0022-5282/00/4805-0865 The Journal of Trauma: Injury, Infection, and Critical Care Copyright 2000 by Lippincott Williams & Wilkins,

, Inc.

Vol. 48, No. 5 Printed in the U.S.A.

Giving Bad News: The Family Perspective

Gregory J. Jurkovich, MD, Becky Pierce, RN, Laura Pananen, RN, and Frederick P. Rivara, MD, MPH
Background: Death from trauma frequently comes without forewarning. Relating the news of death to the family is often the responsibility of trauma surgeons. The purpose of this study was to investigate the key characteristics and methods of delivering bad news from the perspective of surviving family members. Methods: We designed and administered a survey tool to surviving family members of trauma patients dying in the emergency department or intensive care unit. The tool consisted of 14 elements that surviving family members graded in importance when receiving bad news (1, least; 6, most). Respondents also judged the attention given to these elements (good, fair, or poor) by the person giving the bad news of death. Results: Fifty-four family members of 48 patients who died completed the survey (44 intensive care unit deaths, 4 emergency room deaths). Deceased patients ranged in age from 12 to 91 years (mean, 53 years). Death occurred within 2 days of injury in 69% of the patients and within 1 week in 83%. The most important features of delivering bad news were judged to be attitude of the news-giver (ranked most important by 72%), clarity of the message (70%), privacy (65%), and knowledge/ ability to answer questions (57%). The attire of the news-giver ranked as least important (3%). Sympathy, time for questions, and location of the conversation were ranked of intermediate importance. Touching was unwanted by 30% of the respondents, but encouraged or acceptable in 24%. Conclusion: The attitude of the news-giver, combined with clarity of the message and the time, privacy, and knowledge to answer questions are the most important aspects of giving bad news. This information should be incorporated into resident training. Key Words: Trauma, Wounds and injuries, Death, Ethics, Medical, Physician-patient relations, Communication.

rauma is always an unexpected event, and death from trauma frequently comes without any forewarning for the loved ones of the victim. Receiving this news is an emotionally upsetting and poignant moment in an individuals life. Sharing this sad news of death is often the duty of trauma surgeons and nurses. Ideally, this situation should be an opportunity to provide comforting memories for family members and professional satisfaction for the provider. The event can also be an unsettling scene, which creates bitter memories for all parties. Nearly all previous investigations into the giving of bad news have focused on either oncology patients1 6 or pediatric patients and their families.711 Remarkably few studies on the giving of bad news are from the perspective of the surviving family members, and fewer still have appeared in the trauma literature.11,12 This finding is remarkable in that injury is the most common cause of death for people under age 44 in the United States, and the giving of bad news has been highlighted as the most important communication skill a good surgeon must have.13 With this study, we sought to investigate our performance in the giving of bad news of death to surviving family members, and in doing so, determine the most important or significant features of this conversation and its delivery.
Submitted for publication September 24, 1999. Accepted for publication December 30, 1999. From the Department of Surgery (G.J.J.), and Pediatrics (F.P.R.), the Harborview Injury Prevention and Research Center (G.J.J., F.P.R.), and Harborview Trauma ICU (B.P., L.P.) University of Washington School of Medicine, Harborview Medical Center, Seattle, Washington. Presented at the 59th Annual Meeting of the American Association for the Surgery of Trauma September 16 18, 1999, Boston, Massachusetts. Address for reprints: Gregory J. Jurkovich, MD, University of Washington School of Medicine, Harborview Medical Center, 325 Ninth Avenue, Box 359796, Seattle, WA 98104.

MATERIALS AND METHODS We designed and administered a survey tool to surviving family members of patients who died in either the emergency department (ED) or the trauma intensive care unit (TICU) at Harborview Medical Center, a Level I trauma center in Seattle, Washington. This Level I trauma center serves a fourstate region, with many patients coming from long distances. The survey was administered either over the phone by experienced TICU nurses, or a response was solicited by mail. The intent of the survey was to identify the most important characteristics and methods of delivering the bad news of death, to improve the quality of our care in the future. The tool consisted of 14 elements that the surviving family members graded in importance in the delivery of bad news (Table 1). These elements were ranked on a six-point scale from 1 least important to 6 most important. These elements were later collapsed into three categories: low importance (scores of 12), moderate importance (3 4), and high importance (5 6). The respondent also judged the attention given to all but two of these elements (attire; rank) by the physician or nurse who delivered the bad news of death to them. In this case, the surviving family member rated attention to the 12 remaining elements as good, adequate, or poor. The perceived identity of the primary news-giver (attending, resident, doctor, nurse, family member, friend, other) was determined from the respondent, as was the location in which the news was delivered, and the relation of the respondent to the deceased. Surviving family members were also asked their preference regarding the amount of clinical detail desired during the conversation, and whether or not they preferred physical contact (such as a hug, hand-holding, or hand-shake) during or after the conversation. From the hospital records, we determined the age, sex,
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TABLE 1. Items queried for importance in the giving of bad news

