Healthcare unfortunately sometimes sees patients as win or lose. Was the patient saved or cured or did the patient die is the common judge of success. Death, disease and incurable ailments though are part of life and healthcare should not see the death or survival of an individual as a grading process of competence. While all measures and standards of care should be performed and addressed properly, sometimes patients die or cannot be cured and the end result should not be seen as defeat in healthcare. Instead healthcare professionals must be able to extend themselves to another level of care that looks to treat the entirety of the human person who is dying. When the person who is terminal receives the best care that reduces physical and emotional discomfort, then a healthcare professional can truly say they succeeded. Success should be graded on giving the best that is available both physically and emotionally.
Many physicians and nurses are not well versed or well trained to give bad news though to the terminally ill or able to communicate the death of a loved one to a family. Instead, many times, it is handled very sterile or avoided at all costs. Elisabeth Kubler Ross began to turn the table in the 1980s on this sterile and numb approach to communicating death. It, however, involved an entire re-understanding of life and death, medical success vs medical failure and a better understanding of helping those in grief. Of course, this led to Elisabeth Kubler Ross’s famous 5 stages of grieving, which mistakenly were applied to grief in general, when they were designed to retrace reactions of the terminal ill to death. Denial, anger, sadness, bargaining and ultimately acceptance became the norms of grief reaction and they mistakenly became seen as fixed, sequential stages, instead of reactions of the terminally ill to bad news. They still serve as foundational pieces of emotions associated with loss and can be utilized in helping those in healthcare to react to the emotional response to death and loss itself.
Since the turn of the century, the need of grief counseling, pastoral counseling and training in giving bad news to patients has increased. While many healthcare professionals still lack bed side manner, the push to train and certify, and prepare others through module training programs has increased. Healthcare facilities are starting to see the need of trained professionals who can deliver the necessary news in a solemn and professional manner.
In regards to this, those trained learn a variety of grief theories about loss, crisis intervention, and communication skills. In many cases, the patient or family is already in a sense of anxiety due to the wait and emotions are tense. Caregivers should be prepared for a myriad of emotions that can erupt when a bad diagnosis, or death is revealed. Understanding the situation, being calm, and allowing the individuals to express initially is key.
While many caregivers would rather keep it simple, detail is important. The family or person will have numerous questions. A facility should have a quiet and private place to be able to aid the family in digesting the news. Questions will emerge and answers should give the most up to date factual information regarding the situation. In some cases, crisis intervention and emotional support will be required, but one should not limit information. Information should be given as the family is able to digest it. A later follow up meeting may be needed to allow the family to grieve until they are able to ask more logical questions. Hence communication of diagnosis is key but also an understanding of the family system and the emotional response. Each experience will be unique and require adjustment in how it is presented. Silence, or avoidance however is never the answer.
The article, ‘Delivering Bad News to a Patient” by Monden, K., et. al. takes a closer look at question system employed by Rabow and McPhee. The article states,
“Rabow and McPhee also proposed a model for delivering bad news called ABCDE: A, advance preparation; B, build a therapeutic environment/relationship; C, communicate well; D, deal with patient and family reactions; and E, encourage and validate emotions”
Monden, K., Gentry, L., Cox, M. (2016). Delivering bad news to patients. Baylor University Medical Center. 29(1). 101–102.
Access here
Within the context of terminal diagnosis, the bad news could be shocking to those present but it could also be divisive. Some family may wish to keep things a secret, or others may enter into a state of denial, while some may optimistically seek next step solutions. It is essential to understand the state of shock the family is in and to accurately give the diagnosis, statistics and courses of option.
Within immediate death, some family may want more details, while others may fall into silence. Others my need crisis intervention, coping advice, or the aided in relaxing from the traumatic news. Again, training modules with case studies can help prepare healthcare providers with better methods to alleviate the pain and better aid the family in hearing the horrible news of the death.
While some healthcare professionals are naturally better at helping families emotionally, there still must be a continued emphasis on training. Many families leave without any emotional support, confusion, and lack of full information regarding the death or the terminal diagnosis. This only compounds the trauma and emotional stress. Hence it is important that training be applied to all staff. It is fine to have one particular staff member who is more emotionally able to communicate bad news, but sometimes, it is still essential for the primary care giver to be able to answer questions and help those in distress.
AIHCP offers a certification in Pastoral Thanatology that aids professionals in learning more about caring for the terminally ill as well as being better equipped to communicate difficult diagnosis or news. The program equips professionals with knowledge on grief counseling as well as care for the terminally ill. It also equips the professional with information on death itself and multiple cultural, pastoral and religious beliefs related to death. The program is online and independent study and open to qualified professionals seeking a four year certification in Pastoral Thanatology. While many chaplains take the program, it is highly encouraged that nurses and other healthcare professionals also learn more about pastoral care of the dying and giving bad news.
Reference
Postavaru, G., McDermott, H., Biswas, S., Munirm, F. (2023). Receiving and breaking bad news: A qualitative study of family carers managing a cancer diagnosis and interactions with healthcare services. Leading Global Nursing Research, 79(6). 2211-2223. https://doi.org/10.1111/jan.15554
Coyle, N. , Manna, R., Shen, M., Banerjee, S.M, Penn, S, et. al. (2015). Discussing Death, Dying, and End-of-Life Goals of Care: A Communication Skills Training Module for Oncology Nurses. Clinical Journal of Oncology Nursing 19(6). 697-702.
Additional Resources
“How can doctors share bad news with patients?”. Beresford, L. (2017). Medical News Today. Access here
“Delivering bad news: Helping your patients retain dire details”. Augnst, H. (2009). Contemporary Pediatrics. Access here