using common terminology will allow family members to understand and digest the information without misconstruing the seriousness of the news, helping them process the information during their time of emotional distress. Providing information in small amounts allows family members to process information and ensures that the physician can address any additional questions. This approach helps the physician gauge how quickly information can be given and whether it is OK to continue providing additional news. It might be necessary to repeat information to ensure understanding. Always continue to acknowledge the emotional turmoil.
Empathy
Delivering bad news to a family is challenging for emergency physicians, and it is crucial not to withhold information or downplay the situation, since this can cause confusion in the long term. Withholding information also can discredit any additional information the physician provides later. While delivering bad news, it is important to acknowledge and respond to the family’s emotions throughout the conversation.26
An empathetic response technique can help validate a family’s emotions. The first step is to listen and identify the emotion. The second step is to identify the cause or source of the emotion, which usually is the bad news being provided. The third step is for the physician to outwardly show they have made the connection between the two previous steps. The final step is to validate and normalize the emotions that are present.22
Strategy and Summary
It is important for physicians to frequently check with family members to ensure they understand the information that has been given. This aligns with the knowledge step, ensuring there are no gaps in information or expectations regarding the seriousness of the bad news. Providing a summary of the information helps both the physician and the family reach a mutual understanding of the news.
The SPIKES protocol offers a strategy and template for delivering bad news with easy recall. It serves as a guideline to improve the delivery of bad news to families in the ED and has been shown to increase physicians’ confidence and competence during these stressful times.22
Other review articles focus on delivering bad news to the parents of pediatric patients. Many of these topics can be applied to emergency medicine physicians when discussing difficult topics with families. One article considered conversations between physicians and parents concerning a child’s severe diagnosis, limited treatment options, or poor prognosis. The study interviewed many parents with children aged 1-12 years with life-threatening illnesses, defined as medical conditions that can cause death or are life-limiting. Parents reported a lack of satisfaction when receiving bad news related to their children. Although this is not specific to emergency medicine, some direct points from this study can be considered when delivering bad news to families.27
The presence of an unknown healthcare worker can make families feel uncomfortable. Unfortunately, in the ED, the physician often is an unknown healthcare worker to patients and families. To overcome this barrier, it is essential to introduce yourself and everyone in the room, explaining why specific people are present for the conversation.27
It takes time to process bad news, and each family will do so in their own way. Parents have noted that they often do not have time to process the news and make decisions before being asked about their questions and preferences regarding next steps. Parents tend to wish for more time to process or the ability to schedule another meeting after processing. While this can be more difficult in the ED, offering the option for the emergency physician to return if questions arise and providing resources for next steps can be helpful.
Literature has shown that delivering bad news can be practiced using simulation techniques. Physicians are found to be more comfortable giving bad news after practicing simulation cases before delivering bad news in person. While this strategy has been researched for giving bad news to patients directly, minimal research has focused on simulation techniques for delivering bad news to patients’ families.28
The same guidelines should apply to delivering bad news to patients and family members. It is important to find a private space and introduce yourself. Regarding giving bad news specifically in the ED setting, several guidelines used in other settings can be applied. (See Table 1.)
Table 1. Steps to Delivering Bad News to Families in the Emergency Department |
Locate a private area (family room). |
Introduce everyone in the room (including non-healthcare workers). |
Evaluate the family’s understanding of the situation. |
Use a headline statement. |
Let families comprehend the headline statement. |
Help the family understand next steps. |
Ask the family if they have additional questions to ensure their understanding. |
According to the CDC, there are approximately 139.8 million ED visits per year.29 With a U.S. population of approximately 340 million, and a population of 67.8 million people who speak a language other than English at home, this extrapolates to 28.7 million ED visits with patients who do not speak English at home.30,31 It is imperative that patients with limited English proficiency receive health information, particularly bad news, in a language that is easy for them to understand. Physicians are understandably concerned that using an interpreter to assist with the delivery of bad or undesirable news may not be as accurate or delicate as the physician’s own language. However, a 2022 South African paper found that patients preferred information to be delivered in their preferred language, regardless of whether doing so required the use of an interpreter.32 An overall positive or negative impression of the delivery of bad news was not solely based on the language used but also included assurance from physicians. An important limitation of this study is that all interpreters were nurses working within the same hospital, which may limit generalizability.
