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Based
on the ALSO (American Academy of Family, 4th edition, 2006)
and the very good medical book of Thomas J. & Monaghan T.
‘Oxford Handbook of Clinical Examination and Practical Skills’
of Oxford Medical Publications, 2008. www.oup.com
A.
WHEN THE RELATIVES ARRIVE TO THE A&E (ER)
It
is not appropriate for a junior and inexperienced doctor of
the ER to inform the relatives. This is better to be done
by a responsible senior doctor with good communication skills
and empathy. On the reception the relatives will be asked
to wait in a special ‘relative room’ which will be quite,
comfortable and will have a WC facility and a phone outside.
There also will be offered coffee, magazines and tissues.
A responsible nurse or team member will accompany the relatives
and be as a link between them and the resuscitation team.
The team member will inform the relative about the patient’s
critical condition and will also write down the name, address
and telephone of the patient and a close relative.
Many times relatives are allowed to attend during the resuscitation
and this helps them realize and accept the loss and avoid
denial, so it helps the grief process. The relatives can talk
to the patient that dies and this helps them have less stress.
They can also touch and talk to the dead. They also realize
that the doctors did everything possible. However the resuscitation
may be stressful for them, especially if they aren’t informed
from someone. The relatives can impede, emotionally or physically,
the resuscitation process, or the process its self may be
disturbing or offending for the relatives. They can also have
stress from the memories of the resuscitation. So, many relatives
prefer to sit quietly and read e.g. a religious book. Other
prefer to express themselves physically or verbally.
It is important that 1 member of the medical team to accompany
the relatives that wish to watch the resuscitation, making
first sure that they wish so, without make them feel guilt
if they refuse. The team member will explain them that they
will have support either they attend the resuscitation, either
not and also will give them information about what happened
(disease or trauma) and what to expect to see in the ER. He/she
will also make sure that the relatives realize that can leave
any time from the ER and return to a private room and that
will always be accompanied. The team member will also ask
them not to interfere in the resuscitation, and that they
will have the chance to speak and touch their beloved when
it is safe.
During The resuscitation the team member will explain them
the process and if it is not successful he/she will explain
the family that the resuscitation isn’t successful and has
to stop. In case of death they will inform the relatives that
they will need a while to remove the equipment (except the
coroner asks to keep the tubes) and soon they will see the
dead. In case the victim has multiple injuries the family
must be informed to. They need to be encouraged to touch the
dead and always to be accompanied and supported by a team
member.
All the religious, forensic and practical matters and the
will have to be arranged. The legal and practical matters
have to do with informing the coroner and the family’s GP,
discussion with the relatives for organ donation and about
forensic matters, the priest and ceremony matters. Other matters
are the return of the deceased valuable things to the relatives,
the information about social services, self help groups and
a telephone number to communicate for further questions and
the long term support and follow - up.
The team will undertake a debriefing process. The support
and communication after death is better to commence with the
team member that supported them during resuscitation. If the
family hadn’t arrived during resuscitation then a team member
has to support the as soon as they arrive. Always the A&E
reception has to be aware and expect the family to arrive
soon. The announcement of bad news can be done by a doctor
or a nurse that accompanies the relatives, however usually
the relatives prefer to speak with a doctor.
B. HOW TO ANNOUNCE THE DEATH
When you are about to announce bad news, prepare physically
and emotionally. Check your clothes not to have blood and wash
your hands. Make sure you talk to the right relatives and make
sure what they already know. Meet with the relatives as soon
as possible after the death. Ensure whom are you talking to
(that they are indeed the relatives of the specific patient).
Choose a quite room. Encourage the presence of another person
who can support such as relative or friend. Show your sorrow
for their loss.
During the announcement use your voice tone and a non verbal
attitude such as looking them in the eye, touching them on the
shoulder or even giving them a hug and generally using gestures
and facial expressions. Speak with simple words, not medical
jargon. Sit or stand beside the relatives, on the same level.
