How to tell the family that the patient is dead

[hurricanemd]

I just witnessed the absolute wrong way to do this last night. It really got me thinking, what is the best way to tell someone bad news?

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[EM_Rebuilder]

I just witnessed the absolute wrong way to do this last night. It really got me thinking, what is the best way to tell someone bad news?

Good Point by FISKUS!!

Introduce yourself as Dr whatever. Ask the relationship to John Smith (confirming its the right family). Say that John has been in a very terrible accident (or had a terrible condition..whatever fits) and we had out entire trauma (or medical staff...again whatever fits) team working on him/her, we put a tube in to breath, we pumped the heart with CPR, we gave several drugs to try to restart everything in the body...however all our attempts failed. I am sorry but your whatever has died.


Save the outcome for the very end and say died as there is no grey area with that (no longer with us, passed on, etc may be mis-interrputed). If you say died first, they wont hear anything else you say. They need to hear you 'have done everything' and hear that dreaded d word at the end. Expect the entire room to break down after the d word comes out; just prior to that expect to have people fixated on your like never before. Also, some people try to interrupt "did he die" "is my baby gone", but I think its best to just keep talking through it and stick with the above plans... Consider hand shakes or hugs or just get out of there (with more I'm Sorrys if they can be squeezed in)... I think 'you just know' which one will be right with the particular family you are with. Also, last thing you should mention, is to please give us a few minutes and then you can come back and visit, and our social worker will be here to talk to you.


If its a long standing thing, its unlikely the family will be as frantic about the idea...and if you are in more of a PCP setting and know the family better, you can be more fitting to the situation as in he went home (if you are 100% they are very regliious) or it was his time.... I dont think that is appropiate in the typical emergency department setting though.

Just my measly experiences as a PGY1...

 

[FISKUS]

Rule #1 - Always make sure you are talking to the correct family ( I am not kidding)

 

[Wackie]

Along this same topic (and if I need to start a new thread just e-kick me and I'll move), how many will let family come in while running a code?
One doc offers to let family in (telling the team to watch their mouths as family is coming in) and explained to me that sometimes it's good for them to actually see that you're doing everything possible.
But he doesn't offer that to everyone. Not sure how he picks which people he'll offer that to. Maybe it's situational as much as how the family is taking things so far.

 

[dchristismi]

I've done that before... it was a medical case while I was covering the ICU. Gentleman coded on the floor for no apparent reason, got him back, was working him up and family is arriving. Had lengthy discussions with his adult children (mind you, it's 1 am), and a daughter decided to stay the night. It was her birthday. The patient dwindled for the next few hours, and began bradying down around 3:30am. I told the nurse to go get her, and we quietly coded grandpa for awhile while his daughter held his hand and said goodbye.

I think that the family really appreciated it, and since it was a well controlled situation, I didn't have a problem bringing them in. Now, if it had been in the trauma bay, I don't know how I feel about that yet.

As far as breaking bad news, always fire a warning shot - don't just drop the bomb. That moment when they realize what you're about to say and start backing away from you, is truly awful. Yes, you must use the word "died." And I try to have a chaplain there if possible - especially if it was a sudden, unexpected death.

Danielle

 

[Mighty Mouse]

also remember...you don't need to go in there alone. pastoral care (the god squad as we refer to them as) should come with you. that way you can deliver the news, let pastoral care do their thing, and then perhaps come back in after the hysteria is over and answer any further questions they have.

 

[docB]

I do let the family see the code. I think it helps them understand what we mean by "we tried everything."

When the family arrives by car at the main entrance and I have to go get them I will extend codes so they can see and I can start them off with "Things look really bad." rather than "They're dead."

I usually start off with "What do you know about what has happened so far?" It gives you an idea of if they have a grasp of how bad it is and if it's expected or not. In a one week period I had two polar opposite families. One said "Well they were doing CPR so I know it's very bad." That was a guy with some understanding. Another family said "Yeah she always gets like that so when the ambulance takes her we go get dinner then come in to the ER. Can we see her now?" That was a tough one.

I'm all for using clergy or pastoral care or social work or a drunk guy with a soothing voice or whatever. For the death that happens during bankers hours on the alternate Fridays not during a new moon when they're not busy I'm happy to use them.

