Breaking the worst possible news in the best possible manner

September 17, 1999

Hearing that a loved one has died after trauma could be the most emotionally devastating news one might ever hear. How this news is delivered has an immense impact on how people will later reflect on those initial moments of loss.

"You have to know that you're creating a lifelong memory -- people will likely remember every detail of the conversation. Even if they don't remember the words, they will remember the feelings," says Becky Pierce, nurse manager of the Trauma Intensive Care Unit (TICU) at Harborview Medical Center in Seattle, who has spoken on the topic nationwide.

At Harborview, a study began in 1996 on how to best break bad news to people close to trauma victims. Interviews were conducted with 50 family members about six months following the death of a loved one who was treated in the Emergency Room or the TICU. The findings were presented Sept. 17 at the American Association of the Surgery for Trauma in Boston by Dr. Gregory Jurkovich, chief of trauma at Harborview Medical Center and professor of surgery at the University of Washington School of Medicine.

The nurses who conducted these interviews sensed that those who felt their situations were handled well were able to move on more easily. "Although several people refused to respond initially, they later changed their minds," says Pierce. "It was found that people were hungry to talk about their experiences and that everything was crystallized in their minds. If their memories were bitter, the anger was instantly expressed."

The most important aspects of delivering bad news were attitude, clarity of information and privacy. "People didn't like being strung along, and didn't want any sugar-coating," she says. "They also didn't think that touch or hugs were important -- in fact all the men said that anything more than a handshake was inappropriate. According to social workers, unwelcome touch interrupts with the necessary flow of emotions."

Doctors are advised to feel their way into the process of giving information about the death, says Pierce. "For instance, when people stop asking questions, it means they have heard all they can handle and it would be a burden to hear more. If you volunteer too much detail, you risk creating a bad memory. However, it's important to allow them to obtain more information later."

People got the most comfort from being left with the sense that everything possible had been done to save the patients' lives. If information is unclear or not readily available or if doctors are uncaring, people also have to deal with anger, which interferes with the grieving process," Pierce explains.

Relating news of death is the responsibility of the doctor who is the most aware of the events surrounding the death, who can speak frankly and knowledgeably, and has an empathetic demeanor, says Jurkovich. The seniority of the doctors was less important than their manner, and the family members' most positive comments described those who expressed sympathy and sensitivity.

"The doctor who spoke with us asked us what kind of man dad was," said one respondent. "It gave us a chance to talk about him. That was a very positive memory." "The ER doctor initially called my mother," said another. "He talked with her and figured out she was frail and alone. He called her neighbor and me and made sure someone was with her before telling her of my brother's almost certain death."

A private room in which to break the news and letting the family remain there is important, as is allowing them time with the body if they wish. Several respondents expressed gratitude at being able to see the patients as soon as they left the ER, whether or not they were presentable, if the prognosis looked bad. "In the past, we would try to first stabilize the patient but found it might be too late," says Pierce. "At first there was concern that the family would be disruptive, or that we needed to protect them from the patient's appearance, but they're usually so overwhelmed they prefer to go back to the waiting room and appreciate the opportunity to see the reality of what's happened. People often feel cheated if they miss seeing someone during their last minutes of life."

Other recommendations, now in effect at Harborview, included assigning a nurse to the family through the admission and death process to help facilitate the flow of information. Social workers and chaplains are also present whenever available.

Although most responses from the survey were positive, a few physicians were found to be insensitive. "Some doctors are good at delivering bad news, but we need to train those who don't have the natural skills and are uncomfortable in such a highly emotional situation," says Jurkovich. "There is increasing recognition that medical training needs to be extended beyond the science of illness and into the art of caregiving." He plans to extend the project to study the effect of stress on resident physicians, and results will be incorporated into a teaching program.

University of Washington

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