Breaking Bad News
This is something an intensive care physician is required to do frequently.
It is one of the most important aspects of intensive care medicine.
Unfortunately, training does not match its frequency or importance.
To some the skills of breaking bad news will come naturally; to others it will be much harder. But, all doctors can get better at it.
“When you do it badly, they’ll never forgive you – and when you do it well, they’ll never forget you.” Dr Robert Buckman
There are various communication tools available. One, developed in oncology, is called the SPIKES protocol which is easily adapted to ICU:
See spikes for Dr Buckmans paper
Setting
Private, quiet, patient’s nurse with you, ideally more than 1 relative or a friend to provide support, maintain eye contact, sit down.
Perception
Ask how they view the situation.
‘What have you been told so far’ , ‘What do you think is going on’ , ‘How ill do you think your father is’.
Invitation
Ask what / how much they want to know - may range from detailed description of what has happened so far to the ‘bottom line’. They may know their relative is dying and want to talk about withdrawal and palliation before you even mention it.
Knowledge
Always give a ‘warning shot’
‘I’m afraid I’ve got some bad news’
Explain the situation.
Use very simple language - no medical terms unless they are medical.
Note that watching and listening to who you are talking to will guide you about what their level of comprehension is likely to be.
Empathy
Their emotions must be acknowledged and responded to.
Silence works well at this point. It gives them time to absorb the information, express emotion and think of questions.
You might want to ask how they are feeling / if they understand what you have told them so far.
Let them know that their emotional response is normal.
Strategy and summary
Let them know what the next steps are.
If it is a withdrawal conversation do not make it appear as if you are asking them for their permission.
‘When we think we can make people better we do all we can to try and save them. When we know that there is no hope of recovery our focus has to change from trying to keep them alive to allowing them to die with the most dignity and comfort possible’.
Summarise what you have said. Relatives may remember very little of what you have told them.
Pearls
At every step check they have understood what you are saying.
I often ask ‘does that make sense?’
Try not to talk to much.
Leave plenty of silences and listen.
A huge amount of information will come from visual cues, body language etc. Your body language, affect, volume, anxiety will all come through to them too so be aware of how you act.
Get people to sit in and observe and debrief your technique.
