One of the hardest roles of the emergency physician is giving bad news to a patient or their family members. Difficult topics that are often challenging for physicians to discuss include reporting the death of a family member or giving the diagnosis of a terminal illness. The optimal way to relay these topics is yet to be determined and each practitioner typically develops their own communication style. Some choose to deliver the message in a direct and succinct manner while others prefer a more drawn out and complete explanation. The Emergency Department provides a unique environment as there is often little time to develop any rapport with the patient and their family. This can make communicating these topics more challenging. In addition, breaking bad news involves more than just the verbal component of actually giving the bad news. It also requires the ability to respond effectively to patient’s and family’s emotional reactions and the dilemma of how to give hope when the situation is bleak.
Jurkovich et al studied the characteristics and methods of delivering bad news from the perspective of surviving family members. The chart below details the importance of various elements rated by respondents in the study. The attitude and clarity of the message delivered by the provider were deemed to be most important, while the attire of the provider had little importance to the respondents.
The duty of breaking bad news can be improved by understanding these characteristics and methods and then applying a step-wise method to effectively communicate and counsel patient’s and/or their families. In a recent Wednesday conference, Dr. Flannery, one of our core faculty attendings, introduced us to the SPIKES protocol for breaking bad news. The purpose of the protocol is to help the clinician fulfill the essential goals of gathering information, providing intelligible information, and supporting the patient or family by reducing their emotional impact and isolation. When we are informing our patients of an unfortunate diagnosis, the protocol also calls for collaborating in developing a strategy or treatment plan for the future. From the Emergency Department standpoint, this means guiding patients to the correct consultant for further workup and treatment options.
During our Wednesday conference, we broke into small groups and practiced situations that would be considered difficult to give bad news. The experience was positive and allowed us to give each other constructive criticism on ways to improve our approach to giving bad news. As a senior resident, I have unfortunately been involved in many of these situations throughout my residency. I have learned that despite the challenges involved in delivering bad news, there is also tremendous gratification in providing a therapeutic presence during a patient or family’s greatest need.
1. Jurkovich et al. Giving bad news: the family perspective. J Trauma. May 2000
2. Baile W.F. et al. SPIKES – A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist. June 12, 2000.
In comes a 34-year-old male who is obtunded with pinpoint pupils and breathing at five times a minute; likely due to heroin abuse. He wakes up after Narcan is appropriately administered, but now he wants to leave. What is the risk of death if he leaves? Do we restrain him against his will to monitor him for possible recurrent respiratory depression?
We have some pre-hospital literature that looked into this issue. The studies looked at patients who refused care after pre-hospital providers administered Narcan for a suspected opiate overdose. They then searched the death registry to see if those patients later died after refusing care (transport to the hospital).
Wampler et al. looked at 552 patients and found that no one died until at least 4 days later (1). These deaths four days later were unlikely to be from the initial overdose. A second study recently published in March of 2016 had 205 patients and showed only one death in 24 hours (2). Two others died in the 30-day follow up period which again were not likely due to the initial overdose. Combining the numbers from these two studies equates to 1/757 (0.13%) deaths.
There are limitations with all studies, but death seems unlikely after refusal of care post-narcan administration. However, our practice should not change as it relates to monitoring patients for about 4 hours to those willing. Recurrent respiratory depression is a real concern particularly seen in those patients who abuse long acting opiates. Despite this, some patients who have the capacity to make decisions may not choose the wisest care plan and may leave AMA. We must still make considerable attempts at providing substance abuse referrals and other appropriate resources as these patients are in great need of help.
Post by: Joe Bove (@jjbove08)
- Wampler D, Molina D, McManus J, Laws P, Manifold C. No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose. Prehosp Emerg Care. 2011;15(3):320-324.
- Levine M, Sanko S, Eckstein M. Assessing the Risk of Prehospital Administration of Naloxone with Subsequent Refusal of Care. Prehosp Emerg Care. March 2016:1-4.
As a residency we have been wanting to get more involved with our surrounding community instead of just interacting with the residents of Paterson in the ED. A couple weeks ago we went to Habitat for Humanity in Paterson to help with some construction instead of being cooped up at St. Joe’s for conference. Joe “Handy-man-chester” single-handedly constructed a single-family home in 8 hours while Dr. Patel did an amazing job observing everyone else working and providing endless amounts of encouragement. It was a lot of fun and we’ll be back soon!
The ALTO program (Alternatives to Opioids) at St. Joe’s has already received national recognition for its work here. In March we held a legislative summit that was attended by U.S. Senators Bob Menendez, Cory Booker, US Congressman Bill Pascrell, Jr and multiple other members of the local and state government to discuss the opioid epidemic and the ALTO initiative. Then we were lucky enough to have the New York Times write a story recent story in June on the ALTO program as well. Not to be outdone, EM Resident recently published a piece to introduce the EMRA readers to the wonders of ALTO and the success we have had thus far with the program, check it out here.
We are hosting our 8th Annual Emergency Medicine Symposium on May 4, 2016 at the Passaic County Public Safety Academy in Wayne, NJ. This year we are fortunate enough to have Dr. Kevin Klauer, DO, EJD, FACEP (@Emergidoc) as our keynote speaker, discussing Efficiency in the Emergency Department. Dr. Klauer is one of the top speakers in Emergency Medicine today and a true leader in our field. Visit emsymposium.org or call 973-754-2240 to register, CME is available.
On March 28, 2016 St. Joe’s announced the ALTO (Alternatives to Opiates) program in front of a Legislative Summit held here at St. Joe’s. This event was attended by U.S. Senators Bob Menendez, Cory Booker, US Congressman Bill Pascrell, Jr and multiple other members of the local and state government. A former graduate of our EM residency and current Medical Director of Pain Management in the Emergency Department, Dr. Alexis LaPietra has led the development of this program with the support of our Emergency Department Chairman and faculty member, Dr. Mark Rosenberg (@drmrosen). If you want to find out more about the ALTO program please check out the recent Webinar below.