Photo Credit: Halfpoint

Communicating bad news to a patient requires clarity, empathy, and preparation, and is a critical skill which physicians must continue to develop.

Multi-system organ failure is likely to present with or develop in patients who are critically ill and even, in the best cases, have a vacillating course of recovery. Associated with improved and sometimes protocolized care, overall ICU outcomes have improved over the last few years despite admitted patients generally being a bit sicker. Despite these improvements, mortality in adult US ICUs remains high-averaging 10-29%, according to the Society of Critical Care Medicine, depending on the patient’s illness severity, age, and co-morbid conditions. As such, delivering bad news to patients and families is a common duty among intensivists.

Some intensivists summarize according to the Setting, Perception, Information, Knowledge, Empathy, and Summarization (SPIKES) protocol mnemonic, but most adapt their preferred interventions in ways associated with the flexibility needed to communicate in any specific case.

An important part of preparing the patient and family is honestly sharing, from the admission, the relatively poor prognosis of most common ICU conditions—mortality from septic shock in the US may be in the 40% range with an absolute increase of 12 to 17% each among those with acute kidney injury or acute respiratory failure. The development of ARDS is associated with mortalities of around 39%, greater with increasing severities of ARDS. The mortality after ICU admission from in-hospital cardiac arrest is in the 83 to 86% range and around 70% from out-of-hospital cardiac arrests, with around 1/3-1/2 in each surviving group with neurologic compromise. Mortality from all these conditions considerably increases after age 80.

Delivering bad news is challenging and necessitates the greatest communication skills of the intensivist. Most intensivists will not be surprised by the processes noted below:

1. The intensivist must be familiar with all aspects of the patient’s care and social situation. It is reasonable to fully review the patient’s medical charting before discussions with the patient or family.
2. These discussions must be held in a comfortable, quiet, private area. The timing should be flexible based on the patient/family schedule rather than the physician’s, and an open-ended time commitment should be prepared for.
3. Generally, only one physician should be involved, lest the patient/family feel outnumbered or receive mixed messages. A chaplain should NOT be present unless requested by the patient/family.
4. The physician ought to be seated and at eye level with the patient.
5. The discussion should be started with a gentle and sympathetic statement of bad news to share.
6. It may be necessary or appropriate first to ask the patient/family what their understanding of the medical situation is.
7. Bad news should be delivered in a calm, concise, direct, and empathetic manner. Medical jargon should not be avoided unless requested by the patient/family.
8. Empathy is important but ought not to be taken to extremes. There is no reason for the patient/family to be concerned about your medical or personal history and the high possibility of seeming condescending.
9. After the news is shared, the physician should be ready to advise on the next steps in treatment, if any, discuss other goals of care, and arrange emotional or psychological resources for the patient/family. After this point, chaplaincy and palliative care professionals may be introduced or re-introduced, as appropriate.
10. As patients may not retain information given after preparing for bad news, assessment of the patient/family’s understanding of the situation should be next evaluated.
11. Regular follow-up is crucial to assure patient/family compliance and understanding but equally to avoid sensations of abandonment, which I think occurs more commonly than generally recognized.
12. Respect must be made for cultural and personal diversity among the patient/family. Additional time is likely required to achieve this goal. The inclusion of certified interpreters and additional family is often necessary.

Delivery of bad news is a skill that should improve with practice and time. A thorough preparation, necessary time, and clear but empathetic communication will allow the best possible experience for our vulnerable patients.