Miscellaneous: Delivering Bad News

“SUNBURN Protocol”

Definition

  • Protocol for Delivering Bad News in Trauma & Acute Care Surgery

Factors

  • S: Set Up
  • U: Understand Perceptions
  • N: Notify (“Warning Shot”)
  • B: Brief Narrative & Break Bad News
  • U: Understand Emotions
  • R: Respond
  • N: Next Steps

Unique Challenges in Trauma

  • “SPIKES” and Other Protocols Poorly Correlate in Trauma
  • No Previously Established Rapport
  • Injury is Unexpected
  • Patients are Generally Younger
  • Fewer Resources for Grief Support – Often Present on Nights/Weekends (Not Fully Staffed)

“SPIKES Protocol”

Definition

  • Protocol for Delivering Bad News
  • Designed for the Use in Oncology Patients at MD Anderson Cancer Center
  • Generally the Most Common Model Described in Surgery

Factors

  • S: Setting – Set Up the Interview
  • P: Perception – Assess the Patient/Family Perception
  • I: Invitation – See What the Patient Wants to Know
  • K: Knowledge – Share Knowledge
  • E: Emotions – Respond to Patient/Family Emotions
  • S: Strategy/Summary – Recap & Decide Next Plan

Other Models for Delivering Bad News

“ABCDE” Protocol

  • A: Advanced Preparation – Review History & Prepare
  • B: Build a Therapeutic Environment/Relationship – Ensure Adequate Time & Privacy in Appropriate Setting
  • C: Communicate Well – Avoid Medical Jargon & Allow for Silence
  • D: Deal with Patient/Family Reactions – Actively Listen & Explore Empathy
  • E: Encourage & Validate Emotions
  • *Designed for the Family Medicine Environment

“BREAKS” Protocol

  • B: Background – Review the Clinical History & Relevant Information Before Hand
  • R: Rapport – Build Rapport & Allow Time to Understand Patient/Family Concerns
  • E: Explore – Determine Patient/Family Understanding of Illness
  • A: Announce – Give a “Warning Shot” & Deliver the News
  • K: Kindle – Address Emotions as they Arise
  • S: Summarize – Summarize the News & patient Concerns
  • *From the Indian Journal of Palliative Care

General Considerations

Preparation

  • Take a Moment to Compose Yourself
  • Anticipate & Understand the Details Surrounding the Event & Clinical Course
  • Mentally Prepare What You Will Say
  • Bringing an Experienced Nurse Can Be Helpful
  • Remove Any Blood-Stained Clothing

Setting

  • Use a Quiet Room
  • Have a Safety Strategy to Exit the Physical Space in the Case of a Violent Response
  • Multiple Family Members Can Be Supportive but Avoid Excessively Large Groups
    • Particularly in Pediatric Traumas – Larger Groups May Detract from the Ability to Provide Support to Parents

Delivery

  • Sit Down – Do Not Stand by the Door
  • Look at Who You are Addressing
  • Understand What Information They Already Know
  • Begin with a “Warning Shot”
    • “I’m Afraid I Have Some Bad News”
    • “I Am So Sorry…”
  • Be Honest and Direct, Do Not Beat Around the Bush
    • Give a Brief Narrative for Context (1-2 Sentences) & Then Deliver the News
    • If Patient Has Died, Use the Word “Death” or “Dead” & Avoid Euphemisms (“Passed Away”)
    • Avoid Excessively Long Drawn Out Narratives that Delay Delivery – There is No Way to Soften the Impact
  • Avoid Excessive Technical Information
  • Do Not Rush

After

  • Allow Silence to Allow Facts to Sink In
  • Allow for the Bereaved to React to the News – Varied Reactions May Be Seen
  • Provide Tissues
  • Touching/Holding a Hand to Comfort is Generally Appropriate but Should Be Considered in Various Social/Cultural Settings
  • Avoid Platitudes or False Sympathy
    • “You Have Another Son”
    • “I Know What it is Like”
  • Do Not Concentrate on Yourself
    • “I Have a Child Too”
    • “You Know, This Isn’t Easy for Me”
  • Provide an Opportunity for Family to See the Patient – Even if Injuries are Mutilating, Although Cover Wounds as Able
  • Debrief with the Medical Team & Ensure the Emotional Stability of the Staff

Most Important Factors in Trauma (From the Perspective of Family)

  • Most Important:
    • Attitude of the News-Giver (72% Consider Important)
    • Clarity of the Message (70%)
    • Privacy (65%)
    • Knowledge/Ability to Answer Questions (57%)
  • Intermediate Importance:
    • Sympathy
    • Time for Questions
    • Location of the Conversation
  • Least Important:
    • Attire of the News-Giver (3%)