Breaking Bad News at the A&E

A recent resuscitation case at the department prompted me to write this post.

Attending to collapse and resuscitation cases is something we are prepared to do as emergency doctors and nurses, but sometimes we may be too caught up with the medical situation (What is the cause of the collapse/ what drugs should I give/ Should I defibrillate etc) that we do not give enough thought to the anxious family members waiting outside the resus room. Managing them can be as difficult, if not more difficult, than managing the collapsed patient himself.

Throughout my career in emergency medicine I have had my fair share of resus cases. In some cases we manage to restore a rhythm and BP, but the majority of cases do not make it despite our best efforts. Below are some practical points that might be helpful for the doctor who is about to break the bad news to the anxious and expectant family members.

(1) Always prime and prepare the family members. The resuscitation period may be prolonged, and during this time, someone should update the family members regularly. If the outcome does not look good, the family members should be prepared mentally to be ready for the worst, so that when the eventual bad news is broken, the impact would (hopefully) be less devastating.

(2) When it's time to break the bad news,

• location - choose an empty consultation room where all the family members can be gathered around. Some departments have specific grieving rooms for this purpose. Do not break the news in the common areas (e.g. at the counter/ waiting area) if possible. This is to allow the family members privacy and dignity while they grieve, and also to minimize emotional disturbance to the other patients in the department.
• Have another staff on hand to assist you while you break the bad news. You never know how people may react.
• If possible, have enough chairs around the room so people can be seated. The last thing you want is a vasovagal syncope and head injury after you break the bad news.
• Speak in a slow and clear manner. Be factual. Explain the sequence of events that has taken place during the resuscitation but avoid excessive jargon or details. Maintain good eye contact all the time.
• Be direct and non-ambiguous. Say something like, 'Despite our efforts, we were unable to revive so-and-so. He has died/ passed away.' Do not use vague terms such as 'he has gone to a better place' or 'he is no longer with us' - you may find it easier speaking this way, but the family members may end up confused.
• Do not talk too much ! After breaking the news, it is useful to pause and allow the information to sink in. Keep a respectful and sympathetic silence, but do not rush out of the door straight away (even though you have another 10 patients waiting). Allow the family to grieve, but be on-hand to answer any questions or render assistance they need.
• Avoid saying things like 'I understand how you feel' or 'Don't worry the pain will ease with time'. You do NOT understand how they feel - you will go home to your loved ones after your shift, but their loved one will never come back. The pain may indeed ease with time, but this is neither the time nor place to say it.

(3) Viewing the body

• once the nurses have tidied up the resus area, the family members should be allowed to view the body and say their goodbyes.
• Before they enter the room, prepare them for what they are going to see, e.g. endotracheal tubes/ IV lines/ chest tubes etc, so they are not shocked when they see it.
• If there are any other patients in the same room/ area, transfer them elsewhere so the family has privacy, and the other patients are not emotionally traumatized.
• This is the most emotionally-charged part of the process - expect an outpour of raw emotions, predominantly grief. It is hard as a human being not to be affected by such scenes, hence one must remember to take a step back - remember our job is to be in the background respectfully, giving them the space and time to grieve but be ready to assist them at any time they need us.

(4) Coroner's Case

• Most deaths at the A&E end up being Coroner's cases, because of their sudden and unexpected nature. It can also be a difficult subject to broach with the relatives, sometimes even more difficult than the news that their loved one has died.
• Personally I usually do so at a later time (after they have come to terms with the demise of the patient) rather than give them 2 blows at the same time. Another method I find useful is to speak to someone who seems to be in an authoritative position and who seems less emotionally affected (e.g. the eldest son).
• Again, be firm and factual. Explain that you are obliged under the laws to make the case a Coroner's case rather than sign it up. Explain the process it entails (notifying police, transferring body to SGH Forensic Path dept etc) and reassure them that your staff will assist them in this.
• Most of the time the family will ask whether an autopsy will be conducted. I always tell them it is up to the discretion of the Coroner, who is assisted by the forensic pathologist. Show that you understand their concerns. Sometimes the family members may request you to include in your notes that they hope an autopsy can be avoided. Personally I will include that information in my notes, but I always tell them that the ultimate decision still lies with the Coroner.

Whatever emotional trauma the medical staff may encounter during a resuscitation, remember that the family members experience it a hundred times worse. You have lost a patient, but they have lost a father/ spouse/ child. Respect and acknowledge their grief, do not trivialize nor magnify it. Be empathetic and professional.