Speak slowly. Do not make a prologue or conversation about the
patient’s health. Do not jump from one topic to another. The
relatives need urgently to learn if their beloved is alive or
not. For a child use its first name.
Give the information with empathy and be precisely and simple.
Do not give unrealistic hopes and perspectives in case the prognosis
can’t be absolutely determined. If you don’t know an answer
for a question say ‘We don’t know yet’. Use the words ‘died’,
‘death’ or ‘dead’ and not other words such as ‘he is gone’,
or ‘went to a better place’ or ‘diseased’. So use a clear term
and repeat it at least 1 other time in order not to be any doubt.
After the announcement of the death make a brief pause and wait
the family’s reaction. Usually the family reacts with distress
or anger or denial or guilt.
During the announcement to the family, give them time to process
the information. Ask them if they need to stay alone and to
answer their questions in a while. Family reactions are determined
from cultural, religious and national believes. Avoid ending
fast the conversation. Inform them providing written or other
evidence and ask them what else do they wish to learn. Avoid
preliminary diagnosis if uncertain. Answer their questions with
simple words and sincerely. If you don’t know an answer then
say so.
Give them time to gather their thoughts by making pauses between
your sentences. Encourage the family to stay with their member.
In case of accident or unexplained death inform the family that
the police will get in touch as a routine. Ask a consent for
autopsy only when the relatives are in the appropriate emotional
condition. Ask also about any religious requirements. Arrange
a follow up for further conversation and inform the social service.
Finally record any information at the patient’s files.
Avoid blaming them or accusing them for doing something wrong,
because it’s not the time for accusations. Sum up the facts
and ask them if they have any personal, religious or other ways
of support. Ask them about who can comfort them with the loss.
They can ask a friend to phone the relatives and friends in
order to avoid repeating the sad scenario. Encourage them to
seek support on family, friends or a psychologist. Arrange a
follow up conversation. Ask the family to ask the opinion of
a psychologist about how to inform properly the children for
the loss. If the loss is a baby or child, then encourage its
siblings to see and say goodbye to the child.
The family has the right to see the diseased. Perhaps you need
to prepare the body by removing the tubes and clean the body
or in case of deformity you can cover it e.g. on a baby with
anencephaly by placing a bonnet on its head. You can prepare
the family with a photo. In case you ask for an autopsy to find
the reasons of death, then prepare the family, assure them that
they will respect the diseased body and in case of a newborn
the results will help the rest family members or the future
generation by preventing a death on a next pregnancy.
If the diseased is a child, its family can see and hold it and
give it a name if it is a newborn and also keep a curl or a
palm print (or a ultrasonography for an embryo) for a remembrance.
Arrange follow ups with the family focusing in their worries,
their financial and social support and the anniversary grief.
Do not forget that the grieving family always remembers the
exact words the hospital personnel used to announced the loss
e.g. when the parents of a dead baby were asked years after
what they remember, they answered that they were touched when
the nurses said that ‘your child is a great fighter’.
It is important that many times the family hasn’t the courage
to seek help, so it is useful to refer them to social and rest
district services. Encourage them to attend special programs
of family support. In case of a newborn, if mother’s attitude
(e.g. smoking, taking drugs or alcohol) contributed to the baby’s
death, do not increase her suspicions. It’s not the right time
for accusations, but for family support. However, on the future
you can make some corrective comments to the mother’s attitude
‘to increase the possibility for a healthy baby this time’.
The more you are supportive with the family the less is possible
to deal with litigation. However, if the relatives press charges,
that mustn’t keep you from not supporting them. Many times the
family overreacts by accusing the doctor saying ‘why didn’t
you prevented this’ or ‘someone has to pay for it’. Explain
them that ‘it is logical to be angry for the loss. The hospital
staff did its best; however situations like this can be avoided
or predicted. Many times in life horrible things occur without
reason.’ Reassure them that the support of all the personnel
is available any time. Family needs support and not a doctor
who is defensive.
Do not forget after the death to inform the police if suspicion
of no physical death. Also inform the coroner and the patient’s
GP. Cancel any appointments to the hospital of the diseased.
