“Doctor, the Family is Here”: The Challenges of Communicating Difficult News in the Emergency Department

By Gabriela Toutin Dias, MSc

This was his first shift as an attending. Fresh out of emergency medicine training, he felt an overall sense of relief and satisfaction; it had been a good shift. As night fell, his thoughts increasingly turned to the moment he would arrive home, hug his wife and son and wind down. He was interrupted by a nurse; motor vehicle accident coming in, 17 year-old boy, multiple fractures, intubated at the scene, blood pressure dropping. He quickly stood up and made his way to the emergency room, it was go time.

As the patient was rushed into the emergency room, the entire team was ready. In his mind, he read off a checklist of all the steps in assessing and managing a trauma case: airway, breathing, circulation, all the letters and acronyms clearly organized; he had seen this so many times and wondered if it should feel automatic by now. It didn’t. He was sweating, heart pounding in his chest. Severe trauma, young patient, he had to get this right; the odds were against him.

He could see all his team members focused and rapidly working their way to make sure this kid survived. He wondered if they were as worried as he was. In front of him, a text book case of hypovolemic shock and a Patriots jersey, his favorite team. Hands moved in a quick, almost orchestrated manner, lots of voices at the same time as he led the case and a palpable tension in the air; they had to move faster. Fluid, blood, voices in the room becoming louder. Cardiac arrest. He stepped up and quickly began compressions, he could not let this one go, he was too young and there was too much life ahead of him. He tried to push away images of his son, but they kept popping in his head. He had to focus, but as his arms became weaker, somebody took over. As he wiped the sweat from his face, he felt a sinking feeling in his stomach and took a step closer to the patient; he didn’t even know his name. He resumed compressions for what felt like a confusing mixture of time standing still and time flying past him; he was in a zone and all he could think of was saving his patient. Someone touched his shoulder and told him 50 minutes had gone by; they had to call it. Everything around him froze. As that person, kindly but firmly, removed his hands from the patient, an unfamiliar voice broke the silence in the room, “Doctor, the family is here”.

The case illustrated above, although fictional, is a realistic representation of what transpires inside an emergency department (ED). During the four years I worked as a clinical psychologist inside the ED of a tertiary teaching hospital in Brazil, I experienced on a daily basis the feeling of working in a high-energy and fast-paced environment. The crisis nature of emergency care often results in healthcare professionals working under constant time pressure and the uncertainty of managing unpredictable situations.

In this context, communication between physicians and patients or families acquires unique aspects in the ED. The task of delivering difficult news is routine and extremely common, yet it is still perceived as one of the most difficult responsibilities in medicine. Furthermore, this particular type of communication is a common source of distress for physicians and, in extreme cases, burnout, fatigue and depression-related symptoms (Brown et al., 2009).

On the other hand, a visit to the ED can also be an overwhelming experience for patients and/or family members when, in many cases, news of a serious illness or, as our case scenario illustrates, death may come up. This news, often given in an abrupt manner, may lead to feelings of abandonment, loneliness and loss of control. Many will forever remember the moment in which bad news was given to them (Takayesu & Hutson, 2004).

In the ED, most encounters between physicians and patients (or family members) occur for the first time, neither party entering this relationship by choice, a set-up that can potentially favor mistrust or negative stereotyping. In addition, assessment, rapport building and patient education tend to happen simultaneously rather than sequentially because of the rhythm in which care is provided. With these elements in mind, it becomes clear that communicating effectively with patients and families is a core skill for emergency physicians. The effective management of communicating difficult news results in patients’ better comprehension of information, satisfaction with medical care, level of hopefulness, and subsequent psychological adjustment (Toutin-Dias et al., 2016).

So, what can we do to achieve the effective communication of difficult news? Here is where simulation-based training becomes a powerful ally. Communication is a skill that can be enhanced by training, therefore it is essential that we offer the opportunity for every professional involved in patient care to experience the event of communicating difficult news in a controlled and psychologically safe environment. With the help of standardized patients, we can design realistic and engaging interprofessional scenarios that ultimately lead to the creation of individual “skill set archives,” or mental resources that can rapidly be accessed when faced with real-life situations like the ones seen inside the simulation center. As for our attending, wouldn’t it be ideal if he could reflect on lessons learned from previous experiences with simulated pediatric death notifications before stepping in to talk to the patient’s parents?

Gabriela Toutin Dias, MSc is a psychologist from Sao Paulo, Brazil where she worked in the emergency department of the Hospital das Clinicas (tertiary teaching hospital affiliated with the University of Sao Paulo’s Medical School) as a clinical psychologist and simulation educator. Currently, Gabriela is a fellow in the Institute’s Faculty Fellowship for Leaders in Collaborative and Humanistic Interprofessional Education. In addition, she works alongside staff, faculty, and leadership on several projects and initiatives within the Institute.

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