Clear and concise communication is key while delivering bad news

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“Guys, are you alright in there?” I ask casually while taking the first bite of my dinner on a 24-hour PICU shift.

No answer.

“What is going on? Why is she beeping so much? Is her tube blocked?” My voice gets louder.

Complete human silence. Except for the deafening hypoxia monitor going to 30s. Heart rate monitor dipping to below 60s. All this beeping was coming from a six-month-old girl with a history of brain malformation who was intubated for seizures.

I rush to the patient’s room and quickly realize that she is cyanotic and not breathing. I start sweating and can barely keep my hands to myself. I wanted to do everything, but all the things that I want to do are already being done by someone else. I catch my breath. I walk up to the respiratory therapist.

“What is going on, man?”

“I don’t know. I was just re-taping her tube, and it came out.” Those words echo in my ears, but my ears were trying to hear everything going on in our surrounding. I notice the patient’s heart rate persistently below the 60s. My heart rate probably above 160s.

“OK, everyone. We are in a code situation. Call the anesthesia attending to the PICU STAT. Call the trauma surgeon STAT. Ask the PICU attending to turn the car around. This patient might need a critical airway real soon. Nurse, I want you on the chest compressions. RT, you are on airway with bag-mask ventilation.” My code voice comes out.

Five minutes later, we have a PICU attending, a trauma attending and anesthesia attending who were unsuccessful at re-intubating her. As a lowly second-year resident, I didn’t stand a chance even to attempt to put this tube in. PICU attending, in her distinct code voice, assigns me a role to call the parents to update them about this situation.

I remember that earlier in the day, these parents had specifically asked me if they can go to a different city, about 300 miles from where their child was to look at alternative housing arrangements. I was the one who reassured them that we will take good care of their daughter. My hands shiver while dialing this mother’s cellphone number.

Ring. Ring.

I secretly was hoping she wouldn’t answer. She answers the phone right away. I introduce myself. Before proceeding further, I peak at the room and see the trauma surgeon preparing for a tracheostomy tube placement while the anesthesia resident continuing chest compression for persistent bradycardia. “I am calling you to let you know that your daughter is dying. Right now we are trying to put the tube back indirectly through her neck so that she can breathe. We are compressing her chest to keep her heart beating. There is a high chance that she will not make it tonight.”

Silence. Uncomfortable silence. Sighs, and a big blast. Yelling ensues and possibly some cursing. It is all a blur, but I think the gist of it was this mother trying to find out why I was messing with her tube, especially when I had reassured them earlier that she is going to be alright? I apologize profusely, explain the reasoning as much as I can, but I do not think that went through. “I am going to kill that mo*******ker,” I hear her father yell in the background. “She better not be dead when I am there.” Mother yells at me and hangs up.

I rush to the room, look around at all the doctors working hard to save the patient’s life; probably also trying to save me from these upset parents. I realize that this was the first time I ever told a parent that their child is dying, let alone over the phone. A few minutes later beeping stops and the nurse yells, “Heart rate above 100. Stop the compressions.” With a little glimmer of hope, I look up at the monitor to confirm. The trauma surgeon still working on that “trach.” I pray to God, “She better not be dead when the mom is there.”

The next 15 minutes felt more like a decade to me. The trauma surgeon finally looks at me with a wry smile and a twinkle of hope in his eyes. It appeared that he was successful at the emergent procedure. She is not going to be dead when her parents arrive.

About a year later, when I sit here to reflect on this incident, I realize that delivering bad news is part of our profession. You learn it one way or another. As a physician, you are the leader of the team. Clear and concise communication is key while delivering bad news. Beating around the bushes may be an easy way out. Offering a solution may be something you might want to yell — but, rest assured, parents or relatives do not want to hear that. As crude as this may sound, any variation of “dead” may need to be in this conversation.

After all this moment of excitement that evening, around 11 p.m., I page my senior resident on the pediatric wards to bring me some Motrin. I proceed to interpret blood gas and electrolyte for the patient with DKA next door.

Shubham Bakshi is a pediatric resident.

Image credit: Shutterstock.com

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