Finally you and the rest the resuscitation team need 5 – 10
min break before you return to your duties.
C. HOW TO BREAK BAD NEWS
There are 4 conditions in announcing bad news:
a) Rationalization: ‘he doesn’t want to know’. b) Intellectualization
e.g. when you refer to statistics e.g. ‘ 40% of patients with
stage III live 5 tears’. c) Absolutely sincere e.g. ‘it's not
possible to live more than 6 months’. d) Inappropriate refer
e.g. ‘your brother will explain you everything when you calm
down’.
The patient needs to be informed because he/she already knows
the half, but is afraid to speak about his/her fears or is afraid
that his/her family won’t be able to handle it. However there
are many personal things that the patient will have to arrange
and also to decide if a therapy with many side effects worth’s
it. Most patients are informed less than they wanted to. The
right is the patient to learn what he/she wants to learn and
can handle.
Before you start, confirm you have all the adequate
information yourself and that you have
all the information to hand (e.g. test results, X’ Rays,
CTs/MRIs etc). Talk to the nurses to ascertain
what the patient already knows, their fears and their
relationship with close relatives or friends.
Choose
a private and quite room where you won’t
be disturbed. Confirm there is
not any desk or other furniture between you and the patient.
Arrange the chairs so that you and the patient are seen equally
in the same level. Give your cell phone and beeper (pager) to
a colleague to hold it for a while. Invite
a person from the nursing staff to join you – especially
if he/she has established a relationship with the patient. Do
not forget that the nurses are dealing with the patients and
their relatives, so the nursing staff should be aware of what
exactly has been said to the patient.
When meeting the patient before announcing bad news, avoid positive
expressions such as ‘good morning’ or ‘good afternoon’! Say
just ‘Hallo’.
Ask the patient if he/she would like any
relative present.
Find out what the patient already knows. Things are different
if the patient e.g. knows that you are looking for cancer to
one who thinks that his cough is due to an infection. Ask the
patient ‘What do you know so far?’ ‘What
have the other doctors told you’?
Ascertain how much does the patient wants to know. Ask the patient
‘Have you thought about what might be
the cause of these problems?’ ‘Do you know why we have been
doing these tests?’
Ascertain if the patient wants to hear what you might have to
say. Ask the patient: ‘are you the type
of person that if something goes wrong you want to learn all
the available details’?
If the patient does want to know, then
you should break the news in a step – wise way, delivering multiple
warning shots. This gives the patient the chance to stop
you if he/she has heard enough or to ask further information.
Speak clearly, use simple words, short sentences and avoid medical
jargon.
Next, give a warning shot: ‘there are
some bad news we have to discuss’ or say ‘I
am afraid the test results show that things are more serious
than we first thought. The dialogue may continue as the
following example:
Patient: ‘What do you mean more serious?’
Dr: ‘Some of the cells on the biopsy look
abnormal’.
Patient: ‘Do you mean that a have cancer?’
Dr: ‘Yes’.
The following conversation may have a different way if the patient
is signalling that he/she doesn’t wish to hear more. Many patients
don’t wish to hear the words said aloud as a coping strategy,
and this must respected from the doctor who shouldn’t say the
full story in that case. The following example shows this:
Dr: ‘I am afraid the test results show
that things are more serious than we first thought’.
Patient: ‘Just tell me what we can do
next’.
Doctor: ‘Ok’.
Inform your patient about the diagnosis, the prognosis and also
about social services, self help groups, hospital and hospices.
Do not use medical jargon. Speak slowly and clearly. Be honest
all the time, never guess or lie or give false hopes. If
asked a direct question, then be honest and straight. For
example
Dr: ‘I am afraid the test results show
that…’
Patient: ‘Just tell me: have I got cancer?’
Doctor: ‘Yes, I am afraid you have’.
