RESIDENT PORTFOLIO

Reflections on Giving Bad News

AbstractDeath in the emergency department (ED) is fairly common. Giving bad news can be difficult, but it is askill that is vitally important for the emergency physician. In the past it may have been difficult to findgood resources on the subject, but now there are many reviews and guidelines; the SPIKES andGRIEV_ING protocols are two such guidelines. Furthermore, giving bad news is now taught in medicalschool and residency. This reflection is about giving the news of the death of a family member over thetelephone. Little literature addresses giving bad news over the telephone.

ACADEMIC EMERGENCY MEDICINE 2012; 19:356–358 ª 2012 by the Society for Academic EmergencyMedicine

I magine that you are a parent with a 23-year-old son.Perhaps you already are. He lives in Center City Phil-adelphia; a Temple graduate, he has a professional

job in the city. You live more than 5 hours away, in theTri-state region. It is midnight and raining outside. Theringing phone jars you from your sleep. It rings a fewtimes before you answer.

‘‘Hello?’’ You fumble and murmur, a little groggystill.

‘‘This is Dr. Gilmore from Thomas Jefferson Uni-versity Hospital. Is this Mrs. Smith, mother of JonSmith?’’

Confused, you affirm you are.

‘‘I took care of Jon tonight. I have to tell you aboutJon. Are you sitting down?’’

‘‘Why? Why would I need to sit down? Is he ok?’’

‘‘Jon came to the emergency department tonight.I have some news, and it is not good.’’

You are awake now.

‘‘What happened to my Jon?’’

‘‘Jon arrived at our emergency department by taxi.He was not breathing on his own, and his heartwas not beating when he arrived. We had a team ofdoctors, nurses, and technicians helping Jon. Wedid everything we could. We performed CPR andpushed on his heart to keep it pumping. Webreathed for him. We worked for a long time, butJon did not make it and he died. He is now dead.’’

You scream as you drop the phone and leave theroom. Soon, your husband picks up the phone. ‘‘Whathappened?’’ he asks quietly.

The same conversation is repeated, this one not end-ing with Mr. Smith dropping the phone. Silence falls.Dr. Gilmore waits quite some time, finally stating ‘‘Doyou have any questions? Is there anything I can do foryou now?’’

‘‘No.’’ The words barely escape his dry lips.

‘‘Jon is here at Thomas Jefferson … you shouldcome to the hospital. Please feel free to call theemergency department with any questions youmight have.’’

I wish sincerely this was a fictional conversation, butit was not. It was a conversation I had with a family2 hours after my shift had ended. Jon Smith hadarrived by cab around 9:59 (my shift ended at 10 PM). Ithad rained very hard that night. What we did not andcould not have known at the time as I ran to the frontdoor and pushed his wet lifeless body atop a stretcherwas that his friends had put him in a cab. They hadjumped out of the car a block away from the hospital,leaving the cab driver dumbfounded. The cab driverpulled up to the emergency department (ED) and askedfor help. After the body was pulled out of the cab, hedrove away. We brought Jon to the resuscitation bay,initiated CPR, checked his vitals, found his very lowcore temperature, attempted multiple intravenous lines,checked his blood sugar (which was low, followed byD50 and glucagon bolus IM, as access was nearlyimpossible), prepared for intubation, tried to open hisjaw, and found it was rigid. Why was it rigid? The restof his body was soft? We pulled apart his lips. No evi-dence of a wired-shut jaw. We began to realize thefutility of our efforts, but continued the code anyway.He was 23, barely yet embarked on his life. He couldhave been cold and severely hypothermic, so wepressed ahead. Wishful thinking as it was, we knew hewas dead. Eventually, an attending rushed into theroom, as this resuscitation had not been paged over-head. The attending hears the details of the case. Thecode is called. Our efforts cease.

ISSN 1069–6563 ª 2012 by the Society for Academic Emergency Medicine

356 PII ISSN 1069–6563583 doi:10.1111/j.1553-2712.2012.01305.x

A related commentary appears on page 359.

