The document discusses giving bad news to patients and families. It provides background on the topic, noting that most previous literature focused on oncology and pediatrics. The document then describes a quality improvement process to study how well surgeons at one hospital deliver bad news of death to families. A survey was administered to family members of patients who had died, asking about important elements and how well the news giver addressed them. Key findings included families valuing empathy, clarity and being able to answer questions. Some news deliveries were judged as lacking sympathy or clarity.

1. Giving Bad News
Giving Bad News
Gregory J. Jurkovich, MDGregory J. Jurkovich, MD
Chief of Surgery, Denver Health Medical CenterChief of Surgery, Denver Health Medical Center
Rockwell Distinguished Professor of Trauma SurgeryRockwell Distinguished Professor of Trauma Surgery
University of Colorado School of MedicineUniversity of Colorado School of Medicine
Denver, ColoradoDenver, Colorado

2. Giving Bad News
Giving Bad News
Giving such news can be difficult
Previous work largely focused on
oncology and pediatric patients
Little surgical literature
Oliver & Fallat: Grieving parents
Rappaport & Witzke: Student education
Vetto et al: Early clinical clerkship

3. Giving Bad News
Literature
Talking about Death with Children WhoTalking about Death with Children Who
Have Severe Malignant DiseaseHave Severe Malignant Disease
Ulrika Kreicbergs, R.N., Unnur Valdimarsdottir,́Ulrika Kreicbergs, R.N., Unnur Valdimarsdottir,́
Ph.D., Erik Onelov, M.Sc., Jan-Inge Henter, M.D.,̈Ph.D., Erik Onelov, M.Sc., Jan-Inge Henter, M.D.,̈
Ph.D., and Gunnar Steineck, M.D., Ph.D.Ph.D., and Gunnar Steineck, M.D., Ph.D.
NEJM, Sept. 16 , 2004 Vol.351 no.12NEJM, Sept. 16 , 2004 Vol.351 no.12

4. Giving Bad News
Specialized
Obituaries
Giving Bad News
Death from injuryDeath from injury
usually unexpectedusually unexpected

5. Giving Bad News
Literature review
Ptacek & Eberhardt, JAMA, 1996Ptacek & Eberhardt, JAMA, 1996
67 (181) pertinent articles since 198567 (181) pertinent articles since 1985
Nearly all articles written from physicianNearly all articles written from physician
perspective (2 exceptions)perspective (2 exceptions)
Lack of empirical validation major limitationLack of empirical validation major limitation
and needand need
Does how the news is delivered make aDoes how the news is delivered make a
difference?difference?

6. Giving Bad News
Oncologist concern: sit or stand?
“ Cancer patients (especially females) prefer physicians to sit
when breaking bad news . . . . . However, sitting posture alone is
unlikely to compensate for poor communication skills . . .”

7. Giving Bad News
Background
Quality improvement process: toQuality improvement process: to
investigate our performance in theinvestigate our performance in the
giving of the bad news of deathgiving of the bad news of death
To determine the most important orTo determine the most important or
significant features of the delivery ofsignificant features of the delivery of
bad newsbad news from the perspective offrom the perspective of
surviving family memberssurviving family members

8. Giving Bad News
Methods
Designed a survey toolDesigned a survey tool
Administered tool to surviving familyAdministered tool to surviving family
members of patients who had diedmembers of patients who had died
ED or Trauma ICU deaths onlyED or Trauma ICU deaths only
Mail or phone responseMail or phone response
Experienced ICU nurses administered phoneExperienced ICU nurses administered phone
surveysurvey
Becky Pierce, RN, Laura Pananen, RN,Becky Pierce, RN, Laura Pananen, RN,
Frederick P. Rivara, MD, MPHFrederick P. Rivara, MD, MPH

9. Giving Bad News
Survey tool
What elements are important in theWhat elements are important in the
delivery of bad news?delivery of bad news?
We gave them 14 options to chose fromWe gave them 14 options to chose from
1 = least important; 6 = most important1 = least important; 6 = most important
Collapsed into three categoriesCollapsed into three categories
How well did theHow well did the “bad new giver” attend“bad new giver” attend
to these elements?to these elements?
Good, adequate, or poorGood, adequate, or poor