 

[southerndoc]

We were trained in medical school how to deliver bad news. We learned a four-step approach:

1. Ask them what they know so far (i.e., get a basic history of events),
2. Summarize steps taken by everyone on the team,
3. Deliver the news (as many have mentioned, specifically say "died"),
4. Offer condolences and ask if they have any questions.

This has worked the best for me when delivering bad news. Asking them what they know happened can give you a lot of information as to how to deliver the news. It's different delivering news to someone who answers that question "the paramedics said his heart stopped, they were doing CPR and trying to revive him" as compared to "I don't know, somebody said he passed out at work."

As others have said, make sure you're delivering news to the correct person. Also, make sure you have a chaplain or somebody else that can stay with them after you leave (this is the best approach if you have the staff to make it available).

 

[oldbearprofessor]

If you don't mind someone coming in from another field who does this too regularly, I would absolutely agree with using the term "died" rather than passed away, etc.

I would say that we have always taught that for babies in the hospital (your situation is quite different, I understand), that it is important to get to the fact of the death fairly early on in the discussion. This is especially true when one is calling by phone. Although this happens rarely, it does happen that a critically ill baby dies suddenly at night and the parents aren't there and it wasn't expected.

We know that parents assume that all phone calls at night when their child is in the NICU are bad news (mostly true, but of course, many are just to let them know about sepsis work-ups, etc), so they will not really be listening -they are waiting to hear if their baby is still alive. Details will come when they arrive at the hospital. So, although you may give a few sentences about what happened up to the death, we try to get to the bad news, whether it is death or a very serious setback (e.g. NEC) quickly in the conversation, give the families time to process a bit and go on. Everything will need to be repeated anyway.

Finally, in terms of babies, I'm sure you wouldn't do this, but we are always careful to avoid saying things like "Now you have a little angel in heaven", or "it was for the best [because s/he was so sick]", etc.

Hope this is helpful.

 

[SolidGold]

I just witnessed the absolute wrong way to do this last night. It really got me thinking, what is the best way to tell someone bad news?

Just out of curiosity, how wrong was it?

 

[katrinadams9]

Just out of curiosity, how wrong was it?

I haven't had any bad experiences yet, thank god.

 

[hurricanemd]

Just out of curiosity, how wrong was it?

Let's see:

1. It was done in the middle of the hallway, not in a private setting.
2. The resident did not wait for the whole family to get there, he just told the one daughter and I guess she must've told the others after we left.
3. He didn't even look her in the eyes when he said her mom was dead, just looked at the ground the whole time.
4. The phrase "I'm sorry for your loss" was not used (nor was anything remotely like that in what was said).
5. There was no pat on the shoulder or hug.
6. He didn't say anything like how nice her mother was while she was with us (and she was a very nice old lady).
7. The daughter wasn't even sitting down when she was told.
8. My resident didn't ask if she had any questions, just told her and walked away.

Those are just some things that I noticed and would not want to happen if I was ever on the receiving end of bad news.

 

[Hawkeye Kid]

agree with ID'ing not only the correct family, but also finding out who's who. this is especially true when you're talking to a large family--i was tought to identify the primary players (ie. spouse, parents, etc) and to try to address them directly if possible.
also agree with the warning shot right before the d-word and using the d-word. i've heard people talk about saying it three times in three ways to make sure it gets across (something like "he died. he's dead. he's no longer with us.") but i'm not sure i like that too much and i've never used it or actually seen it done.
finally--and this seems like common sense, but i've seen it happen--do not blame the patient, even if you're 1000000% sure that their death was the direct consequence of their actions. i actually had a security guard with me one night, in addition to SW, and he chimed in after i was done that "witnesses said he was driving over 100mph and we think he was drunk." while i'd heard the same story and it was probably true, it did absolutely no one absolutely no good to hear that, and obviously it wasn't his place to speak anyway. luckily i was working with a great SW who quickly doused that fire.

 

[roja]

Ditto what docB and southerndoc said. All excellent points and a good protocol to follow.

Ask what they know
Tell them what has been done
Tell them they have died
Ask them if they need anything else. (can you call someone, pastor, etc)

Most importantly, be sincere.

 

[leviathan]

Ditto what docB and southerndoc said. All excellent points and a good protocol to follow.

Ask what they know
Tell them what has been done
Tell them they have died
Ask them if they need anything else. (can you call someone, pastor, etc)

Most importantly, be sincere.