Use fear words such as ‘cancer’ and ‘leukaemia’
only if you are sure that the patient wants to learn the full
story. However, avoiding these words may cause confusion by
not giving the full story. Also avoid using words that
instinctively to most patients are connected with something
serious e.g. using the word ‘shadow’ on a lung X’ Ray to most
people means cancer. Don’t use it if you are talking about consolidation
from pneumonia!
Do not rush to the positive. When the
patient is told bad news, he/she needs a few moments to let
the information sink in. After saying
‘Yes, you have cancer’ you should better
wait for a while in silence for the patient to speak next.
If the patient break down in tears offer
tissues and family’s support (if relatives are nearby).
If the patient is emotionally distressed he/she may not be able
to hear what you have to say next, so allow
the patient to have some time alone or with a nurse or a family
member, before you continue with the treatment options
and the prognosis.
Don’t give false hope. Don’t give in to
the instinctive move to positive things such as ‘the
good news is...’, or ‘there are some things we can do...’ etc.
Avoid it.
Allow time for each piece of the information
to sink in. Ensure the patient understands all what you have
said and repeat any important information. Not all the
patients remember the exact details of what have been said.
You may need to arrange at a later time
to talk about treatment options and/or prognosis.
Give your patient some information and then give
him/her a chance to ask more. Say for example ‘I
have the impression that there are more things that bother you’.
‘Is there anything else you want me to explain?’ or say:
‘Do you understand everything that we
have discussed?’
‘I there anything else you would like
to ask me?’
Allow the patient to refuse. Do not press him/her. Cancer has
negative associations on people. Explain that 50% of cancer
is curable. Listen your patient’s worries
and encourage his/her emotions. Make a synopsis and a plan about
therapy. The patient has to leave with the impression
that you are with him/her whatever happens.
On questions about prognosis (‘How long
have I got, doctor?’) don’t guess, don’t lie, and don’t give
false hope. If it is difficult to estimate, it is better to
say ‘I don’t know’. Don’t assume that patients ask from
fear. Many are practical and just want to put their affairs
in order, before they die.
Before ending the conversation, you need to summarize the information,
check if the patients understands all the relevant information,
repeat any information if necessary and allow time for questions.
Make arrangements for a new meeting for follow up and/or to
ask further questions. Don’t promise things you can keep e.g.
don’t say that you will come back in the afternoon, if you have
to leave. Instead say:
‘I will be along to see you tomorrow morning.
I will be happy to come back in the meanwhile if you think of
anything you would like to ask or if you need to talk. Just
inform the nursing staff to call me’.
Make sure that the nurses and the patient’s GP are aware about
what have you informed the patient. You also need to write on
the files what information you gave to the patient.
D.
A NEWBORN WITH DISSABILITY
Refer to the baby with its name. Put its cloths with a way that
intones its more physiological body parts. Accept the baby’s
condition and emphasize its positive facts encouraging the parents
to do so. Also encourage the bond between the baby and its parents,
especially its mother. Fulfill the developmental needs of the
child and compare the positive elements of the child with the
parent’s ones. Deal with the continue stress of the parents
or the kid. Other parents with similar situation can offer enormous
help. Inform them about benefits and social and self support
groups. The hospital’s personnel attitude influences the parent’s
attitude. Create a plan and a framework of continuous support
for the family and the child.
REFERENCE
1.Thomas
J. & Monaghan T. ‘Oxford Handbook of Clinical Examination
and Practical Skills’ of Oxford Medical Publications, 2008.
www.oup.com
2.ALSO, American Academy of Family, 4th edition, 2006.
3.Oxford
Handbook of General Practice, C. Simon, H. Everitt, T. Kendrick,
2nd edition, Oxford University Press, 2005.
www.oup.com
4.Oxford Handbook of Emergency Medicine, J.P. Wyatt, R.N. Illingworth,
C.A. Graham, M.J. Clancy, C.E. Robertson, 3rd edition, Oxford
University Press, 2
www.oup.com
5.ALS, European Resuscitation Council, 2006.
www.erc.edu
6.EPLS, European Resuscitation Council, 2006.
www.erc.edu
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