10. Giving Bad News
Survey tool elements
AttireAttire KnowledgeKnowledge
AttitudeAttitude LocationLocation
AutopsyAutopsy PrivacyPrivacy
ClarityClarity SenioritySeniority
Clergy availableClergy available SympathySympathy
DirectionsDirections Time for questionsTime for questions
Follow-up contactFollow-up contact TimingTiming

11. Giving Bad News
Survey tool, msc. items
Perceived identity of news giverPerceived identity of news giver
Relation of respondent to deceasedRelation of respondent to deceased
Clinical detail desiredClinical detail desired
Desirability of touchingDesirability of touching
Demographics, length of stay, injuryDemographics, length of stay, injury
Clinical care service providersClinical care service providers
CommentsComments

12. Giving Bad News
2000, Vol 48 (5), p867-872
59th AAST Annual Meeting, Boston, MA 1999

13. Giving Bad News
Results
Conducted over 18 months; 119 deathsConducted over 18 months; 119 deaths
Families contact 2 m - 6 m after deathFamilies contact 2 m - 6 m after death
Poor mail response (25%) n=20Poor mail response (25%) n=20
Excellent phone response (87%) n=34Excellent phone response (87%) n=34
54 family members54 family members
48 deceased patients48 deceased patients

14. Giving Bad News
Results : Deceased patients
Mean age: 53 years (SD 24)Mean age: 53 years (SD 24)
Age range: 12 - 91 yearsAge range: 12 - 91 years
2 < 18 yrs; 10 > 75 yrs; 2 > 85 yrs2 < 18 yrs; 10 > 75 yrs; 2 > 85 yrs
67% male; 33% female67% male; 33% female
TICU deaths: 44 (49 surveys)TICU deaths: 44 (49 surveys)
ED deaths: 4 (5 surveys)ED deaths: 4 (5 surveys)

15. Giving Bad News
Results: Cause of death
Blunt
Penetrating
GS/Vasc.
Head Bleed
Cardiac
11%
6%
4%
4%
75%

16. Giving Bad News
Results: Cause of Death
Blunt traumaBlunt trauma 3636 75%75%
Penetrating traumaPenetrating trauma 22 4%4%
Gen-Vasc. CatastropheGen-Vasc. Catastrophe 55 11%11%
Subarch. BleedSubarch. Bleed 33 6%6%
CardiacCardiac 22 4%4%

17. Giving Bad News
Results: Primary Care Service
GS/Tr.
NS
ED
Med.
8%
4%
58%
29%

18. Giving Bad News
Results: Primary Care Service
%Deaths%Deaths %Survey%Survey
GS /TraumaGS /Trauma 58%58% 56%56%
NeurosurgeryNeurosurgery 29%29% 31%31%
Emerg.Dept.Emerg.Dept. 8%8% 9%9%
CardiologyCardiology 4%4% 4%4%

19. Giving Bad News
Results: Length of Stay
49% within 24 hours49% within 24 hours
69% within 2 days69% within 2 days
83% within 7 days83% within 7 days
Longest stay: 5 weeksLongest stay: 5 weeks
Length of stay did not correlate withLength of stay did not correlate with
results of surveyresults of survey

20. Giving Bad News
Results: When informed
Before deathBefore death 2424 44%44%
While patient agonalWhile patient agonal 1414 26%26%
After deathAfter death 1313 24%24%
““Never”Never” 33 6%6%

21. Giving Bad News
Results: Who gave the news?
AttendingAttending 44 7%7%
ResidentResident 99 17%17%
““Doctor”Doctor” 3131 57%57%
NurseNurse 55 9%9%
Family/FriendFamily/Friend 33 6%6%
CanCan’t recall’t recall 22 4%4%

22. Giving Bad News
Results: Where was the news given
Conference roomConference room 1414 26%26%
Waiting roomWaiting room 1010 19%19%
PhonePhone 88 15%15%
HallwayHallway 88 15%15%
PatientPatient’s room’s room 77 13%13%
ICU/HospitalICU/Hospital 44 7%7%
Other/no responseOther/no response 33 5%5%

23. Giving Bad News
Qualities Valued
We asked the question:We asked the question:
What qualities of the giving of badWhat qualities of the giving of bad
news do you most value?news do you most value?