However, the use of an interpreter alone does not guarantee full understanding of the topic at hand because of the complexity of the topics discussed.32 Additionally, nonverbal communication and cultural differences may affect patient understanding outside of the language barrier. For example, Zulu-speaking patients in the study interpreted silence in multiple ways — neutral, positive, or negative — and some common clinician phrases such as “I’m sorry” or “I’m worried” were perceived not as empathy but as signs of diminished hope.32
Delivering Bad News About Children
In the case of children, primary communication about the patient’s status occurs not directly with the patient but rather with their parents or caregivers. The majority of research in this realm has been performed on children with oncologic diagnoses; however, in the ED, bad news regarding diagnosis in a child patient may include a variety of topics, ranging from physical injury (broken bones, etc.) to patient death. As such, delivering bad news to parents or guardians is a crucial part of the care of pediatric patients. A 2021 Dutch article used parent experiences to identify 10 barriers that affect the communication of bad news to parents of ill children, of which many are relevant to the practice of emergency medicine.33 These barriers are described in the following sections.
Lack of timely communication. Several parents endorsed that they had not been explicitly told about the uncertainty of their child’s future or that their child may die until shortly before death. In some cases, this conversation did not take place because some patients were referred to another center, and the receiving center assumed that the conversation had taken place at the referring center. Parents also stated that requiring the parents to take the initiative regarding conversations about the possibility of death made the parents feel as if they were giving up on their child.33
Failure to ask parents for input. Parents want their contributions to be taken seriously when discussing their child’s quality of life. They also request that physicians ask how much medical information is desired.33
Parents feel unprepared for the conversation and adrift afterward. Setting the stage by ensuring that there are minimal distractions and preparing the families for bad news may alleviate some of the feelings of being overwhelmed. Additionally, being unable to find a quiet space to decompress and discuss the logistics of moving forward leaves parents adrift.33
Lack of clarity about future treatment. When their child’s disease is determined to be incurable, parents want to know what to expect in terms of future care and support. However, depending on the diagnosis, this may not be feasible in the ED.33
Physician failure to voice uncertainties. Parents could discern when physicians found it difficult to discuss the patient’s diagnosis/prognosis. Some of these conversations were postponed until confirmation. Ultimately, parents preferred hearing the physician’s uncertainty and ability to refer to other specialists. This also assured some parents, since having experts who also were uncertain mirrored the parents’ own uncertainty.33
Failure to schedule follow-up conversations. Parents were expected to ask questions and make decisions immediately after receiving bad news, without time to process. Those who had undergone this experience recommended that bad news conversations be carried out over two stages, wherein the first stage is delivering bad news and the second stage is an opportunity to discuss next steps. While this approach is certainly reasonable in the outpatient setting, it may be difficult to implement in the ED because of the emergent nature of certain acutely life-threatening diagnoses and the need to make quick decisions. However, in those cases where the news is life-altering but not acutely life-threatening, it would be possible to have two discussions separated by a small but significant amount of time to allow for processing.33
The presence of too many or unknown healthcare professionals. Parents would prefer to avoid additional or unknown physicians in the room. If additional personnel are necessary, introductions should occur first.33
How to deliver bad news to the child. Parents differ regarding the amount of information that the child should be given, as well as who should deliver the information.33
Non-conversational indications of bad news. Some parents noted that they inadvertently received bad news through overhead conversations, additional laboratory tests or workup, or rescheduling of imaging because of concern for the acuity of the diagnosis.33
Misunderstanding medical terminology. Medical professionals still should assess the level of medical literacy before using medical terminology to discuss the child’s diagnosis and treatment.33
Overall, parents stated that they may have made different decisions regarding their child’s care if they had more information about their child’s prognosis.33
How to Deliver Bad News
Patients prefer to be treated as equal participants in the conversation regarding their prognosis by being given honest information; however, they would like this to be tempered with a warning and gradual build-up to the news.34
Setting the Stage
Bad news should be delivered privately. The ED environment, including the sounds of other patients and people entering and leaving the room without announcing themselves, all can contribute additional stress to an already overwhelming situation.34
Delivering Bad News Over the Phone
In an ideal situation, physicians would be able to set the stage in a quiet area of the ED and gently share sensitive information with the patient’s family members in a face-to-face interaction. However, in the ED, acute presentations with poor prognosis may result in the need for emergency interactions with family members who may be present. Emergency physicians often are tasked with delivering news over the phone to a family member whom they have never met and with whom they have no established rapport.35
Much of the literature evaluating giving bad news discusses oncological news in a face-to-face encounter. However, it is apparent that telephone communication differs from face-to-face discussions.35 Communications over the phone are more challenging than face-to-face interactions, given the lack of all nonverbal forms of communication. The loss of body language, facial expressions, and other nonverbal forms of communication makes it harder for physicians to express empathy and support for the patient and/or family. In phone discussions, physicians are more likely to discuss factual information over the psychosocial context of the information they are presenting. Other subtle changes may occur, such as the contextual warning of moving the family to a quiet room, providing physical contact by holding the patient’s hand, or staying with the family member to prevent isolation after the delivery of bad news.
