Communication and Organ Donation
Breaking bad newsCommunication with patients and their relatives should be part of ongoing care, and should, where possible, be provided at regular intervals or whenever the clinical situation changes.
Given the severity of illness and high probability of death of patients requiring critical care, communicating bad news with patients and/or their families is a common occurrence. Breaking bad news can be difficult and distressing for all concerned. Where possible, the breaking of bad news should be led by a consultant who has received training in how to do this, but the speed with which patients deteriorate may mean that this is not possible, and what follows is a simplified template for ensuring that this is done as professionally as possible. It may need to be adapted for certain situations and according to the individuals involved.
Breaking bad news
Preparation
Confirm you have the right patient and check the latest details regarding their condition and ongoing management.
Maintain relatives’/patient’s privacy if possible by using a quiet room or pulling curtains around bed.
Ensure you are not interrupted (if possible hand pagers and phones to someone else).
Where possible have the nurse caring for the patient present at the interview to ensure good continuity of information.
Introduce yourself to the patient or their relatives and confirm who you are talking with.
Sit at the same level as the person you are talking to and maintain appropriate eye-to-eye contact.
What do the relatives or the patient know?
Enquire as to what information has already been passed on to the patient or their relatives.
Confirm their understanding of what they have already been told.
What information is wanted?
Enquire as to what information they want to know next.
Give a ‘warning shot’
Give patients and relatives time to prepare for any bad news by giving a ‘warning shot’ such as: ‘I’m afraid I have some bad news’ or ‘I’m afraid the situation is very serious’.
Allow relatives/patient to refuse further information
Some patients or relatives may not want to hear bad news at this point, and they should be allowed to refuse to hear any more at this time; if they refuse then inform them that they can always ask for more information in the future.
Relatives are not allowed to refuse on behalf of a relative who has capacity; it should be made clear that if the patient asks for information it will be given to them.
Give explanation (if requested)
Give an honest explanation of the patient’s clinical condition and likely prognosis.
Use language which is clear and avoids, or simplifies, medical terms wherever possible.
Avoid euphemisms, where it is appropriate to use words such as ‘death’ or ‘dying’ then do so.
Do not provide false reassurance.
If you do not know the diagnosis or likelihood of injury/death then it is appropriate to say so, it is also appropriate to explain in terms of what you suspect the most likely diagnosis/outcome will be.
Re-iterate important points and confirm that they are understood: ‘Does that make sense?’
Listen to concerns
Enquire as to whether the patient/relatives have questions they want to ask. Time must be provided for them to absorb information and to ask questions—their agenda may be very different from what you are expecting and it is important to listen to any concerns.
Encourage expression of feelings
A phrase such as ‘How does that news leave you feeling?’ may allow the relatives or patient to express their feelings and emotions which may be therapeutic in its own right.
Summarize explanation and explain plan, then offer availability and support
Ensure that the patient or their relatives are aware that you, or a member of your team, will be available to provide further information as and when it is requested.
Communicate with team
A summary of the conversation should be recorded in the patient’s medical records; this should include any key points along with any specific concerns raised.
Adapted from Guidelines for communicating bad news with patients and their families, East Midlands Cancer Network (2010) by P Costello and G Finn, with permission 
http://www.eastmidlandscancernetwork.nhs.uk/Library/BreakingBadNewsGuidelines.pdf
http://www.eastmidlandscancernetwork.nhs.uk/Library/BreakingBadNewsGuidelines.pdfPitfalls/difficult situations
Communication is a process. The severity of a situation may require several conversations with different clinicians before it is fully accepted.
Patients/relatives may be angry about the situation or about previous management. This anger should be acknowledged, and where appropriate an apology offered. Do not enter into criticism of previous management.
Further reading
Buckman R. How to break bad news. Baltimore, MD: John Hopkins University Press, 1992.
Fallowfield L, et al. Communicating sad, bad, and difficult news in medicine. Lancet 2004; 363: 312-19.
Kaye P. Breaking bad news: A ten step approach. Northampton: EPL Publications, 1996.
Referral to the coronerIt is not uncommon to be required to discuss the deaths of critically ill patients with a member of the coroner’s office, or to the procurator fiscal in Scotland
The role of the coroner is to investigate deaths that are unexpected, unexplained, violent or unnatural, occur whilst in custody, or occur as the result of a medical mishap. The coroner is tasked with establishing who the deceased was, as well as where, when, and how they died.
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