24. Giving Bad News
Survey tool elements
AttireAttire KnowledgeKnowledge
AttitudeAttitude LocationLocation
AutopsyAutopsy PrivacyPrivacy
ClarityClarity SenioritySeniority
Clergy availableClergy available SympathySympathy
DirectionsDirections Time for questionsTime for questions
Follow-up contactFollow-up contact TimingTiming

25. Giving Bad News
Results: Qualities valued
HighHigh MediumMedium LowLow
AttitudeAttitude 72%72% 19%19% 2%2%
ClarityClarity 70%70% 9%9% 4%4%
PrivacyPrivacy 65%65% 11%11% 7%7%
KnowledgeKnowledge 57%57% 13%13% 7%7%

26. Giving Bad News
Results: Qualities valued
HighHigh MediumMedium LowLow
SympathySympathy 48%48% 24%24% 7%7%
Time for ?Time for ? 48%48% 15%15% 15%15%
Autopsy infoAutopsy info 47%47% 15%15% 12%12%
ClergyClergy 39%39% 13%13% 9%9%
39% did not even rank availability of clergy as an39% did not even rank availability of clergy as an
important element of giving bad newsimportant element of giving bad news

27. Giving Bad News
Results: Qualities valued
HighHigh MediumMedium LowLow
Rank/SeniorityRank/Seniority 24%24% 22%22% 19%19%
Follow-upFollow-up 20%20% 26%26% 13%13%
AttireAttire 4%4% 15%15% 44%44%
35%-41% of respondents did not even35%-41% of respondents did not even
rank these 3 elements in importance in therank these 3 elements in importance in the
giving of bad newsgiving of bad news

28. Giving Bad News
Results: Clinical detail
Amount of clinical details desiredAmount of clinical details desired
In-depth detailIn-depth detail 1616 30%30%
Progress from generalProgress from general information toinformation to
detaileddetailed 1111 20%20%
General terms onlyGeneral terms only 77 13%13%
No commentNo comment 2020 37%37%

29. Giving Bad News
Results: Physical contact
Touching during news deliveryTouching during news delivery
Do not touchDo not touch 1616 30%30%
Touch desiredTouch desired 99 17%17%
Hand-shake onlyHand-shake only 44 7%7%
No commentNo comment 2525 46%46%

30. Giving Bad News
Attention Given
We asked the question:We asked the question:
How much attention was give to thisHow much attention was give to this
particular issue by the bad newsparticular issue by the bad news
giver?giver?

31. Giving Bad News
Results: Good Attention Given
%Respondent%Respondent
Appropriate attitudeAppropriate attitude 44%44%
Clarity of messageClarity of message 52%52%
PrivacyPrivacy 17%17%
Answer questionsAnswer questions 48%48%

32. Giving Bad News
Results: Poor Attention Given
% Respondents% Respondents
Likelihood of autopsyLikelihood of autopsy 26%26%
Clergy availableClergy available 20%20%
Timing of conversationTiming of conversation 17%17%
LocationLocation 17%17%

33. Giving Bad News
Results: Attention Given
Nearly every respondent commented onNearly every respondent commented on
these four elementsthese four elements
Empathy of the news giverEmpathy of the news giver
Clarity of the messageClarity of the message
Attitude of the news giverAttitude of the news giver
Ability to answer questionsAbility to answer questions

34. Giving Bad News
Results: “poor attitude”
6 news givers judged6 news givers judged “poor attitude”“poor attitude”
6 lacked sympathy (empathy)6 lacked sympathy (empathy)
5 unable to effectively answer5 unable to effectively answer
questionsquestions
4 lacked clarity of messages4 lacked clarity of messages
5 on one clinical service5 on one clinical service

35. Giving Bad News
Results: “poor attention given to”
key areas
96 total96 total “Poor Attention Given”“Poor Attention Given”
ratingsratings
Neurosurgery: 55%Neurosurgery: 55%
General-Trauma: 32%General-Trauma: 32%
ED: 13%ED: 13%