1. Attire: How was the news-giver dresseda 2. Attitude of the person speaking 3. Availability of clergy 4. Clarity of the message 5. Directions given immediately after death 6. Family given time to ask questions 7. Follow-up provided after death 8. Location of the conversation 9. News-givers knowledge and ability to answer questions 10. News-giver presented feeling of sympathy 11. Privacy 12. Seniority: Rank of news-givera 13. Timing of the conversation 14. Told of autopsy possibility
a Respondents did not rate the attention given to these two items during the giving of bad news.

admitting diagnosis, clinical service with primary care responsibility at time of death, length of stay, and location of death. None of the patients were declared dead on arrival in the ED; deaths occurring in the operating room or other critical care units within the hospital were specifically excluded. We also solicited comments on the most positive and negative aspect of the conversation, as well as specific examples of how the giving of bad news might have been improved. Family members were given the opportunity to discuss (or write comments on) any other aspect of care. RESULTS Study Sample The study was conducted over an 18-month period (January of 1996 to July of 1997). Families were contacted at least 2 months and no longer than 6 months after the death. In the initial survey, questionnaires were mailed to a convenience sample of 80 family members; 20 questionnaires were returned, representing 19 deceased patients. Because of the low response rate, a subsequent sample of 39 family members was contacted by phone; 34 agreed to be interviewed, representing the families of 29 patients. Thus, a total of 54 surviving family members of 48 patients responded to the survey; two family members responded to the survey in six deaths. Notably, once contacted, several people called back three and four times to share their stories. Several people who initially felt it would be too difficult to be interviewed called back after a few days. Although difficult to portray in this report, respondents were often eager to talk about their experiences and the events crystallized in their memories. The

impact of the conversation regarding the giving of bad news was significant. The mean and median age of the deceased patients was 53 years (SD 24 years), ranging from 12 to 91 years. Two patients were under the age of 18 years, 17 patients were older than 65 years, 10 patients were older than 75 years, and two patients were older than 85 years. Sixteen of the patients were female (33%) and 32 (67%) male. Forty-four of the deaths occurred in the TICU and 4 deaths occurred in the ED. Seventy-five percent of the deaths were caused by blunt trauma, 4% caused by penetrating trauma, and 10% caused by general surgical catastrophes. The remaining few cases were the result of subarachnoid hemorrhage (three patients) and cardiac complications (two patients). The primary service responsible for the patient at the time of death is shown in Table 2. General/trauma surgery was primarily responsible for the care of 58% of the patients who died, neurosurgery for 29%, and the remaining few patients by the ED or cardiology/ medicine ICU service. Most of the deaths occurred soon after arrival at the hospital. Forty-nine percent of the deaths occurred within 24 hours of admission, 69% occurred within 2 days, and 83% occurred within the first week. Seventeen percent (n 6) of the patients died after being hospitalized for more than 1 week, the longest being hospitalized in the ICU for 5 weeks. The length of time patients were in the hospital did not correlate with how the respondents felt about their experience of hearing about the death. If family members were satisfied with how communication was handled, they felt very positive about the caregivers. On the other hand, if family members did not feel informed appropriately, their memory of the caregivers was negative, whether it was based on a brief relationship or one that lasted for several weeks. There was wide variation in when in the course of events the family was informed of the death, who gave the news, and where the conversation was held, as shown in Table 3. Nearly half of the family members reported that they were told of an impending death before it actually happened. Approximately one fourth of respondents reported being told while the patient was agonal or immediately after the death. Family members were often not very clear on the status of the physician who gave them the news of death, reporting that it was the doctor in 57% of the cases. A resident was specifically named by only 17% of the respondents. Although a conference room was the single most commonly used site for delivering bad news (26%), more public areas (hallway, waiting room, in front of everyone) accounted for over one third of the sites where bad news was delivered.

TABLE 2.
Primary Care Service No. of Patients % of Deaths No. of Survey Respondents % of Survey Responses

General surgery/trauma Neurosurgery Emergency department Cardiology/medicine Total

28 14 4 2 48

58.3 29.2 8.3 4.2 100

30 17 5 2 54

55.6 31.5 9.2 3.7 100

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TABLE 3. Reported characteristics by the respondents of giving bad news

Parameter No. of respondents %

When informed Before death While patient was agonal After death Never Total Who gave the news? Attending physician Resident Doctor Nurse Family/friend Cant recall Total Where was the news given? Conference room Waiting room Phone Hallway Patient room ICU/hospital Other/no response Total

