Death in the hospital: Breaking the bad news to the bereaved family.

Informing the family members about the sudden death of their loved one is a highly stressful experience for the treating doctors. Breaking the bad news to the bereaved family needs special skill on the part of the clinicians. An elaborate, step-wise modified action plan for breaking the sad news and grief reduction based on the literature has been presented here. The guidelines mentioned in the article are simply the tips to the clinicians and not to be considered as any form of protocols. Inclusion of this subject into the undergraduate medical curriculum has to be considered. By doing so, we can look forward to produce junior doctors who are better at coping with this awkward but extremely important aspect of clinical medicine.

Introduction

Informing the family members about the sudden death of their loved one is a highly stressful experience for the treating doctors. Breaking the bad news to the bereaved family needs special skill on the part of the clinicians. Unfortunately, there is little guidance on to the approach of this very sensitive matter.[1] The doctors depend on their own experience rather than any training received in the medical school.[2] A well-trained doctor in this field will be in a better position to handle the daunting task of breaking the bad news.[3] It is high time to include this subject into the undergraduate medical curriculum.

In general, irrespective of the diagnosis, death can take place in the hospital under two circumstances. Firstly, the more common one, the expected death, where the patient's relatives are aware of the serious nature of the illness, and naturally death is expected. The second situation would be sudden and unexpected death. In the first instance, the relatives will be mentally prepared for the sad news, and the doctors would find it relatively easy to announce such deaths as and when they occur.[4] But, when the death occurs unexpected and suddenly, the relatives find it difficult to cope with the bad news. They can hardly believe the sudden loss of their loved one. In this situation, the relatives will be very sensitive and emotionally highly charged.[5] In this situation, any lack of compassion and kindness on the part of the health care team may in fact trigger violent grief reaction, and anger may be directed towards the hospital staff.

Possible reactions of people who are suddenly bereaved

Reactions to the news of a sudden death are often intense, and health care team should be prepared to tackle varied range of emotional outbursts. Behavioral response to sudden death depends on the cultural, social, and ethnic background. Expressions of sorrow may vary from silence to crying, loud shrieks, wailing, and bodily movements. Grief reaction is unique, and it will differ from one individual to another. The bereaved relatives perceive the sudden death as ‘untimely’ and ‘unfair’ and may show following grief reactions.

Initial shock reaction

Denial- This is initial defense mechanism after unexpected, devastating news, and it should be recognized and tolerated. Acceptance may be possible by encouraging the relatives to view the body of the deceased, especially to those relatives who were not present at time of death

Anger- This is a common reaction after sudden death of a beloved relative. The expression of this anger can vary from mild irritation to violent behavior. This can be expressed on self, hospital staff or any other person. Anger will gradually diminish once expressed

Guilt- This is nothing but the inward expression of anger and self-blame. Consoling words of the health care team will help to do away with this emotion.

The onus of convincing the bereaved family members about the circumstances, which lead to sudden demise of the patient, definitely lies on the health care team and should be carried out with utmost priority. Studies have shown that clinicians feel inadequate in these situations and willing to undertake experimental approaches.[2]

Whenever an inpatient becomes seriously ill in the hospital unexpectedly, the health care team will try their best to save the patient's life. However, all these efforts will be taking place behind the closed doors of the ICU. It is very important to brief the relatives about the efforts being taken to save the life of their relative. Otherwise, there may be serious doubts in the minds of the relatives about the circumstances, which lead to the death of their beloved one. The health care team should make use of whatever little time available to prepare the relatives mentally for the inevitable news. This short communication will give the relatives some breathing time to cool their nerves and prepare themselves for the bad news.

Hospitals across the globe have adopted various protocols and guidelines to break the sad news and helping a deceased patient's family cope with the initial grief and loss that accompanies the unexpected death of a loved one.[5]

Here is the elaborate, step-wise modified action plan for breaking the sad news and grief reduction based on the literature.[56]

Initial contact with the family

If the family members are in the hospital, summon them to the ICU as emergency. However, problem comes when nobody is around.

A senior member of the health care team should call the family members. Inform them that the patient has become ill suddenly and initiation of the prompt treatment. The family member should be asked to come to the hospital immediately.[789] If the patient is already dead, care should be taken not to break news on the telephone unless the family members live a long distance away. However, if the death is expected, simply break the news to anyone who receives the phone and note down the person's identity and his/her relation to the deceased

If we are to break the sad news over the phone, make sure that someone is around with the person who is going to receive it.[610]

Receiving the family members at the ICU

A relatively confident member of the health care team should receive the relatives at the ICU and confirm their identity and relation to the patient. Prefer to talk to somebody who is familiar to the health care team already

A comfortably furnished room should be available near ICU to talk to the relatives.[1112] Try to limit the discussions to only one or two members of the family.

Handling of the family members will differ if the patient is already dead or if the patient is alive and receiving resuscitation.

When the patient is alive: Prepare the relatives for the possibility of death

A relatively senior and confident clinician should introduce himself first and then begin the talk.