36. Giving Bad News
Results: Comments
87% had a positive comment87% had a positive comment
51% were about nurses or hospital staff51% were about nurses or hospital staff
19% remarked on skilled and professional care19% remarked on skilled and professional care
11% specified physicians11% specified physicians
11% detailed specific kindness, single act11% detailed specific kindness, single act
74% had a negative comment74% had a negative comment
12% about physicians12% about physicians
12% parking and housing12% parking and housing

37. Giving Bad News
Comments
““Be kind, direct and to theBe kind, direct and to the
point. Look them directly in thepoint. Look them directly in the
eye and briefly share the pain.”eye and briefly share the pain.”

38. Giving Bad News
Comments
““The ER doctor realized myThe ER doctor realized my
mother was alone. He arranged formother was alone. He arranged for
a neighbor and I to come be witha neighbor and I to come be with
her before telling her. I appreciateher before telling her. I appreciate
that more than you know.”that more than you know.”

39. Giving Bad News
Comments
““The doctor who spoke with usThe doctor who spoke with us
asked us what kind of man dadasked us what kind of man dad
was. It gave us a chance to talkwas. It gave us a chance to talk
about him. It was a very positiveabout him. It was a very positive
memory.”memory.”

40. Giving Bad News
Comments
““Be very clear but not too graphic.Be very clear but not too graphic.
The doctor said he couldn’t saveThe doctor said he couldn’t save
my son’s legs. My husbandmy son’s legs. My husband
thought, and still does, that youthought, and still does, that you
had to cut his legs off.”had to cut his legs off.”

41. Giving Bad News
Comments
““When we arrived in theWhen we arrived in the
Emergency Room, we were toldEmergency Room, we were told
our son was “D.O.E. It was veryour son was “D.O.E. It was very
scary until they explained he wasscary until they explained he was
a John Doe.”a John Doe.”

42. Giving Bad News
Comments
““He told us in the hallway.”He told us in the hallway.”

43. Giving Bad News
Comments
““She’s going to die and you’re justShe’s going to die and you’re just
going to have to deal with it.”going to have to deal with it.”

44. Giving Bad News
How you say it matters !
SurgeonsSurgeons’ tone of voice: A clue to malpractice history.’ tone of voice: A clue to malpractice history.
Ambady et al, Surgery, 2002.Ambady et al, Surgery, 2002.
• Psychologists; AHCPR fundedPsychologists; AHCPR funded
• Audiotaped 65 surgeons (ortho and GS) clinic visitsAudiotaped 65 surgeons (ortho and GS) clinic visits
in Portland, Denver, Salemin Portland, Denver, Salem
• 10 sec. clips, 2 patients each, begin and end of visit10 sec. clips, 2 patients each, begin and end of visit
• 12 blinded raters, Harvard psychology undergrads12 blinded raters, Harvard psychology undergrads
• Scale 1-7 these areas: warmth, anxiety/concern,Scale 1-7 these areas: warmth, anxiety/concern,
interested, hostile, sympathetic, professional,interested, hostile, sympathetic, professional,
competent, dominant, satisfied, and genuine.competent, dominant, satisfied, and genuine.

45. Giving Bad News
How you say it matters !
SurgeonsSurgeons’ tone of voice: A clue to malpractice history.’ tone of voice: A clue to malpractice history.
Ambady et al, Surgery, 2002.Ambady et al, Surgery, 2002.
• Interjudge reliability: 0.54Interjudge reliability: 0.54
• 4 key variables:4 key variables:
• 1. Warm/professional 2. Concerned/anxious1. Warm/professional 2. Concerned/anxious
• 3. Hostile 4. Dominant3. Hostile 4. Dominant
• Surgeons with a tone of voice that was moreSurgeons with a tone of voice that was more
dominant and less concerned = surgeons moredominant and less concerned = surgeons more
likely to have been sued.likely to have been sued.
• Dominance OR 2.74; Concern OR 0.46Dominance OR 2.74; Concern OR 0.46

49. Giving Bad News
Table 1
Table 1. Tasks of mourning.Table 1. Tasks of mourning.
Copyright © 2011 The Journal of Trauma. Published by Lippincott Williams & Wilkins. 49
Traumatic Childhood Death: How Well Do Parents Cope?Traumatic Childhood Death: How Well Do Parents Cope?
Oliver, Ronald C.; Fallat, Mary E.Oliver, Ronald C.; Fallat, Mary E.
The Journal of Trauma. 39(2):303-308, August 1995The Journal of Trauma. 39(2):303-308, August 1995..