The police arrived after I had called Jon’s parents,and we gave them the story. The police believed he hadlikely overdosed on drugs. Perhaps his friends wereusing with him and, in their stupor, discovered he haddied. They brought him to the hospital. They broughthim to the hospital for me to deal with. They broughthim to the hospital so I could call his family in the mid-dle of the night and inform them their son was dead.

I wonder if I did the right thing by calling. I rememberfilling out the death packet. When we discovered theidentity of his parents, we realized they lived very faraway. ‘‘I think we should call his parents and let themknow,’’ I numbly told my attending. The morgue ready,the staff asked me insistently if I had completed thedeath packet. Space is at a premium when the waitingroom is full. Jon Smith was reaping no benefit from aroom at our hospital. I wondered: should I tell them tocome to the hospital, so we can tell them the news inperson? Who is going to tell them, someone at the mor-gue? A person who knows nothing about what hap-pened? Should I sign this out to another resident? Theywould not know what happened really, and they mighthave to sign it out to another distant person, who at thatpoint would be so far removed from the situation, emo-tions might not even be stirred. I imagined the interac-tion of someone forgetting to sign out Jon Smith’sdeath—with his parents on the way to the hospital.

Imagine that hours later the Smiths enter the hospi-tal. They walk up to the registration desk. ‘‘We weretold to come here by Dr. Gilmore. It’s our son, JonSmith. Can you tell us anything? Anything at all?’’ Reg-istration finds the triage nurse, who comes out andannounces after checking, ‘‘Jon is not on the board, buthe may have been admitted … let me go find out.’’

The triage nurse approaches the attending. ‘‘Doyou know anything about Jon Smith?’’

‘‘Jon who? I haven’t heard anything about him,’’says the attending absentmindedly, with his mindon 30 other matters.

This event occurred when we used paper charts, sonothing easily accessible would be around to let usknow what happened to Jon. The nurse could go backout and say any number of things from sending themhome with ‘‘he was seen, but he is not admitted, hecould have been discharged’’ or ‘‘are you sure this isthe hospital he was seen at, maybe you should call hos-pital X or Y … maybe he went there’’ or figuring out,after several hours of tense waiting, his location in themorgue. The next approach to the attending is with thisrequest, ‘‘Jon Smith died last night. Do you want to talkto the parents?’’ which of course comes during the bus-iest peak of the shift, during the management of septicpatient during a central line placement, someone need-ing a lumbar puncture with supervision, and a chesttube required for a patient in the trauma bay. ‘‘What,they didn’t tell them this last night?’’

I could have let the police officers deliver the news tohis family. At the time I had not thought of that as anoption. Even today, I am uncertain if they would havetaken that responsibility. I could have stayed. I onlyhad to work the next day, and there is a couch in the

resident’s office. I could sleep there overnight and waituntil they arrived the following day. Is that too much togive? Was I being selfish by not staying to talk to them?This event would likely be the most memorable momentin their lives, and I chose to call them over the phone.Had I done the right thing?

Death in the ED is fairly common. National statisticsestimate 139,000 patients died in the ED in 2007, 0.1%of all patient visits.1 Therefore, giving bad or sad newsis a skill that is vitally important for the emergency phy-sician. Thirty years ago it may have been difficult tofind good resources on giving bad news, but now thereare many reviews and guidelines, some of which arespecialty-specific.2–4

Delivering bad news in medicine is now taught inmedical school as well as residency. Teaching strategiesinvolve didactics, small groups, role-playing, and stan-dardized patients.5 I received didactics, small-group,and simulation training in residency and medical school.I feel quite comfortable giving bad news in person.

Several models exist to structure the bad news dis-cussion. The SPIKES method was developed by medicaloncologists.6 It has been used by many other special-ties, as well as in medical schools. ‘‘S’’ stands for setthe stage; this is done by introducing yourself and yourrole in the resuscitation. The ‘‘P’’ is for perception,determining what the family knows currently. ‘‘I’’ isinform, which involves relating the events concerningthe patient in plain language. The ‘‘K’’ is for knowledge,allowing the survivor(s) to react and ask questions. ‘‘E’’is for empathy, validating the survivor’s emotions anddemonstrating concern for their grief. Finally, ‘‘S’’ isfor summary and strategy, which involves remainingprofessional, establishing personal availability for thesurvivors to contact you, and concluding the conversa-tion appropriately.6 I felt I had done all of these in myconversation, except setting the stage and empathy. Itis difficult to emote over the telephone—the mostmeaningful aspects of communication are expressedthrough body language.

