On a cold winter evening, Marc runs into the grocery store for some last-minute ingredients. He wants to surprise his family with homemade pasta when they arrive later from out of town. His winter coat taut over his protruding belly, he’s a little short of breath from the dash into the store.
As he’s leaving, he feels a heaviness in his chest and collapses. A store clerk calls an ambulance and Marc arrives in your ER fifteen minutes later. The crash team begins resuscitative measures, but Marc doesn’t respond, and time of death is called. There aren’t any family members at the hospital, and one of the nurses finds his cell phone and calls his emergency contacts. No one answers. She leaves a message for them to call the hospital.
An hour later, the desk clerk comes to get you. “Marc’s family is here,” she says. Maybe you’re a first-year resident and everyone else on your team is busy with another code, so you’re the one who has to talk to them. Maybe you’re the attending in charge of the team and haven’t even had time to understand what happened. How do you approach Marc’s family? How do you communicate the bad news?
How to Share Bad News
In his talk “Breaking Bad News,” emergency medicine physician Dr. Andrew Bazakis discusses an approach to how to communicate bad news to patients and/or family members. Although his experience is in the emergency room, his approach to the topic can be used with other specialties and situations.
Unfortunately, as Dr. Bazakis explains, only 14% of residents actually receive formal training in how to communicate bad news to patients. This means that if the job of telling the patient or the family bad news falls on a resident, the information can often be shared in a hurried and inappropriate way.
Even for those of us with experience, delivering bad news can be a new challenge each time, whether we’re telling a patient they have cancer or a life-altering STD or informing a family about a loved one’s death.
The ASHES Approach
Dr. Bazakis describes a mnemonic system, known by the acronym ASHES, for communicating bad news to patients.
- A — Assemble your team: Don’t give bad news by yourself. Each member of your team can offer support to the patient or family in a different way. In addition, you won’t be deserting the patient or family if you’re called away. Consider bringing a nurse, a social worker or a chaplain and possibly security.
- S — Sit: Patients feel like you’ve spent more time with them if you sit.
- H — History: Before presenting the bad news, learn the history of the patient, especially if it’s someone new to you (say someone you’re encountering in an emergency room setting). If the patient has died, find out what the family knows so far before you share what the hospital staff did to take care of them.
- E — Explain: Explain the events that transpired as clearly as possible, using simple terms.
- S — Stay: If you can, stay while the recipient expresses their emotions instead of running off immediately. They may have tuned you out as soon as you said the word “cancer” or “your father died” and may need time to fully understand the news.
How to Take Care of Yourself
Dr. Bazakis also discusses the importance of devoting time to debriefing, both as a team and alone. In an emergency room setting, you may be delivering bad news several times a day, and burnout, depression and post-traumatic stress disorder are common issues with physicians who don’t give themselves time to work through these challenging scenarios. In addition, patients or families may lash out at the healthcare team in the moment of crisis, and the team will need to process this, ideally before returning to work.
Breaking bad news is always difficult — it’s not something we ever get used to. But if we feel prepared beforehand, we may be able to better help our patients and their families.