Bad News

An important distinction needs to be made between bad and catastrophic news. Catastrophic news needs to be delivered immediately - don’t beat around the bush.

Catastrophic News

Process:

What is catastrophic may vary a bit depending on the person; but death is always catastrophic.

  1. Check identify
    Ensure you have the right patient and the right family member.
  2. Introduce self
    You can do this with a bundled warning shot (“I am terribly sorry to meet you like this.”, but avoid dragging it out.
  3. Deliver the message
    Concisely and completely.
  4. Fallout
    “Sit in the rubble with them.”
    • Offer to call someone else

Warning shots prepare someone to hear bad news. People who are prepared have better retention and feel more empathy from the clinician than those who are unprepared.

Warning shots must strike a balance between maximising and minimising language:

  • Maximisers
    e.g. “The scan results are terrible.”
    • Overly dire
    • Negates the benefit of the warning shot
  • Minimisers
    e.g. “We’re a bit worried.”
    • Under-done
    • Fails to convey the level of concern

Bad News

Process:

The key difference between bad and catastrophic news is that it is reasonable to spend some time clarifying understanding before delivering the message.

  1. Check identity
  2. Introduce self
  3. Ask what they already understand
    Avoid this if there is catastrophic news, i.e. some major change that obviates previous discussions. Important first question as it reveals:
    • What they already know
    • Health literacy
    • Communication style
  4. Deliver the message
  5. Fallout

Key Studies

  • COSMIC-EOL (2022)
    • 454 French-speaking relatives of patients receiving end-of-life care in 34 ICU in France, prior to the COVID-19 pandemic
    • Randomised to 3-step support strategy vs. usual care
      • Intervention included 3 separate family meetings:
        • Family conference to prepare for imminent death, with:
          • Opportunity to ask questions and express emotion
          • Encouragement to talk and say goodbye
          • Option to be present, involved in physical care, and discuss spiritual needs
        • Active support at the bedside during the dying process
        • Meeting after death to offer condolences and closure
          • In person, if family present
          • Via telephone, if family not present
      • Usual care was standard support and communication strategies employed
    • 1-month implementation period for staff familiarity
      • 67% of control group had end-of-life meeting
    • Intervention group showed significant ↓ in:
      • Prolonged grief
      • Difficulty of end-of-life experience
      • Quality of death
      • PTSD-related symptoms
    • Unclear external validity due to cultural differences in grieving

References

  1. CICM Communications Course. Course Notes. 2023.
  2. Kentish-Barnes N, Chevret S, Valade S, et al. A three-step support strategy for relatives of patients dying in the intensive care unit: a cluster randomised trial. The Lancet. 2022;399(10325):656-664.