Breaking Bad News in the Emergency Department

AUDIENCE: The primary audience for this simulation is emergency medicine (EM) residents, but this curriculum could also be used for EM-bound medical students. INTRODUCTION: Breaking bad news is a difficult but necessary skill for EM physicians. Bad news can range from informing family that a patient is in the emergency department (ED), to shared decision making regarding a life-threatening situation, to family notification of patient death.1 Although there are many structured approaches to death notification and breaking bad news, such as GRIEV_ING2 and SPIKES,3 EM physicians often lack confidence in their ability to effectively communicate bad news.1,4–6 Goals of care discussions and shared decision making become especially complex in the ED environment because critically ill patients often arrive without advanced directives, lack pre-existing rapport with the EM physician, and may require rapid engagement with surrogate decision-makers on emergent interventions.7 This simulation curriculum was developed to provide EM trainees with a psychologically safe environment to practice effective communication in breaking bad news, incorporating clinical scenarios commonly encountered in the ED. EDUCATIONAL OBJECTIVES: At the conclusion of these two simulation cases, learners will be able to 1) recognize signs of poor prognosis requiring emergent family notification, 2) take practical steps to contact family using available resources and personnel, 3) establish goals of care through effective family discussion, 4) use a structured approach, such as GRIEV_ING, to deliver bad news to patients’ families, and 5) name the advantages of family-witnessed resuscitation. EDUCATIONAL METHODS: This curriculum consists of two simulation cases. Prior to the simulation, learners were assigned pre-reading on the GRIEV_ING approach to death notification, and how this approach could translate into breaking bad news in the ED. Although we chose to implement GRIEV_ING at our institution, other structured approaches (such as SPIKES) are reasonable as well. Each simulation case was conducted using a high-fidelity mannequin capable of intubation, respiratory examination findings such as abnormal breath sounds, and dynamic vital sign changes. Both cases required a standardized patient or other case confederate. Following each case, the learners underwent a debriefing session discussing how to break bad news in a high-pressure, time-sensitive ED environment. This case was designed as a high-fidelity simulation with a standardized patient, but it can be adapted to a low-fidelity simulation with a standardized patient. RESEARCH METHODS: Learners filled out a survey before and after the simulation describing their confidence in establishing goals of care with patients and surrogates, notifying family members of bad news in the ED, and their use of a consistent approach to breaking bad news. Scores were analyzed using the related-samples Wilcoxon signed rank test. RESULTS: Learners exhibited improvement on all surveyed items, with statistically significant improvement on the survey item asking about their confidence in implementing a consistent approach to breaking bad news. Qualitative feedback was positive, with learners consistently endorsing the value of practicing difficult conversations in a simulated environment. First- and second-year residents appeared to benefit from the cases more strongly than senior residents. DISCUSSION: These cases provided a safe environment for learners to practice a structured approach to breaking bad news. Learners tended to aggressively resuscitate the elderly septic patient and perform invasive procedures, such as intubation and mechanical ventilation, prior to contacting family or establishing goals of care, which generated good discussion points during debriefing. TOPICS: Simulation, breaking bad news, goals of care discussion, death notification, sepsis, cardiac arrest, family witnessed resuscitation.