Other protocols have been developed beyondSPIKES; there are emergency medicine–specificcourses on giving bad news. The GRIEV_ING protocolhas been shown to increase confidence and compe-tence in giving bad news.7,8 Even with all efforts toeducate physicians in delivering bad news, areas stillneed improvement. It appears that oversight in givingbad news is lacking, as 95% of instances of bad newstelling occur without attending supervision. Only 10%of instances have any supervision at all, this includessupervision from attendings or senior residents.9 In abusy ED it may be difficult for an attending physicianto supervise a conversation breaking bad news to afamily. Nonetheless, breaking bad news is a skill likeany other in medicine, and supervision, practice, andappropriate feedback should lead to better perfor-mance.

In regard to giving bad news over the telephone,there is little information on the subject. A literaturesearch results in only one article, in the outpatient set-ting. It reported several appropriate settings to givebad news over the phone, such as low-risk diagno-ses requiring treatment (gonorrhea), serious urgent

ACADEMIC EMERGENCY MEDICINE • March 2012, Vol. 19, No. 3 • www.aemj.org 357

time-dependent diagnoses, and patients insisting onreceiving their results over the phone.10

I still question the manner in which I delivered thenews to the Smith family. Because of my doubt, I haveread and investigated evidence-based literature regard-ing the delivery of bad news. As much as I dislike theactions of his friends, dropping his lifeless body off inour department, I am grateful to have had the experi-ence to broaden my understanding of giving bad news,the key to which is simple: add the unique touch ofhuman compassion and connection—a concept that isin blunt contrast to their cowardly actions.

Thomas Gilmore, MD(thomas_gilmore@hotmail.com)Department of Emergency MedicineThomas Jefferson University HospitalPhiladelphia, PA

Supervising Editor: Carey Chisholm, MD.

References

1. Niska R, Bhuiya F, Xu J. National Hospital Ambula-tory Medical Care Survey: 2007 emergencydepartment summary. Natl Health Stat Report.2010; 26:1–31.

2. Ptacek JT, Eberhardt TL. Breaking bad news.A review of the literature. JAMA. 1996; 276:496–502.

3. Fallowfield L, Jenkins V. Communicating sad, bad,and difficult news in medicine. Lancet. 2004;363:312–9.

4. Marrow J. Telling relatives that a family memberhas died suddenly. Postgrad Med J. 1996; 72:413–8.

5. Rosenbaum ME, Ferguson KJ, Lobas JG. Teachingmedical students and residents skills for deliveringbad news: a review of strategies. Acad Med. 2004;79:107–17.

6. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA,Kudelka AP. SPIKES—a six-step protocol for deliv-ering bad news: application to the patient withcancer. Oncologist. 2000; 5:302–11.

7. Hobgood C, Harward D, Newton K, Davis W. Theeducational intervention ‘‘GRIEV_ING’’ improvesthe death notification skills of residents. AcadEmerg Med. 2005; 12:296–301.

8. Hobgood C. Delivering the News with Compassion.The GRIEV_ING death notification protocol - Trai-ner’s Manual. A project supported by Grant No.2005-VF-GX-K021 awarded by the Office for Victimsof Crime office of Justice Programs. Washington,DC: U.S. Department of Justice, 2005.

9. Orlander JD, Fincke BG, Hermanns D, Johnson GA.Medical residents’ first clearly remembered experi-ences of giving bad news. J Gen Intern Med. 2002;17:825–31.

10. Ngo-Metzger Q. Breaking bad news over thephone. Am Fam Physician. 2009; 80:520–2.

358 Gilmore • REFLECTIONS ON GIVING BAD NEWS