However, there are benefits to phone communication. In some circumstances, it is more feasible to disclose bad news by telephone, whether because of the physical distance between the patient/care team and the family, difficulty obtaining transport, or when there are impairments that may affect the mobility of the patient or family.36 In cases of sudden deterioration or other recent changes, calling family members to deliver bad news rather than waiting for family to be present at the bedside also may spare the family time spent in uncertainty.
Some phone-specific difficulties include ensuring that the recipient has phone service, ensuring the recipient is in a safe space (i.e., not driving), and determining whether other people are present with the caller and if the patient would want the additional individuals to be privy to private health information.35
A recent meta-analysis found that, although there are few studies with a small number of patients, the way in which bad news is communicated may be more important than the modality.37 Patients who had bad news disclosed over the phone did not have an increase in anxiety as compared to those with whom bad news was shared in person. Similarly, depression at follow-up was unchanged based on the modality of information sharing. There was no association between the level of patient trust in the disclosing physician and modality of disclosure.
Why Do Emergency Physicians Need to Know How to Deliver Bad News?
Receiving bad news can be life-altering. Some research has shown that patients who have an established relationship with their primary care physician prefer to receive their bad news from that physician.34 However, others stated that where news is delivered has less effect than how it is delivered.
The ED often is the first point of contact for patients with various and potentially undiagnosed issues. Patients at the end of life frequently receive care in the ED, whether this is due to acute illness/injury or exacerbation of a chronic condition.38 More than 50% of seriously ill older adults visit the ED in the last six months of life.39 The ED may be the first location to diagnose new issues or to determine exacerbations of existing diseases and, thus, may be the first place a patient receives a prognosis.40 In a recent study, 31.6% of residents in internal medicine, surgery, and emergency medicine reported delivering bad news to their patients more than five times in one month.41 In the ED, goals of care conversations and shared decision-making are particularly complex since critically ill patients often arrive without known advance directives. They also may arrive alone, without surrogate decision-makers present or identified. Additionally, there is no established rapport with the ED physician. The ED physician then must identify and engage with surrogate decision-makers, establish rapport, and engage in shared decision-making on emergent interventions in a timely manner while managing the fast-paced ED environment.42 Improper delivery of bad news can increase stress and anxiety, decrease understanding of the diagnosis, and result in undesirable outcomes, particularly when the bad news is especially unexpected and/or tragic, such as when it affects a young person or a child.40,43,44
Training Medical Professionals to Deliver Bad News
Death notification is a critical aspect of practicing emergency medicine; however, developing instructional interventions for emergency medicine physicians presents a challenge for educators. These sessions must balance the emotional weight of death notification, the variety of social and cultural norms surrounding death, and the emotional and physical strain physicians may experience after prolonged resuscitations. These sessions also must be accessible to emergency medicine professionals who have busy clinical shifts, limited conference time, and variable schedules.
One effective approach uses the GRIEV_ING educational intervention, which is a two-hour workshop that combines didactic sessions with role play to simulate delivery of bad news to a patient or family. The mnemonic stands for:
- G: Gather the family;
- R: Call for support Resources like chaplaincy, friends;
- I: Identify yourself and your role, use the patient’s name, and the identify level of understanding of preceding events;
- E: Educate the family on the events that have occurred and the state of their loved one;
- V: Verify that the patient has died, using the words “dead” or “died”;
- _: Give the family personal space and time for emotions;
- I: Inquire about questions;
- N: Address the Nuts and bolts regarding organ donation, funeral services, etc.;
- G: Give the family your card for follow-up.
This intervention has been shown to increase residents’ self confidence in death notification as well as their competence in information delivery.45 The intervention also has been shown to be helpful in training medical students, resulting in increased self-confidence when delivering bad news.46
An alternative option for training uses the SPIKES method. One study found that a four-hour training that paired didactic teaching with role playing improved medical students’ and residents’ self-perception of efficacy in delivering bad news.47 A similar five-hour training session that combined didactics, role play, and simulation cases also was deemed highly useful by the residents who completed that session.48
The relatively short time commitment required for these training courses makes them well-suited for integration into the demanding schedules of emergency physicians and learners. Despite their brevity, these training sessions overall demonstrate that dedicated training on delivering bad news in the ED is effective and can improve physician, resident, and student efficacy of information delivery and overall comfort in speaking with patients and their families.
Paige Kompa, BS, is a Medical Student at Ohio State University College of Medicine, Columbus.
Farha Khan, MD, is Emergency Medicine/Internal Medicine Resident, Ohio State University College of Medicine, Columbus.
Meryl Sudhakar, MD, is a Palliative Medicine and Emergency Medicine Physician, Ohio State University Wexner Medical Center, Columbus.
Hilary Stroud, DO, is Associate Professor of Emergency Medicine, Ohio State University Wexner Medical Center, Columbus.
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Clear, timely communication during critical events can significantly reduce long-term psychological distress in families, underscoring that how providers communicate in the emergency department can be as impactful as the medical care delivered.
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