Bereavement

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Bereavement The Art of Giving Bad News
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What is bad news

• DEATH
• Life-threatening injury or condition
• Severe injury / loss of function
• New diagnosis
• Prognosis outlining the horizon

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Who should give Bad News (about death dying)

• For inpatients
• Registrar
• Consultant
• For outpatients
• GP
• Consultant
• The Intern / RMO should NEVER need to break bad
  news to a patient or family.

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Why is it important to be good at Bad News?

• We do it often
• When we do it poorly, its a disaster
• We often do it poorly
• Were not taught,
• We have few protocols.
• When we do it well, its both uncomfortable and
  distressing. It hurts us too.

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John Donne (1572 1631)
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Any man's death diminishes me because I am
involved in mankind and therefore never send to
know for whom the bell tolls it tolls for thee.

• John Donne
• from Meditation XVII

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Basic Principles
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• Tell them in person
• NEVER over the phone
• (but if you must there are rules).
• Tell them together
• UNITED WE (can) STAND (it)
• The family is a unit.
• No family is so dysfunctional that it cannot be
  made weaker and worse by splitting the unit

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• Psychological protection Girding the loins
• (telling them that shes gone up on the roof.)
• Im sorry, but I have bad news I must tell you
• I have bad news for you
• I have to tell you about your son. The news is
  not good.

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• Regression of Coping mechanisms
• When confronted with new stressors / unfamiliar
  situations, people regress to simple coping
  strategies.
• youll always be talking to a bunch of teenagers
• Responses are unpredictable
• Anger, denial, bargaining, depression
  (acceptance)
• Transference
• Dont expect to be liked.

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Medical Coping Mechanisms

• Doing something clever
• Having the answer

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Information.

• Information is dangerous
• Too much
• Too little
• Too early
• Wrong time
• Wrong people
• Having the answer as a coping mechanism

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• Im sorry Mrs Jones your husband is dying, and
  all I can really do for you is make you a cup of
  tea.

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• Statements like I know how you feel are to be
  discouraged.
• You do not know how they feel!
• Even if you have had an identical experience, you
  only know how you felt at the time, not how they
  feel.

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Team Approach to Bad News

• Two Member team
• News-Giver (senior doctor)
• Representative of authority
• Support-Giver (RN, social worker)
• Trustworthy
• Nurturing
• Compassionate

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The Process of Giving Bad News

• Step by Step
• Eight simple (but never easy) steps

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Step 1.

• Support-Giver brings family together into a
  quiet, private environment.
• Adequate chairs
• Tissues
• Cold water / tea / coffee
• Phone
• Support-Giver establishes central family
  members within the group.

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But they want to know what has happened? What
do I say?

• Your fathers condition has deteriorated. The
  doctor will be here soon, she would like to speak
  with you.
• I dont have that information at the moment
• The Support-Giver must not break news.
• The News-Giver must not unduly delay the
  interview with the family. 5 minutes is an
  eternity of waiting.

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Step 2.

• Support-Giver introduces News-Giver to family,
  and introduces central family members.
• This is Dr Brown, our medical registrar. Dr
  Brown, this is Mr Smiths wife and two sons.
• News-Giver confirms their name / position and
  role for the family.
• I am Dr Brown, Im the medical Registrar whos
  been looking after Mr Smith.

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Step 3.

• News-Giver gives news.
• May commence with a question about the familys
  understanding of the situation.
• Use simple, brief statements
• Avoid euphemisms clichés
• DEAD mental full stop for 60 70
• Ask for questions.
• Support-Giver remains in room
• Says nothing
• Defers direct questions to the News-Giver

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Step 4

• News-Giver leaves for 5 10 minutes
• Support-Giver
• Answers any questions they can
• Offers to contact family / friends
• Offers to contact clergy / religious leader
• Offers water / drink / tissues
• Gives support

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Step 5.

• News-Giver returns
• Answers questions as able
• May need to explain coronial processes
• Offers the family the opportunity to view the
  body
• would you like to come and sit with your
  fathers body for a while?

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Viewing the body

• viewing is actually being in the presence of
  the body.
• Viewing is very important
• 20 - 30 request to view the body
• 70 - 80 want to in retrospect
• No-one MUST view the body
• No-one MUST NOT view the body

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Step 6Practicalities of viewing

• Ensure adequate chairs available
• Explain the scene prior to going in
• Both members of the team escort the family into
  the scene.
• Allow the family to stay as long as they like,
  and behave as they like (within reason)
• (viewings at funeral directors)

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Step 7.

• Formally disengage contact with the family.
• When they, or you, are leaving
• Answer any questions
• Give contact numbers

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Step 8Staff Support - Remember that you will
take something away each time.

• Team members take a 30 45 minute break
• Think about what you have taken away
• Watch yourself for signs of depression, anxiety.
• Be receptive to the observations of your
  colleagues.
• Consider counselling.
• Actively seek out positive experiences.

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Absent Family

• What to do when youre NEVER giving Bad News over
  the phone.

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Principles are the same.

• Much harder to get feedback
• Introduce yourself first.
• Your fathers condition has deteriorated, can
  you come in to the hospital?
• We need you to come in now. I will speak with
  you when you get here.

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If NOT able to come in

• Assess their situation
• Are they with someone
• Can we / they contact someone
• Are they sitting down
• (the only cliché youre allowed to use.)

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Finally .

• Look out for yourselves.
• Be attentive to your moods, your relationships
  (particularly your families)
• Listen to the advice of your colleagues
• Actively seek positive experiences.

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