An ICU nurse says that when there is bad news to deliver, doctors often lack the bedside manner to deliver it well. “Doctors are sometimes not so great at it and they leave us standing there to deal with the family. I give them a hug because I’m that type of person. We don’t have any formal program to tell the family. Of course, after the fact, they can see grief counselors. There was this one guy who didn’t make it after open-heart surgery. We were just waiting for him to die and even after we unplugged everything he still held on. We couldn’t figure out what was holding him on. All the while the family was at his bedside – all but a twin son who didn’t get there until much later. Once he arrived, he held his father’s hand and at that moment he passed. There was something special about that and while we can’t explain it, there is more to life than we understand. The family was grateful that we stayed with them as long as necessary.”
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It’s never easy delivering bad new whether it’s as mundane as explaining why a minor procedure didn’t work as expected, or as sad as telling the family the patient died.
In a litigious society, the way bad news is announced can be the difference between the successful delivery of a message versus the messenger being shot. As unfortunate and callous as it may sound, avoiding litigation is a reality in a world that assumes if something went wrong it was the doctor’s fault.
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A Gastroenterologist’s Experiences
“I once had six deaths in 24 hours in ICU. There is no right way to tell the family. I use the euphemism: ‘I’m sorry, but your mother moved on.’ Quite often I would hear the loved ones say things like: ‘Did you see my mom’s soul go to heaven?’ I would reply: ‘God hasn’t given me the privilege to see or understand that kind of thing.’ The physician is in a no-win situation. How can you console a mother who lost a daughter? Never say, ‘I know how you feel.’ It’s better to say, ‘I know you feel bad.’”
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“I had to tell an eighty-year-old woman and her daughter that her husband (the daughter’s father) had died. Not a moment after I told the wife, she passed out right there on the floor and died. I initiated a code and we tried to revive her, but to no avail. I looked up to the daughter and said, ‘Please don’t die on me.’ It sounded so cruel, but she understood and kindly said, ‘Don’t worry, I’m all right.’”
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Many times people say they are going to sue the doctor when they have a loss. They often don’t understand or believe the doctor’s explanation, and once they institute a suit, the explanation will come in a long, tiring, brutal, and hostile environment of depositions and testimony. If complications are explained in a compassionate, understandable manner, the courtroom can be avoided, and the aggrieved will better cope with their loss.
The most difficult bad news involves telling the family the patient died. “I’m terribly sorry, Mary, but I just killed you mother,” is not the way you would ever deliver bad news, but you can be sure that’s the message the personal injury attorney is going to deliver to the jury of laymen who will decide your fate. While compassion has to be the utmost concern at the time of delivering news of loss, you also must be concerned with protecting yourself.
Since blame is the essence of personal injury law, you must make sure you assign blame to the patient, unless you truly performed an act of malpractice and wish to make such a pronouncement. Assuming you did nothing wrong, it is best to begin by establishing a rapport with any of the family members you may not already know. This is especially true for the emergency room physician, who often meets the family for the first time to deliver the news that a loved one died.
You need to introduce yourself and determine to whom you are speaking:
DOCTOR
“I’m Doctor Smith.”
In most instances the person will tell you who they are, if not, you ask:
DOCTOR
“How are you related to Joan?”
You put out your hand, take their hand in both of yours. This immediately shows concern and compassion. You repeat this for each person you need to know.
DOCTOR
“Please, let’s sit down and let me explain.”
Once everyone is seated:
DOCTOR
“We did everything we could, but Joan’s injuries were just too extensive and she didn’t make it.”
Often the loved one will try to get the bad news by shouting, “Did she die?” It is best to respond to the demand since this personality doesn’t want to wait for protocol.
Notice the blame is placed upon the injuries, and you avoided the harsh sound of dead or died by using the euphemism “didn’t make it.” You now must allow time for the response, which will often be hysteria. If the person grabs you, you hug them and tell them how terribly sorry you are and that you wish there was something more you could say or do to make things better.
The more difficult situation arises when you have to tell the family their loved one died in a case where it was never expected. Probably the worst such scenario is when the patient dies during routine cosmetic surgery. Again, blame should be placed upon the patient.
Every doctor knows there is risk associated with surgery and general anesthesia. These risks are supposed to be spelled out in the informed consent and that consent is your best protection. Though the patient consents to the procedure and is supposed to understand the risk, that doesn’t mean they, or their family, will not still attempt to sue the doctor.
