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Delivering Bad News WhenUnanticipated Events Occur

Restoring Control in an uncontrolled moment

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This is how CNN describes us inthe media.

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What the medical community knows

What the patient and family understand

Outcome measuresLength of stayInfection rates

Parking issuesQuality of mealsCourtesyCleanlinessProblems lead to ANGER!

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What is so frighteningis how easilycommunicationcan bemisinterpreted.

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A bridge to those we love

Where to start?

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Maintaining that bridge….

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Technology has elevated patient expectations

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Is this not a beautiful baby?

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The mostImportantPicture?

Say hello to Bobby!And the journey begins…

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Like leaves floating down a stream, hearing bad news creates a sense of loss of control.

Effective communication restores that control and can reduce the anger.

This is the origin of ANGER!

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DELIVERING BAD NEWSWhy am I so anxious?

I did not do it.What will be their response?How will they react?

•Silence?•Crying?•Anger?

•No threat to me.

Did I miss something?

Will they be angryat me?Have I lost their trust?I really feel guilty.

They could sue me!

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0

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Coombs 1993

Medical School

Residency Fellow PracticePreMed

Do we shield ourselves at theexpense of our patients?

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18 secondsTime from initial patientstatement of complaint

until interruption bycare provider—Are we our

own worst enemy?

Beckman 1984

Are We Good Listeners?

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Patient –Are you a psychologist?

Me - No, I am an obstetrician. Why do you ask?

Patient –Because you are asking me all these things about my feelings.

Me – Why does that surprise you?

Patient –Because I thought all obstetricians just came in,

did their thing, and went about their business.

Are we appreciated by our patients? Sometimes

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If you, the patient, don’t talk about it, because I, the physician, don’t ask, you won’t think about it.

If you don’t think about it, you will forget.

Conspiracy of Silence

Lewis, 1979

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Strategies for care during the initial hospitalization

See the patient twice a day. FIND THE TIME.

Use the baby’s name in the conversation.

Allow the family to create the “rules:”Seeing and touching the baby.A memory box.Participation of sibs or grandparents.Pictures, wrist bands, blanket.Special requests (circumcision, time)

QMCQMCQMCQMCLetters say it all.

The 10 minute chat

“I’m sorry your familyis going through sucha hard time.”

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Advise patients to be prepared forawkward moments once they

get home.

The grocery storeChurch

Their children’s schoolThe neighborhood gas station

Neighbors

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When an unanticipated adverse event occursin the hospital, always bring the patient and

her family back in the FIRST week after discharge to review the details of the

event and the follow-up.

AVOID MEDICAL TALK. TALK TO THE ISSUES.

Later steps:

Review the autopsy when available.

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If anger reflects loss of control,do you know the agenda?

The safetarget for anger!

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DID I MISSANYTHING?

I’m hersister. Did someonemake a mistake?

She did nottake care ofherself! I failed my

baby.

I’m her mom. Whowill talk to me about myfeelings?

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Questions to Ask at First Office Visit

How did they treat you in the hospital?

Should more have been done to help you then?

How did it feel to go home?

What was the hardest part for you?

Have you had awkward encounters?

What were the responses of family members?

How did your husband’s co-workers react?

Have similar past events occurred? How did you respond to them?

Who is your main support person?

What do you think caused your baby’s death?

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THE “FEARED” ACRONYM

A Strategy for Delivering Bad News

State the FACTS. Discuss the case.

Express EMPATHY.

Search for sources of ANGER. Tell the truth.

Have the patient REPEAT back your explanation.

Evaluate the EXTENDED family response.

DOCUMENT the conversation

and next steps.

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TeamSteppsChain of CommandChart/Tracing reviewsOb rapid response team

Physician/nurse certification of EFM

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Patient-centered rounds

RESTORINGCONTROL.

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Safety Walk-RoundsWhere are the near misses?

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21 Year old has cardiac arrest on OR table during CS.

The Debriefing Session

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Simulated obstetric education

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Thank you

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I walked a mile with pleasure,She chattered all the way;But left me none the wiserFor all she had to say.

I walked a mile with sorrowAnd Ne’er a word said she;But oh, the things I learned

from herWhen sorrow walked with me.

Robert Browning Hamilton

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Hearingbad news.

Menwomen

6 MONTHS EDC 1 YEAR

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The Letter

Dear Jimmy,

I am writing this letter to tell you of the hopes and dreams that your dad and I had for you, but were never able to tell you. We had made a lot of plans . . .

Starting the process of recovery

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“The hour I spent with Nicholas before he died was a cherished gift I will never forget. During that hour, I dressed him in baby clothes I had made. And then as they took away the tubes, I said I love you. And then he died.”

M. Det., mother to a newborn male who died at one hour with Potter’s Syndrome.

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In normal life, “I LOVE YOU” is sometimes difficult to say. “I love you” can mean “don’t ever leave

me” and also “I have to let you go now.”

Sometimes it means hello, and sometimes, sadly, goodbye.

Cox News Service. When words fail, simply say this: I love you. 9/17/01

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M.Det is a 32-year-old G2P1 who, at 28 weeks gestation, was found to carry a male fetus with renal agenesis. After several lengthy discussions, she and her husband chose to have a cesarean section, knowing full well that this condition is 100 percent lethal.

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A year ago today, my baby died.

A year ago today, around 9:15 in the morning, I held him in my arms, at home, and watched him stop breathing. And cried, and felt scared, and felt relief, and felt pain that is indescribable. I can’t believe it’s been a whole year since I last touched him, held him, heard his voice.

This day had to come. There’s no way around it. So far it’s not much more horrible than the 364 before it without Aaron. The worst part is the passage of time. It just gets farther and farther away from the time when Aaron was with us. It’s hard to remember how he *felt*.

I’ll, of course, never forget Aaron, my little Bubby. Life goes on, and so do his memories. He changed my life forever. He was a special, beautiful, sensitive, loving, wonderful child.

Thanks for listening.

On the Internet

3 June 1994

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DISCLAIMER

The information contained in this presentation and accompanying materials is designed and intended for educational training purposes. It does not constitute risk management or legal advice. For such advice, consult with an institutional risk manager, general counsel, or individual legal advisor.

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For further information about this, or other Quality Medical Communication products, please contact -

www.QMCLLCVA.com

QUALITY MEDICAL COMMUNICATION, LLC

Telephone: (860) 242-1302

FAX: (860) 242-1075

E-Mail: mail@QMCLLCVA.com

272 Duncaster Road

Bloomfield, CT 06002

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Picturesare worth

a 1000Words.

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Thank you.

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Which setting do you use to

communicate bad news?

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