50. Giving Bad News
Table 2
Table 2. Indices of pathologic and normalTable 2. Indices of pathologic and normal
outcomes of mourning.outcomes of mourning.
Copyright © 2011 The Journal of Trauma. Published by Lippincott Williams & Wilkins. 50

51. Giving Bad News
Beneficial Effects of a HospitalBeneficial Effects of a Hospital
Bereavement Intervention ProgramBereavement Intervention Program
after Traumatic Childhood Deathafter Traumatic Childhood Death
Oliver, Ronald C. PhD; Sturtevant, Joel P. DMin;Oliver, Ronald C. PhD; Sturtevant, Joel P. DMin;
Scheetz, James P. PhD, and; Fallat, Mary E. MDScheetz, James P. PhD, and; Fallat, Mary E. MD
J Trauma, 2001 Volume 50 (3) pp 440-448J Trauma, 2001 Volume 50 (3) pp 440-448

52. Giving Bad News
Beneficial Effects of Hospital
Bereavment Program
59 of 77 families participated59 of 77 families participated
81 deaths (3501 admissions, children only)81 deaths (3501 admissions, children only)
Family contact at hospital, home visit withinFamily contact at hospital, home visit within
1 month, educational meeting within 21 month, educational meeting within 2
months, follow – up surveymonths, follow – up survey
Key comments: Poor conceptualization ofKey comments: Poor conceptualization of
medical care, brain death, and delayed regretmedical care, brain death, and delayed regret
for missed organ donationfor missed organ donation

53. Giving Bad News
Table 4
Table 4. How Are Parents Doing?Table 4. How Are Parents Doing?
Copyright © 2011 The Journal of Trauma. Published by Lippincott Williams & Wilkins. 53

54. Giving Bad News
Table 2
Table 2. Supporters Survey after EducationalTable 2. Supporters Survey after Educational
Meeting (245 Individual Responses)Meeting (245 Individual Responses)
Copyright © 2011 The Journal of Trauma. Published by Lippincott Williams & Wilkins. 54

55. Giving Bad News
Table 1
Table 1. Parent Survey after EducationalTable 1. Parent Survey after Educational
Meeting (44 Individual Responses)Meeting (44 Individual Responses)
Copyright © 2011 The Journal of Trauma. Published by Lippincott Williams & Wilkins. 55

56. Giving Bad News
Parents view of lasting effectiveness of theParents view of lasting effectiveness of the
dinner meeting and the role of theirdinner meeting and the role of their
support network of family and friendssupport network of family and friends
Copyright © 2011 The Journal of Trauma. Published by Lippincott Williams & Wilkins. 56

57. Giving Bad News
Table 3
Table 3. Communicating with parents.Table 3. Communicating with parents.
Copyright © 2011 The Journal of Trauma. Published by Lippincott Williams & Wilkins. 57
• Clergy and Mother-in-laws help the most– for
both moms and dads
• 8% divorce rate attributed to child death

59. Giving Bad News
Summary
The manner in which bad news is givenThe manner in which bad news is given
has a long-lasting impacthas a long-lasting impact
Most comforting behaviorMost comforting behavior::
AttitudeAttitude: Caring and empathetic
ClarityClarity of the message
KnowledgeableKnowledgeable: well informed and
able to answer questions
PrivacyPrivacy

60. Giving Bad News
CQI-PI Recommendations
Educate hospital staff
Physicians
Students and residents
Allied health care
Develop a system for initial visit
Create a “news team” model

61. Giving Bad News
Successful news team
Physician
Well informed, able to answer questions
Unrushed, focused, calm
Empathetic behavior, gestures
Nurses
Ensure privacy
Communication liaison

