RESIDENT PORTFOLIO

Words: The ‘‘Drug’’ With the HighestFrequency of Dispensing Errors

AbstractEffective communication is the key component of every patient–physician encounter and is essential forshared decision-making. ‘‘Words’’ are perhaps the most frequently dispensed ‘‘drug,’’ while communica-tion is the most frequently performed ‘‘procedure’’ in emergency medicine. Yet, communication skillsare often learned by trial and error, as opposed to the methodical approach followed for teachingall other technical procedures. The case presented below highlights the importance of incorporatingeffective communication skills as tools for our daily practice.

ACADEMIC EMERGENCY MEDICINE 2011; 18:93–95 ª 2011 by the Society for Academic EmergencyMedicine

The single biggest problem in communication is theillusion that it has taken place.

–George Bernard Shaw

Mrs. M, a 56-year-old cachectic female, pale, short ofbreath, restless, confused, and moaning, arrived in theemergency department (ED) at change of shift. Herrespiratory rate was 48 breaths ⁄ min, her blood pres-sure was 70 mm Hg by palpation, and her oxygen satu-ration was 91% on 100% oxygen via a nonrebreathermask. Her anxious husband provided a brief history atthe bedside: breast cancer diagnosed 6 months ago,with extensive metastatic disease to bone, lungs, andliver. Palliative chemotherapy and radiation failed toslow the progression of the disease, and hospice carewas recently recommended by the oncologist.

INITIAL CONVERSATION WITH AN ED CAREPROVIDER:

E mergency department provider: ‘‘Sir, your wifeis having severe shortness of breath. We need tomake a decision right now for her treatment. Do

you want us to put a tube in her lungs and put her on abreathing machine or not do anything because she hasmetastatic cancer?’’Husband: ‘‘Will that machine help her breathe and getbetter?’’

ED: ‘‘It will oxygenate her better.’’Husband: ‘‘Will she die if we don’t put the tube in?

What would you recommend?’’ED: ‘‘She will die soon without the machine. This is

not my decision; you have to let us know what youwant.’’

Husband: ‘‘Do whatever you need to do in order tostop her from suffering. I cannot see her like this.’’

Interpretation provided to incoming staff: ‘‘Thepatient is not a do not resuscitate ⁄ do not intubate(DNR ⁄ DNI). Knowing she has such widespread meta-static cancer, her husband wants everything done, sowe have no choice but to intubate, place her on a venti-lator, and admit her to the intensive care unit (ICU).’’

Reflection: Given the above conversation and choicesprovided, would anyone choose the ‘‘death and doingnothing’’ option for their loved one? Providing informa-tion for feasible treatment options and eliciting goalsof care is part of the daily practice of emergency medi-cine (EM). Failure to communicate effectively hindersthis practice of patient-centered medicine, and this per-ceived lack of communication remains the impetus formost malpractice suits initiated in medicine.1

In the busy ED environment, it is easy to make com-munication errors, not just in end-of-life situations, butduring other interactions, as well, especially if a system-atic approach is not followed. For example, after hisabdominal computed tomography (CT) scan, a patientis advised by the physician to follow-up with his oncol-ogist for worsening disease; however, only then doesthe physician discover that the patient was unawarethat he had cancer.

Emergency physicians face unique communicationchallenges: 1) the ED environment is loud with manydistractions, from beeping monitors to agitatedpatients; 2) no prior patient–physician relationshipsexist; 3) limited background information is available tohelp families make decisions; 4) acute situations oftennecessitate fast decision-making; 5) gathering informa-tion from families is a lower priority compared to sav-ing a life; 6) many patients present with preexistingcognitive deficits due to psychiatric illness, substanceabuse, dementia, etc.; 7) reimbursement favorsan aggressive procedure-driven approach; 8) time

ª 2010 by the Society for Academic Emergency Medicine ISSN 1069–6563doi:10.1111/j.1553-2712.2010.00965.x PII ISSN 1069–6563583 93

A related commentary appears on page 96.Supervising Editor: Carey Chisholm, MD.

constraints due to overcrowding; 9) lack of privacy andadequate space to sit down and converse; 10) emotion-ally charged and sometimes hostile situations due to anunexpected or traumatic death; and 11) patients withvaried cultural backgrounds and sometimes significantlanguage barriers. However, effective communication isthe backbone of daily EM practice since, along withpatients, we routinely interact with multiple consultantsfrom varied fields, primary care and prehospital careproviders, hospital administrators, and varied ED staff,from volunteers and security personnel to nursing andmedical students. Understandably, eliciting patient pref-erences and determining goals of care takes time, and abusy ED is not conducive to lengthy communications.Therefore, it is vital to learn techniques to be efficientcommunicators and to develop a consistent approachto every medical encounter.

Communication remains one of the six core compe-tencies for EM residency training.2 Established guide-lines exist for performance and certification in manyEM procedures. For example, a central line placementtriggers an automatic mental checklist so all steps frominitial site identification and obtaining supplies to dis-carding all used sharps and ordering a follow-up radio-graph are meticulously followed. However, no specificguidelines to teach skills for effective communicationare offered, and it is still a skill often learned by resi-dents using a ‘‘trial-and-error’’ method.3 Perhaps com-munication should also be taught like a procedure, so ittriggers a similar consistent mental checklist.