Patients usually don’t sue doctors they love and trust. While the patient may have loved you and would never sue, that doesn’t mean their family feels the same way. It is at this time that you have to establish the rapport, trust, and bond with the loved ones to prevent a lawsuit. Beyond protecting yourself, you should understand that the most important motive to establishing this relationship with the family is to help them deal with a most unfortunate event in their lives.
Defensive posturing is not compassionate and makes the doctor look suspect. It is best to explain the nature of surgical risk in the most lay fashion possible:
DOCTOR
“I have terrible news for you. Your wife had a bad reaction to the anesthesia and we couldn’t revive her.”
Most loved ones will respond to the euphemism:
FAMILY MEMBER
“You mean she died?”
DOCTOR
“I’m sorry.”
It is imperative to stay with the family as long as is necessary. Rushing away without cause appears callous. If you are the emergency room physician and it’s a busy day, you may have to excuse yourself, but you should make sure there is some protocol in your hospital to have a grief counselor, or nurse trained in dealing with these matters, take over once you have explained the situation. At that point you must explain that there is another emergency for which you are needed and introduce the counselor before you make your exit.
Never rush the family of the bereaved. Try to answer all the questions they may have. Always ask if there are any questions before you leave and say, “If there is anything else I can do for you please don’t hesitate to give me a call.” That offer to “give me a call” goes a long way toward making the patient, or the family, feel comfortable.
Now that you can tell a family member their loved one just died, everything else is easy. Maybe not. No one likes bad news and when you have to deliver it, it’s never pleasant for either party. Again, you must be prepared for any and all situations and have a script ready. No matter how trivial you think a loss may be, to a particular patient it could be devastating.
Failing Procedures
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An Endodontist
“Telling patients a procedure failed is very uncomfortable for me. I always plan for failure when making a treatment plan. I tell the patient what we will have to do in the event that things don’t go as planned. I explain the alternatives, risks, and costs. I want my patients to be comfortable with any outcome.”
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When a procedure fails, patients are at minimum disappointed, and others may exhibit hostility. Much of the reaction depends upon expectations, importance of the procedure, and financial loss. The loss of sight would be more disconcerting than the loss of a tooth. A loss involving a simple procedure with a high expectation for success is more upsetting than the failure of a procedure that had limited chance of success. And the failure of any procedure that required large out-of-pocket expense is less acceptable than the failing procedure fully covered by insurance.
All of these considerations must be addressed before treatment to avoid the bad feeling engendered when procedures fail. By preparing before the failure, delivering the bad news is much easier and preserves your relationship with the patient.
Besides the written informed consent, the doctor should deliver the oral consent and address all the possibilities of complications and chance of failure. If presented in a friendly, non-threatening manner, treatment acceptance will be high and disappointment minimized when treatment fails.
Most reasonable patients will understand a failing procedure and accept the need to move on. Some might question you about a refund. There are two schools of thought on this issue. You can offer some type of refund, best tied into an alternative treatment or you can revert to your informed consent where you prepared the patient so well they shouldn’t even consider asking for a refund. In spite of the best preparation, telling the patient who never understood your presentation that there is no refund, and they will now have to pay for the new device, is not well received. Which doctor are you going to love? I think we all know the answer.
To make a fair settlement, you can offer to apply the funds from the failed procedure towards an alternative or you can tell them they will get some sort of discount. Patients will be much happier if they feel they didn’t lose everything. While you will take a loss for a minimal amount, you will have a very happy patient. Since failures should be an uncommon occurrence, you can afford to be nice.
Some practitioners feel that offering a discount or refund is tantamount to admitting guilt. While that is a concern, most patients do not think that way. Even if they tried to use the refund against you in a lawsuit, good records and documentation that you are making a hardship adjustment will look favorable for you in the courtroom, though you’ll not likely get there.
Many doctors spend thousands of dollars marketing their practices and they are reluctant to make an adjustment when things go wrong. The goodwill generated by a patient who doesn’t have to pay twice for the same thing is worth many times more than marketing costs. The badmouthing that takes place when the disgruntled patient pays twice costs even more.
Besides death and failing procedures, there are lesser bits of bad news that need attention as well if you want to run the premier professional practice. It is bad enough that health-care providers are often behind schedule and keep patients waiting; sometimes hospital emergencies require them to miss appointments. The chapter on the waiting room addresses such problems.