Day 2 | CME- Trauma Symposium | Delivering bad news jurkovich

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  • Several years ago, a local pediatrician asked two mothers who ’d lost children as the result of trauma to come speak with his residents about their experiences. It was a moving conference. The mothers were then invited to speak at surgery grand rounds. Again, the health care givers were very responsive and eager for guidance on the best way to handle giving bad news. There was evidence that a sensitive nerve had been tapped and there was a need for physicians and nurses to learn more about feeling comfortable talking with families about the death of a loved one. Both women were upper middle class and within ten years of the same age. They each had different needs through their experience. For instance, one mother was grateful for not being able to see her daughter ’s body until she’d been cleaned up. The other was not able to see her daughter’s body at the hospital. She found no peace until the state patrol released pictures of her daughter’s broken body on the side of the freeway. She needed the visual reality of the trauma to be able to move on through her grieving process. The CQI team undertook the project described in this paper in an effort to provide a framework for giving bad news that would assist grief stricken people with coping with their situation and help caregivers face this difficult obligation.
  • Day 2 | CME- Trauma Symposium | Delivering bad news jurkovich

    1. 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. 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. 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. 4. Giving Bad News Specialized Obituaries Giving Bad News Death from injuryDeath from injury usually unexpectedusually unexpected
    5. 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. 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. 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. 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. 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. 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. 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. 12. Giving Bad News 2000, Vol 48 (5), p867-872 59th AAST Annual Meeting, Boston, MA 1999
    13. 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. 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. 15. Giving Bad News Results: Cause of death Blunt Penetrating GS/Vasc. Head Bleed Cardiac 11% 6% 4% 4% 75%
    16. 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. 17. Giving Bad News Results: Primary Care Service GS/Tr. NS ED Med. 8% 4% 58% 29%
    18. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 42. Giving Bad News Comments ““He told us in the hallway.”He told us in the hallway.”
    43. 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. 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. 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
    46. 46. 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..
    47. 47. 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
    48. 48. 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
    49. 49. 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
    50. 50. 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
    51. 51. 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
    52. 52. 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
    53. 53. 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
    54. 54. 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
    55. 55. 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
    56. 56. 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
    57. 57. Giving Bad News Successful news team Physician Well informed, able to answer questions Unrushed, focused, calm Empathetic behavior, gestures Nurses Ensure privacy Communication liaison
    58. 58. 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
    59. 59. Giving Bad News Thank youThank you
    60. 60. 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
    61. 61. 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
    62. 62. 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
    63. 63. 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
    64. 64. 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
    65. 65. 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
    66. 66. 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?
    67. 67. 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.
    68. 68. 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
    69. 69. 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
    70. 70. 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
    71. 71. 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

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