24 14 13 3 54 4 9 31 5 3 2 54

44 26 24 6 100 7 17 57 9 6 4 100

14 10 8 8 7 4 3 54

26 18.5 15 15 13 7 5.5 100

The relationship of the family member receiving the news of death to the deceased patient was as follows: 17 family members were parents (11 mothers), 17 family members were adult children of the deceased (12 daughters), 15 family members were spouses (11 wives), 4 family members were siblings, and for one respondent, we did not identify the relationship. No correlation between family relationship and survey response could be ascertained. Characteristics of the Experience Received The surviving family members were queried regarding the attention given to 12 issues we believed might be significant components of the giving of bad news (Table 4). Respondents felt we did the worst at informing surviving family members of the likelihood of an autopsy, having clergy available, and the timing, location, and privacy afforded during the conversation. Conversely, we seemed to do the best at providing the news of death with clarity, having the news-giver capable of
TABLE 4. Respondents rating of attention given to items during the telling of bad news
Element Surveyed

answering family questions, and having an attitude that was deemed appropriate. Interestingly, although 44% of the respondents felt that good attention was given to information regarding an autopsy, 26% stated that poor attention was given to this topic. In our county, nearly all trauma patients undergo an autopsy by a medical examiner; failure to raise this issue initially only to be later informed about the postmortem findings probably accounts for the unhappiness of some respondents. Nearly every respondent commented on attention given to four elements: sympathy of the news-giver, clarity of the message, attitude of the news-giver, and ability of the newsgiver to answer questions. In contrast, over 50% of the respondents did not comment on the attention given to availability of clergy. Six of the respondents (11%) noted that they had their own clergy, and two of them rated our attention to this issue as poor. Of the six respondents (11%) who felt the news-giver had a poor attitude, all felt the news-giver lacked sympathy, five respondents said the news-giver was unable to effectively answer questions, and four of these same respondents rated the clarity of the conversation as poor. Five of these six patients were on one clinical service, but cared for by multiple residents and attendings. Of the 96 total poor attention given ratings, neurosurgery was the primary care service in 55%, general/trauma surgery in 32%, the ED in 13%. In a subset of 34 respondents, we asked about the availability of a social worker, and how this impacted on the giving of bad news. Forty-one percent responded that a social worker was available; of these 14 respondents, 6 respondents (43%) still rated some aspects of the conversation as poor, including those issues regarding follow-up contact (2 respondents), directions immediately after death (1 respondents), autopsy information (4 respondents), and location of the conversation (2 respondents). Qualities Valued by Families in Delivering Bad News The respondents were asked to rank their perceptions on the most important elements in the giving of bad news (Table 5). Note that this is distinct from their ranking in how we satisfied certain aspects of the giving of bad news. Perceived attitude of the news-giver, clarity of the message, privacy of the conversation, and adequate knowledge on the part of the

Poor Attention Given (%)

Good Attention Given (%)

No Response (%)

Autopsy information Clergy available Location of conversation Timing of conversation Privacy of conversation Follow-up call Direction after death Attitude of news-giver Sympathy of news-giver Ability/knowledge to answer questions Time for questions Clarity of message

26 20 19 17 17 15 13 11 11 11 11 9

44 15 35 41 39 30 24 44 41 48 39 52

15 52 24 19 15 24 26 7 4 9 17 5

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TABLE 5. Importance rated by respondents of items associated with the giving of bad news
Importance (%) Element High Medium Low Not Rated (%)

Attitude Clarity of message Privacy Ability to answer question Sympathy Time for questions Autopsy information Clergy available Directions after death Location of conversation Timing of conversation Rank/seniority of news-giver Follow-up contact Attire of news-giver