Foreshadow the bad news, “I am sorry, but I have bad news”

Explain the relatives how well the patient was doing earlier and his sudden deterioration. The clinician should try to explain the possible reasons for the sudden deterioration. He should be very patient and encourage the family members to ask questions and express feelings and should be most willing to answer them. This will help to build a sense of trust and good rapport with the family members

One of the relative who is relatively confident and well-versed with the hospital set up should be given opportunity to witness the ongoing resuscitation in the ICU. The senior most clinician in the team should explain the resuscitation procedure and should show the signs of life like spontaneous breathing or heart beat in the cardiac monitor, limb movements etc., The sincere words of this witness will simply help the relatives to confirm that everything possible is being done[1314]

Then, the relative should be taken back to the discussion room and the senior clinician to explain the prognosis and chances of survival

A priest or any other spiritual counselor should be allowed to offer final prayer if the relatives wish so

The staff should keep the family informed with frequent updates on the progress of the resuscitation

Access to the telephone should be provided for relatives so that they communicate with the other family members

These steps will give the family ample of time to prepare themselves mentally for the most inevitable.

Informing family about death

And finally, if the resuscitation is not successful, the senior clinician, who is responsible for the patient, should sit with the relatives and break the bad news

Again, as earlier, try to engage only one or two members of the family. Friends and others should be asked to wait outside the room. Prefer talking to the same person who has been briefed about the patient's critical illness earlier. It is always easier to converse and convince a familiar person than a stranger. Moreover, it will be lot easier to break the sad news to the person who is quite aware of the ongoing treatment and patient's problem rather than to a totally new person

Use plain English like he is dead or died rather than euphemisms like “passed away or left us, no more etc.” This will help to avoid the risk of misinterpretations.[10915]

Facilitating the grief reaction

Having announced the bad news, the doctor's next duty is to help the relatives to go through the process of grief

Encourage the relatives to express their feelings like crying loudly or sobbing etc

Encourage them to talk about the patient's illness, and if they open up, try to explain the efforts taken to save him and the inevitable outcome

Remaining silent with physical touch like placing hand on the sobbing person's hand or head may be tried depending upon the situation and ethnic background

Appreciating the efforts taken by the relatives to get the patient treated may help them to come out of a sense of guilt or self-blame. Convince them again that there has been no shortage of efforts either from the health care team or from the relatives

In certain cases, especially when the diseased has been in deep coma, explain them how peaceful the death was. This would help to convince them that their beloved one did not suffer much. Such reassurances also reduce guilt feelings

Some amounts of religious philosophy like “ultimately everything depends on God's wish” or “Life-span being over as per God calculation” etc., may help to console the bereaved relatives, and again, this depends on ethnicity and religious background

Do not respond or argue with the relatives if they blame or comment on the healthcare team or the hospital

They will realize their mistake and surely apologize when the emotions settles down

Whenever there is a medico-legal implication or other situations where a medical autopsy may be needed to ascertain the cause of death, relatives should be informed about the possible autopsy well in advance.

Arrange for viewing the body of the deceased

Before allowing the relatives to view the body, make it more presentable

Cover the body with proper bed clothes

Disconnect all the life supports like endotracheal tube, cardiac monitors, ventilators etc

Wipe the face neatly to clean blood and other secretions

Clean the jelly on the chest used for the DC shock

Avoid emotionally charged or labile relatives viewing body as they themselves may collapse inside the ICU.

When the patient is already dead before the arrival of the relatives

Receive the relatives at the ICU as described earlier and confirm their identity

Make them seated in the well-furnished room as described before

Again, the relative who is known to health care team should be preferred

A relatively senior and confident clinician should introduce himself first and then begin the talk

Prepare the relatives with foreshadow of the bad news, “I am sorry, but I have bad news”

Break the sad news in simple language and avoid using euphemisms like “passed away or left us, no more etc”

Facilitate the grief reaction as described earlier

Help the family members to view the deceased.

Help the relatives to go through the official formalities

One of the hospital staff should assist the relatives in completing the formalities like filling the details of deceased so as to get a legal death certificate etc.

If an autopsy is needed, guide the relatives about various procedures

And finally, ensure smooth and timely handing over the body of deceased along with valuables and personal belongings.

Conclusion

Thus, all the possible measures should be taken to help the utterly distressed relatives to accept the death with relative equanimity. Irrespective of the final outcome, the health care team's commitment will be definitely appreciated by the family members. The act of kindness shown during the hour of need will definitely help to strengthen the doctor-patient relationship further. A more humane approach from the hospital staff towards the bereaved family not only benefits the relatives of the deceased but also protects the hospital from potential conflicts surrounding the death of the patient. There should be a sense of accomplishment if any of the family members of the expired patient is seen seeking medical care in the same week at the same hospital. A rightly-handled patient care not only brings unmatched consolation to the family of the bereaved patients but also gives long-lasting satisfaction to the treating doctors. Unfortunately, most of the clinicians have little or no formal training for this task. Hence, inclusion of this subject into the undergraduate medical curriculum has to be considered. Just like pilots who gain experience with simulators, medical students should be trained similarly in this art of communication. This skill can be taught like any other aspect of medical care. Thus, we can look forward to produce junior doctors who are better at coping with this difficult but extremely important aspect of clinical medicine. In this article, an effort has been made to highlight the importance of formal training of all the clinicians in the art of breaking bad news to bereaved family and to avoid possible communication pitfalls. The guidelines mentioned in the article are simply some suggestions to the clinicians and not to be considered as any form of protocols. There is ample of scope for research in this subject. Conducting workshops, viewing videotaped interactions between clinicians and simulated bereaved relatives, small group role-plays could be efficient methods to teach clinicians how to break bad news in the stressful environment of an emergency room.