62. Giving Bad News
Successful news team
Nurse (cont.)
Arranges visits
Provides means to get questions answered
Coordinate family information to
bereavement counselors/clergy
Social Services
After death procedures
Obtain belongings
Long term support information

63. Giving Bad News
Thank youThank you

64. Giving Bad News
Trauma ICU Staff Survey
Loss of control
Need to feel connected to the family
Unable to answer the family’s
questions
Protect the family from the patient’s
appearance

65. Giving Bad News
One year later . . . Nurses report
Hard, but worth it
Easier with experience
Preparation important for both the care givers and
the family
Define the parameters and expectations of the
initial, very brief, visit
Special connection between family and liaison
Less family conflict, more trust

66. Giving Bad News
Initial Visit
Get the family in for a brief (sighting)
visit in the first 10 minutes
One resuscitation team member
assigned to be the family liaison
Key to family visitation
Makes initial contact
Prepares the family for subsequent visits

67. Giving Bad News
Liaison
Introduces family to the patient’s nurses
and doctors
Supports the family during a visit
Shepherds the family through a visit
Helps keep the family informed

68. Giving Bad News
One year later . . .
Physicians report
Few (2) initially resistant
Key to success is liaison who understands
the physician’s perspective
ICU is OK, ER is shaky, OR is out of the
question

69. Giving Bad News
Emergency Nurses Association
ENA supports the option of family presence
during invasive procedures and/or
resuscitation efforts.
ENA supports
Research related to family presence
Educational resources for ED personnel
Collaboration with others ….to develop multidisciplinary
guidelines for family presence

70. Giving Bad News
Should Patients be in theShould Patients be in the
Resuscitation Room ?Resuscitation Room ?
““Rights” of the patient v. Rights of theRights” of the patient v. Rights of the
physicians v. Rights of the familyphysicians v. Rights of the family
Whose rights are you infringing upon?
PerspectivePerspective
Let the family members know the perspective of
the caregivers/physicians.
If distracting, do they really want to be there?

71. Giving Bad News
ED Visitor Policy & ProcedureED Visitor Policy & Procedure
Objective: To protect patient privacyObjective: To protect patient privacy
and enhance patient careand enhance patient care
Policy:Policy:
All visitors must wait in the designated waitingAll visitors must wait in the designated waiting
areas until allowed in the treatment area, atareas until allowed in the treatment area, at
the discretion of the zone/charge nurse.the discretion of the zone/charge nurse.

72. Giving Bad News
Should Patients be in the
Resuscitation Room ?
LiaisonLiaison
Bring the family in; stay with them, escortBring the family in; stay with them, escort
them out, answer questions; get stuff; tellthem out, answer questions; get stuff; tell
them what to dothem what to do
RulesRules
How long, how often, how many, what theyHow long, how often, how many, what they
can and cancan and can’t do’t do

73. Giving Bad News
ED Visitor Policy & Procedure
Visitors must check with the triage nurseVisitors must check with the triage nurse
One visitor at a timeOne visitor at a time
Physicians and medical students must clear aPhysicians and medical students must clear a
visitor with the zone nursevisitor with the zone nurse
No food or drinkNo food or drink
No visitors in hallwaysNo visitors in hallways
Verbally of physically abusive visitors will beVerbally of physically abusive visitors will be
escorted outescorted out

74. Giving Bad News
Stress of Giving Bad News
““Losing it”Losing it”
Not the correct term. Your are actuallyNot the correct term. Your are actually
getting something.getting something.
Post-Traumatic StressPost-Traumatic Stress
Debriefing after major stress often veryDebriefing after major stress often very
helpful and effective in resolving andhelpful and effective in resolving and
moving on -- but not always and not a givenmoving on -- but not always and not a given

75. Giving Bad News
Conclusions
Developed new hospital policies for theDeveloped new hospital policies for the
most critically ill or injured patientsmost critically ill or injured patients
Two nurses: one for the patient, and oneTwo nurses: one for the patient, and one
for the familyfor the family
Liaison nurse facilitates visitation andLiaison nurse facilitates visitation and
flow of informationflow of information
Staff educationStaff education