72 70 65 57 48 48 47 39 33 32 32 24 20 4

19 9 11 13 24 15 15 13 15 24 26 22 26 15

2 4 7 7 7 15 12 9 15 9 7 19 13 44

7 17 17 22 20 22 26 39 37 35 35 35 41 37

news-giver to answer family questions dominate the most important attributes of giving bad news successfully. Remarkably, three fourths of the respondents ranked attitude of the news-giver as being highly important in the conversation, and only 7% gave no ranking to this component. In contrast, 37% percent of the respondents did not even bother to rank attire of the news-giver as having any importance, and 44% said it was of low importance. Sympathy on the part of the news-giver, adequate time for questions, and information regarding the possibility of an autopsy, were of significant importance to approximately half of the respondents. Availability of clergy was of high importance to some but of little or no importance to an equal number. The importance of rank or seniority of the news giver was quite variable, with only 24% ranking it of high importance, but 54% ranked this variable as of low or no importance. Respondents were queried as to the amount of clinical detail regarding the cause of death they desired. Sixteen of the respondents (30%) stated that they wanted the clinical information given in great detail; 7 of the respondents (13%) said that they preferred the information to be more general; and 11 of the respondents (20%) preferred that the conversation start with general information, proceeding to more detail as requested. Twenty respondents (37%) did not answer this question. Touching in the form of hand-holding, a hug, or a gently placed hand was unwanted by 16 of the respondents (30%). However, nine of the respondents (17%) did express a desire for this type of physical contact during or after the giving of bad news, and an additional four respondents (7%) replied a simple hand shake was sufficient, or were indifferent on this topic. Twenty-five respondents (46%) did not address this issue. The final series of questions asked surviving family members to comment on the most positive and negative aspect of the giving of bad news, and the overall care received. Eightyseven percent of the respondents had a positive comment. Most notable to surviving family members were the nurses or hospital staff (51% of the positive comments), the skilled and professional care provided (19%), the physicians (11%), or
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some specific detail about the care received or kindness provided (11%). Case conference discussions, other families in the waiting area, and the prehospital personnel were also mentioned. Negative comments were received from 74% of the respondents. These comments were more varied, but complaints about physicians (12%), housing and parking (12%), long waits (10%), and frightening hospital scenes (10%) were most common. DISCUSSION This study provides important information on perhaps the most difficult task faced by health care personnel, i.e., telling the family of a trauma victim that their loved one has died.14 16 The interviews conducted for this study made one point very clearly: the manner in which families are told of the death of a loved one has a lifelong impact on the survivors. The survey was undertaken to improve patient care and has resulted in changes in individual behavior, resident education, and hospital policy. The behavior that families perceived as most comforting and helpful can be succinctly summarized: a caring attitude of a well-informed, sympathetic caregiver who gives families a clear message and is able to answer their questions. In contrast, factors such as rank and attire that physicians might believe to be important, seemed to matter little to most families. Sympathetic caregivers are able to empathize with a family and realize that terrible news such as the death of a trauma victim and the dignity of the family require privacy and time. Giving bad news cannot be done well in a hallway before rushing off to the next patient or crisis. The fact that the seniority of the news giver was relatively unimportant to most families suggests that the task should fall to the person most willing to spend the time the family needs, provided this individual has adequate knowledge regarding the deceaseds clinical care and condition. In many jurisdictions, including ours, autopsies are routinely conducted in trauma victims, and the decision to do so is not at the discretion of the treating physician. Families

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clearly want to be informed when an autopsy will be performed, rather than be surprised by its occurrence. Autopsies can confirm the severity of the injuries and reassure families that all had been done to save the life of their loved one. The importance of touching or physical contact during doctor-patient communications remains unclear. Several contemporary commentaries have stated that physical human contact is a necessary, or at least an important part of physician communication and the giving of bad news.2,1720 Yet others have noted that, although it is accepted as normal to console a pet or a child by touching them, such an approach is less acceptable to distressed adults.21 In a finding similar to our results, Kim and Alvi note that 75% of patients with newly diagnosed head and neck cancer did not want the physician to touch their hands or hug them when given bad news.3 This finding may be gender-dependent, as we observed the most ardent opponents to physical contact during or immediately after the bad news conversation were men. Of the nine survey respondents who desired physical contact during the bad news conversation, six respondents were female (3 daughters, one sister, one mother, one wife). Broadly defined, bad news is any piece of information that changes ones view of the future in a negative way.2,16,22 The giving of bad news is an aspect of medical training and patient care that warrants attention. Just as surgical care and ICU management are taught, attention should be paid to the development of skills for interacting effectively with patients and their families. A 1990 consensus conference on doctorpatient relations concluded that there was evidence to prove that doctor-patient communications problems are common, can adversely affect patient outcomes, and that the teaching of communications skills should be incorporated into both undergraduate and postgraduate medical training.23 Makoul has surveyed medical students and residents regarding their perspectives on the delivering of bad news, focusing on their fears about the delivery of bad news, and their perceived educational needs and wants.24 Both residents and students feared the patients or families reaction to bad news and communications issues such as insensitivity or poor word choice on their part. Both acknowledged the need to learn how to be sensitive, how to approach the topic, and what were the appropriate words, language, and level of emotion. Interpersonal issues tended to be cited more frequently by students, whereas informational issues drew more attention from residents. Both groups believed the best way to learn effective skills in the giving of bad news were observation, practice in simulated situations, and hands-on experience in real situations, a variation of the see one-do one apprenticeship training model so common in surgical residencies. Few preferred reading, classroom discussions, or case studies. Teaching doctors to give bad news effectively has been the focus of several previous studies but most having to do with cancer, chronic medical illnesses, or pediatric patients.5,7,18,25 The development of instruction programs seems warranted, as one study from Great Britain has demonstrated that 59% of younger physicians report no previous training in the delivery of bad news.26 Rappaport and Witzke surveyed third-year
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medical students, finding that 85% of students had never been present when a surgeon had to tell the family that a relative had died; 54% of students believed that they were poorly equipped to deal with terminally ill patients, and 91% welcomed more education in this area.27 Vetto and colleagues at the Oregon Health Sciences University instituted a course of combined classroom and outpatient clinic experience designed to give early medical students more clinical skills, including the giving of bad news.28 They concluded that such instructions could improve students humanistic skills as they relate to the delivery of bad news. Harrahill has described a brief training program conducted in Oregon for the training of ED residents in the giving of bad news.25 Many of the training points of that program are emphasized by the findings of the current study. The findings of this survey should affect medical student and resident education. Residents learn patient care by observing skillful role modeling by nurses, social workers, senior residents, and attending physicians. In the current report, the fact that some services seemed to be far better than others at giving bad news likely reflects the amount of attention given to teaching these skills. As Buckman has noted, giving bad news is a skill and not a divine gift. It can be taught like other aspects of medical care and should be seen as a vital and appreciated part of the job of looking after sick people.16 Some trauma centers have developed trauma bereavement programs to provide follow-up contact and offer support to family members at holiday times or the anniversary of a loved ones death.29 The utility of such a program in our center is unclear, as only 20% of the survey respondents patients ranked such follow-up as very important, and fully 41% did not even rank it at all. Finally, this study suggests changes in hospital policy, which can improve our ability to give bad news. When a critically injured patient is admitted, a nurse is assigned to care for the patient and a second nurse is assigned to care for the family through the admission and death process, should that be the outcome. The nurse assigned to the family facilitates their visitation and flow of information. Patients should be admitted to a room large enough to accommodate the family, and the family allowed to stay as long as needed. The family should be allowed some time alone after hearing the bad news and have a final visit with the patient if they desire. In addition, families should be provided a phone number to call for questions that may come up after they have gone home. Health care givers can make a remarkable impact on how people reflect on this major life experience by how they interact with them during their conversations. This was a rewarding project for the investigators because of the insightful observations that were shared by the families. There are few conversations over the course of a lifetime that have as much impact as those surrounding a death experience. More study is indicated and more education of health caregivers is needed to prepare them for the awesome task of encountering grief stricken families and coming away from the experience knowing they did not add to the burden.

