Silver Linings Handbook: Tips for the Covid Cohort 6 - Breaking Bad News During Isolation
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Breaking Bad News During Isolation


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As I write this over 200,000 people have died from COVID-19 worldwide, which for a virus that did not exist in humans 4 months ago, is a lot (but in context is still fewer deaths over that time period than TB and far fewer than injuries and the non-communicable disease). In the hotspots of transmission, like London where I work, we are having to have difficult conversations around death and dying with patients and their families on an unprecedented scale.

 

Disclaimer: As an F3 Doctor, until recently I have been quite sheltered from having to break news, which is often undertaken by more senior members of the team so I am by no means an expert in this sphere.  In the last month, I have been involved in a number of these conversations and at times felt unprepared (although maybe you are never truly ‘ready’ to tell a family member their loved one is dying) - so I have spoken to a number of experienced colleagues and tried to collate some of the new guidance coming out - which I hope can be of help to you.

 

Don’t Delay:


The field of palliative care has revolutionised how we involve patients and their families at the end of life in recent years, with an emphasis on early shared decision-making and supporting  patients wishes and needs to achieve a good death for all. However, the speed at which COVID-19 causes deterioration in patients often does not allow for patients and families to come to terms or have communicated their wishes around end of life care. As such, honest discussions around prognosis and ceilings of care (see Blog 4) should be initiated as early as possible in the emergency department. Even if you don’t have all of the answers at this point, the Association of Palliative Medicine states that “honest conversations are often what patients and those close to them want” and overall reduces anxiety.


Stick to the Framework:


I’m sure most of you will have learnt the SPIKES framework at medical school and despite its rigidity, I find the simplicity and flow of it really useful during what will likely be quite a stressful conversation.



 

Setting - This is one of the hardest things I have found during the pandemic. Working in intensive care, I will often receive calls from families whilst on the unit in full PPE sounding like a particularly muffled Bane impersonator through my FFP3 mask, creating an immediate communication barrier . If possible, try and take calls outside of the isolation areas to avoid this, and if not make sure you speak as (often uncomfortably) slowly and loudly as you can to avoid misunderstandings. And for speaking to awake, and probably terrified patients - I think it is important to show the human behind your mask and visor - taping a photo onto your scrubs can be a source of comfort during these times. For professionalism's sake, I'd advise keeping tops on for these…
 
It is also important to put yourself in the shoes of a family member, desperate to hear about their loved one who they last saw being loaded into an ambulance, who may have been haplessly on the phone for hours trying to get through the barrage of automated messages and overworked switchboard operators. Don’t be surprised if those at the end of the line are already upset and frustrated when you answer. Acknowledging the difficulty of having to have these conversations at a distance and thanking them for their patience helps absorb some of these emotions before beginning the conversation.
 
Perception -“Before I start, can you tell me what you already know about Mr/Mrs X illness and what you most want to discuss today?.”  This will set the trajectory for the rest of the conversation, you will accrue a huge amount about the person you are talking to (their understanding, expectations, current mental state) and also buy you some time to formulate the next part. Following this, to make sure the family member also feels listened to and included in the conversation, I also ask them to stop me at any point if there is something they don’t understand. You will find your own phrases on how to do this, but I think these two points are the key to getting these conversations started as well as they can. There’s lots of guidance out there, so keep your eyes open and adapt them to your style. The National Healthcare Communication Programme guidance document is a good place to start.

I hope that is helpful, for updates/tips please subscribe to my blogs in the link below.

 



Originally published 08 June 2020 , updated 10/06/2020

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