Having difficult conversations is probably the most overlooked, underappreciated skill in all of healthcare. Very few providers are taught this skill in any sort of structured way. It’s often something that they learn by watching others more senior to them. The problem with that is, those people learned it by watching people more senior to them, who learned it by watching…well, you get the idea. If whoever started the chain didn’t know how to do it, then bad habits kept getting passed down.
As a critical care nurse practitioner, I’ve been involved in hundreds of these conversations. And many of them were very poorly done. And it’s not just trainees. Some of the worst conversations were led by attending physicians with years of experience. And it’s not totally their fault. They were never taught how to do this.
I’ve had the good fortune to learn this skill from some excellent teachers. In school, during my trauma rotation, Dr Cindy Talley taught me how to deliver bad news to a family in a specific way, citing actual research in the field. As an NP, I’ve been fortunate to learn from some great palliative care providers like Dr Jessica McFarlin and see how to expand those principles into leading a goals of care discussion. Here’s how I approach the difficult conversation.
Delivering Bad News
This is the hardest conversation to have. When a patient has died, or is in a position where they are not going to survive, despite our best efforts. Often the difficulty is compounded by shock. Rarely are these expected.
Step 1: Just say it. In most of these cases, a family has been gathered together and placed in a room. They know very little except that their loved one is hurt or sick. Something bad has happened and they’re waiting to find out. The biggest mistake people make at this point is going into all the details. They won’t hear any of that because they’re waiting for the other shoe to drop. I quickly introduce myself and get right to the point.
“Your son was involved in a very serious car accident. He was brought in very badly hurt. We did everything we could. I’m very sorry, but he died.”
You have to say “died” (or “won’t survive if it’s imminent but hasn’t happened yet). Too often, we try to soften the blow by using euphemisms like, “passed” or “gone.” Although we know what we mean, in their worried state, the family can misunderstand that. There is a definite finality to the word death.
Step 2: Sit. This is when you need to shut up and resist the urge to say things or the (overwhelming) urge to leave). It will be uncomfortable. They may cry, they may scream. They will grieve and it will be awkward. But this is what they need to do right now. Let them.
Step 3: Questions. This is why you can’t run away during the grief. Because at some point, they will come around and they’ll be ready to hear all those details that you wanted to give at the start. They’ll have questions and it’s only after they’ve dealt with the initial shock that they can ask them.
That’s the basics of how to deliver bad news to a family. Next time, we’ll talk about how to have a goals of care conversation.
critical care notes 