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REFERENCES 1. 2. 3. 4. 5. Morton R. Breaking bad news to patients with cancer. Prof Nurse. 1996;11:669 671. Ptacek J, Eberhardt T. The patient-physician relationship: breaking bad newsa review of the literature. JAMA. 1996; 276:496 502. Kim MK, Alvi A. Breaking, the bad news of cancer: the patients perspective. Laryngoscope. 1999;109(Pt 1):1064 1067. Fielding R, Wong L, Ko L. Strategies of information disclosure to Chinese cancer patients in an Asian community. Psycho-oncology. 1998;7:240 251. Baile WF, Kudelka AP, Beale EA, et al. Communication skills training in oncology: description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness. Cancer. 1999;86:887 897. Girgis A, Sanson-Fisher R, Schofield M. Is there consensus between breast cancer patients and providers on guidelines for breaking bad news? Behav Med. 1999;25:69 77. Vaidya VU, Greenberg LW, Patel KM, et al. Teaching physicians how to break bad news: a 1-day workshop using standardized parents. Arch Pediatr Adolesc Med. 1999; 153:419 422. Abrams EZ, Goodman JF. Diagnosing developmental problems in children: parents and professionals negotiate bad news. J Pediatr Psychol. 1998;23:8798. Greenberg LW, Ochsenschlager D, ODonnell R, et al. Communicating bad news: a pediatric departments evaluation of a simulated intervention. Pediatrics. 1999;103(Pt 1):1210 1217. Read S. Breaking bad news to people with a learning disability. Br J Nurs. 1998;7:86 91. Oliver R, Fallat M. Traumatic childhood death: how well do parents cope? J Trauma. 1995;39:303308. McLauchlan CA. ABC of major trauma: handling distressed relatives and breaking bad news. BMJ. 1990;301:11451149. Girgis A, Sanson-Fisher RW, McCarthy WH. Communicating with patients: surgeons perceptions of their skills and need for training. Aust N Z J Surg. 1997;67:775780. Ptacek JT, Fries EA, Eberhardt TL, et al. Breaking bad news to patients: physicians perceptions of the process. Support Care Cancer. 1999;7:113120. Sykes, N. Medical students fear about breaking bad news. Lancet. 1989;2:564 569. Buckman R. Breaking bad news: why is it still so difficult? BMJ. 1992;288:15971599. Buis C, de Boo T, Hull R. Touch and breaking bad news [editorial]. Fam Pract. 1991;8:303304. Girgis A, Sanson-Fisher R. Breaking bad news: consensus guidelines for medical practitioners. J Clin Oncol. 1995; 13:2449 2456. Graham J. Touching and imparting of bad news [letter]. Lancet. 1991;337:1608 1609. Marrow J. Telling relatives that a family member has died suddenly. Postgrad Med J. 1996;72:413 418. Buis C, de Boo T, Hull R. Touch and breaking bad news [editorial]. Fam Pract. 1991;8:303304. Miranda J, Brody RV. Communicating bad news. West J Med. 1992;156:83 85. Simpson M, Buckman R, Stewart M. Doctor-patient communication: the Toronto consensus statement. BMJ. 1991;303:13851387. Makoul G. Medical student and resident perspectives on delivering bad news. Acad Med. 1998;73(10 Suppl):S35S37. Harrahill M. Trauma notebook: giving bad news compassionatelya 2-hour medical school educational program. J Emerg Nurs. 1997;23:496 498. Gillard J, Dent T, Aarons F, et al. Pre-registration house 870

