Abstract
Background
T
A: Anticipate
Who
Know the name/identity of the patient. This may be difficult, as some patients arrive in extremis as John/Jane Doe. Ideally, have staff identify family members and their relationship to the patient prior to your arrival. In multiple casualties, it is important to ensure you are speaking to the right family about the right patient. Bring a team member who can stay longer to offer family support—chaplain, social worker, nurse, palliative care clinician, or bereavement specialist.
What
Know the details of (1) the event: often by police report or EMS scene descriptions; and (2) clinical course: extent of injuries, results of diagnostic tests, and consultant opinions.
How
Rehearse how you will deliver information and prepare the team. Focus on the “bottom line” and avoid getting stuck in the details. Families want to know if the patient is dead or alive, and deliver this news up front. For follow-up conversations, mentally organize events into cause and effect using the ABCs of resuscitation, e.g., there was swelling to his face so a breathing tube was placed; his lung was collapsed so we placed a chest tube; he had low blood pressure, so we gave fluids intravenously.
B: Be Aware of Self and Surroundings
• Appearance: Change and remove any blood-splattered clothing/shoe covers; wear a white coat.
• Location: Find a quiet room; place your cell phone/pager on vibrate.
• Safety: Plan to break the news with a partner; have a safety strategy to exit the physical space in case of a violent response from family. This may mean keeping the door to the room open and unblocked when delivering news to a large group. Have security available and aware; however the presence of police or security in the room may escalate the situation.
C: Conversation/Concerns
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For patients who DIE in the trauma bay:
Deliver news of the death first after a brief narrative (one sentence) that provides context that the family can understand. Recognize that there is no way to soften the impact and use the word dead/dying up front. “Your son was in a car crash with major injuries to his heart, brain, and other organs. We tried everything we could; he died a few minutes ago.”
For patients who SURVIVE resuscitative efforts:
Begin by outlining the most serious injury and how it will impact the patient's “big picture” condition. Meaningful information usually falls into several categories: Does he have brain damage? Is he paralyzed? Will he survive? “She has multiple injuries but we are most concerned about the serious brain damage from the injury to her head.” • Resist the tendency to catalog and list every injury/procedure in the initial meeting. Keep information sharing brief. Families will need time to digest the key facts. • Anticipate next steps and prepare the family for what will happen next. Outline those injuries that will impact clinical decision making the most in the coming hours, especially if there are associated medical interventions that will require family consent in the near future. • Prepare family for what they will see at the bedside (e.g., splints, ventilator, wounds). • • • Specify what will be happening prior to the next update as well as when and where it will occur. • Provide an opportunity for family to see the patient. Even if injuries are disfiguring or mutilating, bereavement outcomes are improved if the family has been able to see and touch their loved one. Ensure that devastating injuries and wounds are covered prior to visit.
D: Debrief, Document, and Dictate
• Document conversation in chart using the ABCDE outline.
• Debrief with team. Are they emotionally okay? Validate common emotions generated by death and failed attempts at resuscitation (e.g., child, young adult, expectant mother).
• Decide who will provide follow-up information to family and when.
• Death: Notify medical examiner and organ sharing network as per institutional protocols.
E: End the Encounter
• Engage the chaplain, social worker, palliative care team, or bereavement support as appropriate for the trauma team and family.
• Reflect. What went well? What did not? How could you do this better in the future?