I was taught the same. They know what you're going to be telling them the whole time, but it doesn't seem to finally sink in until you say those words "s/he has died."

 

[docB]

I grant that things could have been done better however sometimes it's tough to do it in the best way possible.

Let's see:

1. It was done in the middle of the hallway, not in a private setting.

We usually don't have a private "quiet" room. Unless we're really slow it's the hallway or the bathroom. I opt for hallway.

2. The resident did not wait for the whole family to get there, he just told the one daughter and I guess she must've told the others after we left.

I often don't wait for the whole family as that can take hours/days. Tell someone and let them fill in the stragglers. Be available for questions that the nurse can't handle. It's often better coming from a family member.

3. He didn't even look her in the eyes when he said her mom was dead, just looked at the ground the whole time.

You do have to be authoritative. Be the guy in charge. "I took care of your loved one. We did everything we could and he died." Don't create the bad situation where they feel like no one knew what was going on, no one was in charge or that if they talke to someone else the info will be different.

4. The phrase "I'm sorry for your loss" was not used (nor was anything remotely like that in what was said).

If it was an oversight it was probably due to anxiety and being uncomfortable with delivering bad news. Some docs have been told by legal types that they should never say "I'm sorry." because it could be used in a lawsuit as an admission of negligence. I disagree with that train of thought and think that "I'm sorry for your loss." or the one I usually use "I'm so sorry to have to tell you this." help more than they hurt.

5. There was no pat on the shoulder or hug.

This is a plus or minus. You have to get a gut felling about the person and decide if they will react well to physical contact or not. Sometimes it's a bad idea such as with family members who are angry.

6. He didn't say anything like how nice her mother was while she was with us (and she was a very nice old lady).

Plus or minus. You don't really know the person. They will likely not recall most of the conversation except the hammer.

7. The daughter wasn't even sitting down when she was told.

Like the quiet room this is not always possible. Do watch for people who may syncopize on you.

8. My resident didn't ask if she had any questions, just told her and walked away.

Those are just some things that I noticed and would not want to happen if I was ever on the receiving end of bad news.

Again, probably anxiety on the resident's part. Those kind of oversights get better with experience.

 

[hurricanemd]

I grant that things could have been done better however sometimes it's tough to do it in the best way possible.

We usually don't have a private "quiet" room. Unless we're really slow it's the hallway or the bathroom. I opt for hallway.


I often don't wait for the whole family as that can take hours/days. Tell someone and let them fill in the stragglers. Be available for questions that the nurse can't handle. It's often better coming from a family member.


You do have to be authoritative. Be the guy in charge. "I took care of your loved one. We did everything we could and he died." Don't create the bad situation where they feel like no one knew what was going on, no one was in charge or that if they talke to someone else the info will be different.


If it was an oversight it was probably due to anxiety and being uncomfortable with delivering bad news. Some docs have been told by legal types that they should never say "I'm sorry." because it could be used in a lawsuit as an admission of negligence. I disagree with that train of thought and think that "I'm sorry for your loss." or the one I usually use "I'm so sorry to have to tell you this." help more than they hurt.


This is a plus or minus. You have to get a gut felling about the person and decide if they will react well to physical contact or not. Sometimes it's a bad idea such as with family members who are angry.


Plus or minus. You don't really know the person. They will likely not recall most of the conversation except the hammer.


Like the quiet room this is not always possible. Do watch for people who may syncopize on you.


Again, probably anxiety on the resident's part. Those kind of oversights get better with experience.

The thing is, this particular resident is a senior. There was a family room just down the hall that was not being used at 2am. Her sister was on her way. I felt like this woman could have used a hug or some kind words about her mother. The patient was on her way slowly downhill (we had consulted hospice to start discussing palliative care the next day), but she went very quickly and I felt it was unexpected for the family.

 

[docB]

The thing is, this particular resident is a senior. There was a family room just down the hall that was not being used at 2am. Her sister was on her way. I felt like this woman could have used a hug or some kind words about her mother. The patient was on her way slowly downhill (we had consulted hospice to start discussing palliative care the next day), but she went very quickly and I felt it was unexpected for the family.

Some seniors don't have a lot of experience with it and some are just bad at it. Many attendings are just bad at it. It's good to see it when it goes wrong so you can know what pitfalls to avoid. The surgical residents have a saying that goes something like "You will never learn as much as you do assisting with a surgery that goes bad." It's the same with EM.