officers in eight English regions: survey of quality training. BMJ. 1993;307:1180 1184. 27. Rappaport W, Witzke D. Education about death and dying during the clinical years of medical school. Surgery. 1993; 113:163165. 28. Vetto JT, Elder NC, Toffler WL, et al. Teaching medical students to give bad news: does formal instruction help? J Cancer Educ. 1999;14:1317. 29. Buchanan H, Geubtner M, Snyder C. Trauma bereavement program: review of development and implementation. Crit Care Nurs Q. 1996;19:35 45.

DISCUSSION Dr. Mary Fallat (Louisville, Kentucky): Dr. Jurkovich and colleagues provide a much-needed view into the hearts and minds of the surviving family members of trauma victims who died. A prevailing theme in the manuscript, with no offense intended, is that we collectively are not trained in death notification and we often could do a better job. Some of you may be familiar with a book called Emotional Intelligence by Daniel Goleman. Condensed into laymans terms, the EQ, or emotional quotient, is how we act on what we feel. Put another way, this is ones ability to handle stress and funnel it into appropriate behavior. We all know that some of us are better at doing this than others. In the context of speaking to families, we must express empathy, not sympathy. This is an important concept, so allow me to define it. Empathy is me grasping your feelings about your situation, whereas sympathy is my feelings about your situation. Empathy is the art of understanding the familys grief from inside their world. Dr. Ken Iserson in Grave Words: Notifying Survivors About Sudden, Unexpected Deaths, outlines four stages of death notification: prepare, inform, support, and afterwards. To do this carefully and correctly requires a team effort, education, and institutional commitment. The issues include, but are not limited to viewing of the body, the familys privacy, postmortem examination, organ and tissue procurement, coroner notification, preservation of evidence, personal effects. And these do not even touch on how the process affects the deliverer of the bad news and the high incidence of posttraumatic stress disorder in care-givers. Trauma is certainly not the only subspecialty in which sudden death occurs, but it may be the one arena where a group of residents or fellows become the messenger without warning. My recommendation is that an effort be made to develop an educational module for incorporation into the trauma curriculum. This module could be added to the new student trauma curriculum developed by the Committee on Trauma of the American College of Surgeons or the ATLS course, or it could be a stand-alone educational tool for trauma services. There are innumerable excellent resources available to use as references. I have two questions for Dr. Jurkovich. The first is, Were any of the victims organ donors, and did this have an effect on the response? And why were OR deaths excluded? These are the most difficult situations encountered, as there is really no opportunity to develop a relationship with the family.

6. 7.

8. 9.

10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.