Current communication literature is often compart-mentalized and addressed as a subspecialty-specificapproach.3–5 Emphasizing an approach such as the‘‘delivery of bad news’’ encourages its use only in spe-cific situations.3 Communication is taught as an art, nota science, with phrases like ‘‘empathize’’ and ‘‘acknowl-edge,’’ which are not familiar to procedure-based spe-cialties. A review of the literature reveals some commonthemes that emerge across disciplines, and incorpora-tion of these elements may provide an effective tool toteach a consistent approach to communication in theED. The act of ‘‘preparation’’ is highlighted: 1) familiar-ize oneself with background information, 2) set a cleargoal for the discussion, and 3) prepare the environment(seating for all participants preferred), because this sig-nals the importance being placed on the discussion.4–6

Eliciting a summary by the patient or family has alsobeen well established as a way of creating rapport, aswell as establishing a baseline to build on.4–7 Identifyingthe patient’s ⁄ family’s main concerns with a direct ques-tion is important to create a shared agenda.4–6 The clos-ing of an encounter by highlighting some defined ‘‘nextsteps’’ for patients and families helps lend a sense ofcontrol and emphasizes nonabandonment.4

Consistent and regular application over time is neces-sary to develop and retain a skill, and mnemonics arefamiliar to most learners as memorizing techniques.8

Some mnemonics like ‘‘SPIKES’’ (setting, perception,invitation, knowledge, empathy, summary), which isused for communicating ‘‘bad news,’’ may have anaction-based, wider applicability. For clinicians inter-ested in pursuing further skill-enhancing courses, theEducation in Palliative and End-of-life Care (EPEC-EM)

is an excellent resource.9 In conclusion, a consistentprocedural approach to effective communication is nec-essary to practice a shared decision-making andpatient-centered model of care.

A SECOND CONVERSATION WITH MRS. M’SHUSBAND FOLLOWED:

Emergency department provider: ‘‘Sir, let us step intothe next room which is quieter, so we can concentrateon discussing the best care options for your wife andher condition.’’—Preparation

ED provider: ‘‘Tell me about what has been going onwith Mrs. M and what you know of her condi-tion.’’—Eliciting a summary

Husband (crying): ‘‘She is dying, and she is sufferingfrom the cancer spread all over her body. Her breath-ing is getting worse and she kept refusing to come tothe hospital for the last week. Today I just could not seeher suffering and decided to bring her in.’’

ED provider: ‘‘I understand this must be very difficultfor you. Looking at her oncologist’s notes, it also seemslike the disease is widespread with no hope for cureand hospice was offered. Is that right?’’—Preparation,validation of emotions, empathy

Husband: ‘‘Yes, we all know she is dying but thoughtwe had more time.’’

ED: ‘‘Since you know your wife best, can you helpme understand her views regarding her disease andwhat would be her main concern now, if she could talkto me?’’—Establishing decision-making as proxy forpatient, eliciting main concerns

Husband: ‘‘She is an independent, stubborn woman,and dislikes hospitals. She fought the cancer hard, butshe would have told you that she hates being helplesslike this.’’

ED: ‘‘Since we know there is no cure for her cancer,we should focus on her now and not the disease. Basedon what you have told me about her, I do not recom-mend a breathing machine because it will not help totreat the cause of her suffering and may actually pro-long it. We will make sure we do everything to makeher comfortable and decrease her discomfort. Are thereany concerns or questions you have that I can help youwith?’’—Eliciting concerns, offering recommendations,summary of plan

Husband: ‘‘I want a pastor to perform last rites. Sheis a woman of faith.’’

ED: ‘‘We will call the pastor and give her some medi-cations through her IV to decrease her discomfort. I willbe here to answer any other questions that you mighthave.’’—Emphasize nonabandonment, outline next steps

The patient died in the ED 45 minutes later with herhusband, son, and pastor at the bedside. The familywas grateful to the ED staff for providing their lovedone a peaceful death and giving them a chance to saygoodbye to her.

Sangeeta Lamba, MD(lambasa@umdnj.edu)Department of Emergency MedicineUMDNJ–NJMSNewark, NJ

94 Lamba • Words

REFERENCES

1. Levinson W, Roter DL, Mullooly JP, Dull VT, FrankelRM. Patient-physician communication: the relation-ship with malpractice claims among primary carephysicians and surgeons. JAMA. 1997; 277:553–9.

2. Council for Graduate Medical Education. ACGMEHome page. Available at: http://www.acgme.org.Accessed Jan 19, 2010.

3. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA,Kudelka AP. SPIKES-A six-step protocol for deliver-ing bad news: application to the patient with cancer.Oncologist. 2000; 5:302–11.

4. Levetown M; Committee on Bioethics. Communicat-ing with children and families: from everyday inter-actions to skill in conveying distressing information.Pediatrics. 2008; 121:e1441–60.

5. Billings JA, Keeley A, Bauman J et al. Mergingcultures; palliative care specialists in the intensive

care unit. Crit Care Med. 2006; 34(11 Suppl):S388–393.

6. Weissman DE. Fast Fact and Concepts #6; DeliveringBad News. June 2000. End-of-life Physician Educa-tion Resource Center. Available at: http://www.eperc.mcw.edu. Accessed Jan 13, 2010.

7. Mauksch LB, Dugdale DC, Dodson S, Epstein R.Relationship, communication, and efficiency inthe medical encounter: creating a clinical modelfrom a literature review. Arch Intern Med. 2008; 168:1387–95.

8. Hulme C, Roodenrys S, Brown G, Mercer R. The roleof long-term memory mechanisms in memory span.Br J Psychol. 1995; 86:527–36.

9. Northwestern University. EPEC: Education in pallia-tive andend-of-lifecare.Availableat:http://www.epec.net.AccessedOct18,2010.

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