 

[hurricanemd]

Some seniors don't have a lot of experience with it and some are just bad at it. Many attendings are just bad at it. It's good to see it when it goes wrong so you can know what pitfalls to avoid. The surgical residents have a saying that goes something like "You will never learn as much as you do assisting with a surgery that goes bad." It's the same with EM.

That thought did cross my mind.

 

[TysonCook]

There is also some data from other fields that Michelle Biros (Hennepin) has discussed with our program that helps other than what is discussed above. I make sure that I bring it up when doing the "death talk":

1. It was quick (nobody wants to hear about a drawn out struggle of life and death for hours)
2. They felt NO or little pain (this should be honestly true, but #1 fear of death and dying process is if it is painful).
3. They were not alone Next biggie is that people are afraid of dying alone.

You can do a very reasonable job by being honest, saying your sorry for their loss and working in the above, several times if necessary.

If you are an intern, MSIV, or off service who doesn't do too much "death talk", ask if you can tag along with an upper level who has experience. Take a mental note of what you liked, and didn't like, some day it will be your turn and the family will remember you.

 

[Midwest Medic]

We were trained in medical school how to deliver bad news. We learned a four-step approach:

1. Ask them what they know so far (i.e., get a basic history of events),
2. Summarize steps taken by everyone on the team,
3. Deliver the news (as many have mentioned, specifically say "died"),
4. Offer condolences and ask if they have any questions.

I might add
5. Tell them that you are having pastoral care/social work come to visit with them to help them through the next few steps after this.

 

[southerndoc]

I might add
5. Tell them that you are having pastoral care/social work come to visit with them to help them through the next few steps after this.

Not a situation in my hospital since we have a chaplain or the social worker present when we deliver the news.

 

[nevadan]

ACtually there is a psychological study that states that you need to say the word death, died, or any form of that word in the first 2 sentences. It shows a better outcome for the family/friends

 

[Flopotomist]

One question I have is what is the actual procedure for the family to follow after the notification in terms of getting their loved one from the ED to the actual grave. Do they call a funeral home? Do they call the coroner to get the body released? What happens? Seems like the logistics are something that would be good to know.

 

[gutonc]

One question I have is what is the actual procedure for the family to follow after the notification in terms of getting their loved one from the ED to the actual grave. Do they call a funeral home? Do they call the coroner to get the body released? What happens? Seems like the logistics are something that would be good to know.

The logistics go like this: Patient X dies (or arrives dead in the truck/chopper) --> Tell Family X that Patient X is dead --> Tell unit clerk/secretary that Patient X is dead --> Fill out death certificate on Patient X --> A lot of other crap that you don't have to deal with because the hospital pays people to do it --> Patient X has autopsy/funeral/memorial service --> Patient X is buried, interred or sprinkled in the ocean/forest/mountain/garden/living room. The End.

I suppose if you wanted to learn what happens in the middle there you could ask the AOD next time it happens but I imagine you have more important things to do.

 

[mikecwru]

One question I have is what is the actual procedure for the family to follow after the notification in terms of getting their loved one from the ED to the actual grave. Do they call a funeral home? Do they call the coroner to get the body released? What happens? Seems like the logistics are something that would be good to know.

To answer this question, you need to have a little knowledge of the procedures for your state.

In Ohio, most deaths that weren't expected in 24 hrs (ie cancer, etc) are automatically coroner's cases. A coroner's case doesn't always mean autopsy, but that means the body has to be viewed by the coroner for the decision to autopsy. If you meet certain exclusion criteria and you have a doctor willing to sign the death certificate GIVING the cause of death, then the body has potential to be released to the family (funeral home).

Usually, the body is being released to the coroner for me. I don't sign the death certificates usually, sometimes I can get ahold of their oncologist who will, etc.

mike

 

[Dr.Evil1]

Another biggie, especially in the ED sense of things is that you need to have someone else to hand the family off to. You can only be there so long before you have to go back to work in the pit. I suggest having either a social worker or pastor etc...whoever you can get to be there with you. Sometimes it is advisable to let security know so that if things get out of hand there is someone that is at least aware of potential for confrontation.

 

[146233]

Sometimes it is advisable to let security know so that if things get out of hand there is someone that is at least aware of potential for confrontation.

I've seen a trauma center or two here use this as their form of a chaplain. Makes things interesting.