Can we do better when delivering bad news in trauma?

On a recent trauma call, we had a busy night, culminating in a horrific motorcycle trauma that came in early in the morning. The patient had devastating injuries and ended up dying. The detectives finally tracked down the patient’s family. I cleaned myself up, put on my white coat and had the family sit down in a private conference room. I entered with my trauma attending and a consulting specialist, and we sat down with them.

I told them their loved one had been involved in a terrible accident and asked them what they knew so far. I filled them in on the rest of the situation, explaining that we’d done a lot of work to try to save him, but the injuries had been too much, and he had died. We spent as much time as we could answering their questions and being with them as they processed the horrible news and finally took them to see him. Naturally, they were devastated. I will never forget the wail of sorrow from his widow. While I have delivered bad news before, this experience felt different and far more difficult, emotionally.

The SPIKES methodology

Delivering bad news to patients is difficult, but it can be made less difficult with a methodology and practice. The SPIKES methodology was developed by physicians at the MD Anderson Cancer Center in Houston, for delivering bad news to oncology patients. Optimizing the following parameters helped improve their patients’ experience:

Setting: ensure a private, quiet place; sit down, invite other family members, avoid external interruptions

Perception: assess the patient’s baseline understanding of the situation before diving into an explanation

Invitation: provide initial information and offer the option of hearing further details

Knowledge: warn that bad news is coming, give information in small chunks, and avoid jargon

Empathy: address the emotional response with empathy

Strategy: summarize concrete next steps

In retrospect, we had addressed most of these issues as recommended. However, unlike the oncology setting in which this framework was created, or even the surgical context I am used to, the emergent trauma setting presented several unique challenges:

No previously established rapport. In trauma, providers do not have an earlier visit to establish a bond with the patient or their family; in contrast, rapport in oncology is built over time. A connection is formed with patients preoperatively, before elective surgery.

Traumatic injury is unexpected. A family member’s death is rarely on the family’s radar since trauma is unexpected. In oncology, patients have been considering their own mortality, and in elective surgery, families know their loved ones are being hospitalized for an operation.

Patients are younger. Trauma patients often are younger, where the loss is more unexpected and perceived to be more unfair.

Fewer resources for grief support. Traumas often present on nights and weekends, when the hospital is not as fully staffed with chaplains, social workers, and grief counselors who would otherwise be instrumental in supporting the bereaved family.

No control of the narrative. Various professionals work together to identify and contact trauma patients’ family; they may not have training in delivering bad news or accurate updates on the patient’s status. So families sometimes arrive at the hospital without the appropriate foreshadowing of the complete situation and are shocked by the news.

We might feel discouraged that some of these aspects are immutable. We can’t control trauma patient demographics nor the unexpected nature of trauma. However, with training and funding, we can better steer the narrative and improve resourcing. And on an individual level, we can soften the blow through a deeper understanding of the specific nature of their pain (“No one should die so young”) when talking with families.

Resilience in the face of delivering bad news

Delivering bad news is tough. Delivering bad news in trauma is tougher still. And this takes a toll on health care providers as well. Thirty minutes after we talked to our patient’s family, wails of sorrow still ringing in our ears, we headed to the OR to take out another patient’s appendix. New patient, fresh game face, another battle to fight — with the same sense of purpose and urgency.

What strategies do you use for delivering bad news in the emergent trauma setting?

Vivek Sant is a general surgery chief resident who blogs at Insights on Residency Training, a part of NEJM Journal Watch.

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