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Conveying bad news

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  • Conveying Bad News: The Death of a ChildDr. Horacio ZaglulDirector, Pediatric Intensive Care UnitChandler Medical CenterUniversity of Kentucky

  • Four Patterns of DeathThe pattern of death determines the course of care as well as reactions of family to the death of a loved oneSudden deaths are often caused by accidentsFluctuating declines are characterized by intermittent remissionsFragile patterns describe those of some children with chronic conditions such as cystic fibrosis

  • Patterns of Pathways of DyingFeudtner, C. Pediatr Clin N Am 54 (2007) 587H. F. Zaglul, MD

  • Problems some physicians have in conveying bad newsSome lack trainingothersAre unwilling to become emotionally involvedPossess a poor capacity for intimacyHave abandoned the ideals they embraced upon entrance to the medical schoolPractice defensive medicineHave no time for recovery after conveying bad newsAvoid it...orare overworkedH. F. Zaglul, MD

  • Conveying Bad News:An OverviewThe conversation to convey bad news has three componentsPreparation of yourself and the recipients of the newsDelivery of the newsFollow-up with the patient and/or familyA summary of this is diagrammed next

  • Breaking Bad News SummaryH. F. Zaglul, MD

  • Preparation: Make a PlanDecide with the staff and family when, where and who should attend the meeting in which you will convey the bad newsInvite the family to a meeting, mentioning a purpose such as the need to discuss their childs careEmpower the family to write down questions or concernsMake sure that clinical staff is knowledgeable and in accordDecide who will run the meeting: who is the right person to give the bad news? Is it you?Consider whether an interpreter is needed; Consider whether there may be cultural attitudes that may affect the familys reactionsKnow as much about the case as you can

    H. F. Zaglul, MD

  • Dr. Zs reflectionsDeath is a process more than a momentThe family needs to hear everything medically possible was done to save their childLet the family do what they can for the childNever force a decision to withdraw supportBe availableLook for support

    H. F. Zaglul, MD

  • Deliver the Bad News:Clues to effective deliveryTimely ClearSimple languageHonestStraightforwardCompassionately RespectfullyShow empathy but do not lose controlOne hour is too longSensitivelyMinimize sufferingAssuranceStrengthen relationshipsEmpowerMinimize interruptionsListen more, talk lessCollaborativelyH. F. Zaglul, MD

  • Delivery:Beginning the meeting

    Assure that everyone is seated comfortably

    Introduce everyone

    Propose an agenda and ask family to contribute to it

    Do not appear rushed or in a hurry

    Brace yourself for an emotional task

    Explore what is known by the patient/family

    Be curious and ask questions

    H. F. Zaglul, MD

  • Delivery:Go for itProvide a warning shot

    Try to avoid being too certain or too vague

    State bad news simply

    Allow and tolerate silence

    Listen to what the parents say. Try to think of the unasked questions

    Acknowledge emotions; parents may respond differently

    Allow time for questions. Reply to all as best you can H. F. Zaglul, MD

  • Delivery: Keep in MindDo not impose the truth, but if the patient asks, do not lie

    Try not to overload parents with too much information

    Do not take all hope away

    Try not to let your own opinions interfere, even if parents push you to make a decision for them. Give the parents sufficient information to be able to make any decision with you

    Seek to establish clear and aligned goals of careH. F. Zaglul, MD

  • Delivery:Making sure the news is conveyed Review agenda and assure that all issues were covered

    Restate the agreed upon goals of care

    If no consensus, acknowledge this and plan for further dialogue and perhaps information gathering

    Confirm agreement

    Thank everyone for their contribution

    H. F. Zaglul, MD

  • COMMON FAULTS IN THE BREAKING OF BAD NEWSNot doing it and hoping someone else will pick up the piecesAvoiding the patient or parents, never seeing them alone, always being in a hurryPutting it off e.g., by ordering more (unnecessary) testsGetting the childs name or other details wrong read the notes thoroughly before talking to anyoneFidgetingAvoiding eye contact; e.g., looking out the windowGoing into undertaker mode there is always something positive to say, even in the most gloomy circumstancesBeing smug because you have got the diagnosis correctIdentifying with the patient or parents so much that your ownpersonal feelings get in the way

    H. F. Zaglul, MD

  • Carefulin using these wordsI know just how you feelYou must be strong for your childrenGod never gives us more than we can handleThis was Gods willTime will heal everythingCount your other blessingsIf there is anything I can do, just callH. F. Zaglul, MD

  • And Carefulin using these wordsHe (she) might not be here with us alreadyGod needed another angel in heavenGod is taking your child for a reasonIt is a blessingI am sorry about your situation

    in using the adjective peaceful indiscriminately

    H. F. Zaglul, MD

  • Closing the meeting: Follow-up

    Arrange a review appointment relatively soonMake the family aware of who to contact if they have questions in the meantime (e.g. ward staff, yourself)Make sure the parents know if there are further results awaited and how they will get theseProvide written information if available Suggest to parents that they write down any questions they think of before the next meetingAfter you have arranged follow-up: leave the room, preferably leaving a nurse with the parents for a period of timeLeave but do not abandon

    H. F. Zaglul, MD

  • Follow-up: After the meetingDocument in the notes what information the parents have been given and who was presentAt review appointments update the news In addition, try to see parents at times when there is no bad newsOffer to talk to other relatives e.g. grandparents(Beware of demanding relatives)Remember to maintain patient confidentialityConsider a debriefing for yourself and the staff involved (do not forget interpreters)Find out about local services for bereaved people

    H. F. Zaglul, MD

  • To summarize

  • H. F. Zaglul, MD