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I would like to thank the Association for the privilege of discussing this paper and Dr. Jurkovich and colleagues for their contribution. Dr. Gerald O. Strauch (Chicago, Illinois): I think this is a super paper, and I think it is extraordinarily timely, especially in view of the intense focus that palliative and end-oflife care is getting these days. My ongoing interest in subjects like this remains piqued because of the responsibility of my office at the American College of Surgeons for staffing the Committee on Ethics of the College. I can tell you that the fact that ethics programs are appearing on a yearly basis at the Clinical Congress is by no means an accident. In the very recent past, I conducted a series of seminars, over about an 18-month period, in my own parish at home, entitled Dying Whole, and what we heard from the people who attended those seminars certainly confirms the basic message of this paper. I was delighted to see no mention of legality or liability in this paper. I do not think it is appropriate here. Having said that, there is no doubt in my mind whatsoever that the proper delivery of bad news prevents a lot of pain from being relived in courtrooms under some circumstances. Although the rank of the news-giver was not seen as being terribly important in this paper, it strikes me that we must remain leaders, whenever possible, in giving bad news, because if our trainees are going to do this and do it well, they will do so primarily, I think, as the paper states, by seeing us as examples. One question, Are you going to share your findings with those who responded to your survey? Thank you. Dr. John A. Morris, Jr. (Nashville, Tennessee): Few papers are going to change the way I practice medicine tomorrow; this one will. My questions are three. First, the information given versus the information heard. You tell us about the information heard. Do you know anything about the information given? Second, do you think there is variability based on socioeconomic class and can you look at your data that way? Third, I am fascinated about your letting patients into the resuscitation area during the resuscitation. Your data does not support that. Intuitively, we have been going back and forth. The nursing staff does not like it. My intuition says it makes sense. Any data? Dr. Marc J. Shapiro (St. Louis, Missouri): Dr. Jurkovich, excellent paper and excellent title. We polled at our hospital individuals who were admitted from the ED a few years ago to find out how many of them could identify their attending physician, and we found that one third could not. As part of our CQI, we ended up passing out information on the attending physicians and currently have over a 97% identification rate. My question is do you think that your results would be a little different in a hospital that was not a teaching hospital such as yours, because of all the people that are involved with the care of that patient, even though your patients families did not identify rank of the individual giving the bad news as being important? Thank you. Dr. Matthew C. Indeck (Danville, Pennsylvania): I want
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to echo what Dr. Morris said actually. I wanted to understand what role it is, or do you see a role for the family in the resuscitation area and how much involvement is it? Do you have the data? I think that is important. Another thing that we find sometimes, particularly where we live in a rural area, families are arriving prior to the patient because they might live closer to the hospital than where the patient might get an accident. What role do you see for information prior to the patients arrival? Dr. Steven E. Ross (Camden, New Jersey): John Morris asked several of my questions. The other parallel to his question as to what information was given is also who gave it? Were clergy actually present and not recognized as such? Two other brief questions. Were any of the notifications of death made by telephone? And the third one was how many of the deaths in the ICU involved advance directives? Dr. Samir M. Fakhry (Falls Church, Virginia): Dr. Jurkovich, I enjoyed your paper. I was fascinated by how you spread amongst your nurses the responsibility for caring for the patient and caring for the family. I did a quick poll of a nurse whos sitting nearby, and that was not probably the most popular thing for them. What has been the response of the nurses, and how did you manage to find enough nurses to get all that done? I enjoyed your paper. Dr. Janice A. Mendelson (San Antonio, Texas): I have noticed tremendous difference in philosophy and outlook among the people in different parts of the United States where I have been. There was one question about socioeconomic status. I again wonder whether there is a little more information about the background of the families who would react differently. Has that been included or should it be? Thank you. Dr. Randall W. Powell (Mobile, Alabama): Dr. Jurkovich, I was just wonderingwhen I was in the Navy in San Diego, we always had a chaplain in the hospital, and I always found that they were worth their weight in gold in these situations. When I moved to Mobile, they were much less available, although when they are there, they can be very helpful. I wish you would comment on the presence of a chaplain or not. Dr. Gregory Jurkovich (closing): Thank you very much for your comments, particularly for expressing an interest in this topic. Dr. Fallat, I want to thank you for your insightful education of me on the difference between empathy and sympathy. I appreciate making that distinction clear. I think you are absolutely right. What we have said was sympathy in the survey was really empathy. But that is just one of the questions that we need to sort out, just as what is the best attitude one should adopt, although I am not quite sure what the term attitude means. We just simply asked the family, Did you like the attitude of the new-giver? I am not sure what part of the attitude they either liked or did not like. Those are two examples of the survey questions that need some straightening out. None of the patients, I am modestly embarrassed to say, were organ donors. We have a reasonable organ procurement response rate in our hospital, but it is not great.

The Journal of Trauma: Injury, Infection, and Critical Care

May 2000

The operating room, as well as every other intensive care unit in the hospital, was excluded from the study specifically to try to minimize the amount of variability in the study. We probably should have also excluded the ED as well and made it strictly a trauma ICU study. And, in fact, to really be ideal, we should have limited the study to only to the general surgery trauma service. Such as it was, we tried to focus on the trauma ICU because, quite honestly, the nurses in that ICU were interested in doing it. And that gets to many of the other questions regarding the nurses. Two of the trauma ICU nurses were coauthors. Ms. Pierce is the nurse manager for our trauma ICU, and Ms. Pananen is one of the senior staff nurses. They are the ones who actually suggested and pushed for the plan of how to contact the family. The ICU charge nurse identifies a second nurse, in addition to the patients primary nurse, when there is a patient who is likely to die. This second nurse is the primary family liaison. This second nurse was their idea, they like doing it, they think it is better. They like to relate to the patients, and we are happy to have them do that. I do not have any objective data on how well this works. It is clearly something we should be following up on to see if it changes our response rates. But it seems to be working. Let me just briefly comment on the issue of the resuscitation room. We are letting family members in to see patients in the TICU, not in the ED. This is when that second nurse contacts the family and the family says, I want to see Dad before he dies. Even though we are in the middle of doing a resuscitation in the ICU, we will let a family member into the room regardless of how messy the resuscitation is. Not many of the family members want to be there, but those that do want to visit adamantly want to be there, and they really do not care what it looks like. They only stay for a few seconds, and then they leave. They have not been in our way. Nobody is complaining about their presence. It seems to be working fine, but it is not many people. We are sharing this information with all the clinical services in our hospital. I have given grand rounds to a number of clinical services in the hospital about this topic as one method of disseminating this information. It is a teaching hospital, no question about it. There is a wide variety of residents, patients, students, and nurses. And I am sure the numbers would be different in a nonteaching hospital, but I am not so sure that the results of the family survey would be any different. Phone information was given in about seven patients. That did not seem to correlate with any adverse responses, although most people did not like receiving bad news information over the phone. Since we get so many of our patients from the Northwest region, including Alaska, Montana, Idaho, and Wyoming, sometimes it is just a fact that the family cannot get there, and you have to call them over the telephone. If that is the case, they do not seem to mind. Clergy were present. Six of the patients had their own personal clergy present. These particular families really did not care whether we did a good job or a bad job at having clergy available, because they had their own clergy present. However, some patients wanted a clergy, and we did not offer
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it to them. Some patients could not care less about it. It is difficult to sort out who desires or needs a clergy available or present, but clearly it is one of the issues you just have to ask about. Dr. Mendelson made a correct observation that there likely are regional differences as well as cultural and probably racial differences in how you want to hear this bad news of death. We have not sorted that out at all, and we made no effort to do so in the results of this survey, but I suspect she is correct. And finally, Dr. Powell, regarding the issue of a chaplain, I think it is someone who in theory should be skilled in the giving of bad news and help you in doing it. And we do have a hospital chaplain that is available, but sometimes we just do not call on that person. As you know, many of these deaths are in the middle of the night, sometimes very suddenly, and we just simply forget to ask for help in the giving of bad news. I hope I answered most of the questions. Again, I thank you for your attention. EDITORIAL COMMENT There is perhaps no more difficult task in all of medical practice than that of delivering the terrible news of unplanned and unexpected death. And yet it is a sufficiently common experience, an average of once a week in this study of 80 deaths over an 18-month period, that planning and education should markedly improve what is described as a rather haphazard approach to the issue. The authors are to be complimented for specifically calling attention to this issue in the trauma area; it is well described in other literature. In this study, more than half of the patients survived for more than 24 hours, more than ample time for a solid relationship to be established between care-givers and families and loved ones. Unfortunately, the survivors seemed vague about who was in charge or who had ultimately given them the news of the death. The place where the news was delivered was often public, and it seems clear from the data presented that the person in charge was rarely the person who had the definitive encounter with those bereaved survivors. That the public may perceive the chief trauma surgeon as too important or too busy with other life-saving activities to address this issue may be self-satisfying. But we in the trauma field know that to not be the case; there is plenty of time. That neurosurgeons would seem to be the least involved also comes as no surprise. Surgeons hate death and still look on it as a failure; that we should seek to avoid the confrontation with the family is understandable. It is time for us to address the issue actively. We have a responsibility to students and residents to show them how to handle this situation as much as we need to show them how to put in a chest tube or do an escharotomy. We have a responsibility, as leaders of a team, to truly organize the team of nurses, social workers, clergy, and others to be actively involved with the survivors in making this a less devastating experience. Finally, like the Sherlock Holmes story about the dog that did not bark during the night, this paper is striking in that the words organ transplant were

Vol. 48, No. 5

Giving Bad News

never mentioned. I recently attended a seminar at the American College of Surgeons meeting on the subject of organ procurement and the room, designed to hold 700 to 800 persons, was occupied by fewer than 3 surgeons. It is no wonder that the organ shortage continues. The trauma service must serve as the primary resource for organs. I should be surprised if the authors of this paper did not have colleagues in the same surgical department elsewhere in the hospital, searching for organs to transplant. The transplant team also usually has skilled persons who are experienced in dealing with bereavement and often making an organ donation the single positive aspect of an otherwise devastating loss of a loved one. My experience, and an admittedly unscientific observation, has been that most organs come from other hospitals and a relatively small percentage of organs for transplant come from the trauma

program of the hospital in which the transplant program is housed. All trauma surgeons want to perceive of themselves as surgical wizards. Wizards are highly respected and skillful persons. Ursula K. LeGuin described in her Earthsea Cycle that wizards find part of the secret of their success when they look into a mirror; it is in themselves. The authors have looked into the mirror of their own experiences and did not like what they saw and are appropriately taking measures to correct them. The authors are holding up a mirror for all trauma surgeons. Thomas J. Krizek, MD The Ethics Center The University of South Florida Tampa, Florida

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