yeah, so, you're having a heart attack

[paramatt_]

I'll try this again, as I don't think I made the concept of the thread clear.

I'd like to hear some way y'all communicate with patients and/or their families who are sick, and who are already anxious, panicked, or stressed (feel free to add another a synonym of your choice). I used this case as an example (albeit poor) but just looking for different approaches to communication strategies in situations like this.

I'm not going to sugar coat anything, but I also want to keep hysterics at a minimum and looking for any insight on how to walk the fine line on how to be direct, clear, and empathetic without completely devastating someone (or their family) with such shitty news

Also, just to clarify, my concern with the student's statement wasn't what he said, but rather the way he articulated it to the patient.

Edited March 15, 2012 by jstalmm

[ERDoc]

I agree with pretty much everyone above. Obviously over the internet we can't judge his tone or body language but his choice of words are exactly what he should say. It's simple, clear and to the point. There is no medical jargon that may confuse the pt. Everyone understands what a heart attack is. To the OP, let me ask you this, as the preceptor, what would you have said to the pt and family?

EDIT: We were posting at the same time. You should always tell the pt/family exactly what is going on in a simple, easy to understand words. Just because they are already anxious does not mean that they shouldn't know what is going on. You should always be empathetic but this doesn't mean avoiding the issue. I guess you could just beat around the bush in the field and let the hospital tell the pt/family what is going on, but that is pretty douchey.

Edited March 15, 2012 by ERDoc

[DFIB]

Mr. Doe we just read your ECG and you are having a heart attack. We have the medications and equipment to help you. I am going to start an IV so I can give you some medications, is that OK? Thank you .... and so on and so forth.

[Just Plain Ruff]

yep, simple language that the patient understands

Stroke "I believe you are having a stroke, we need to take you to a stroke center. They are best able to take care of you"

AMI "I believe you are having a heart attack, you need to go to the hospital"

You get the idea.

On the subject of death - you will develop your own script or way to deal with that. I won't tell you how to broach that subject.

[paramatt_]

To reply to ERDoc: Bascially, what WolfmanHarris posted. I ended up explaining to the patient and family why were suspecting he was having a heart attack, and what was going to happen (in terms of our treatment and what might happen at hospital), which is what the student failed to do.

When we talked about it after, the issue seemed to revolve around his mindset which was focused treatment side of things without giving much thought to how his rapport with the patient might effect the situation.

[Just Plain Ruff]

Yes, rapport is really really important.

If you come off as an non-caring ignorant ass, then you come off as just that.

but if you seem like you care about their condition and a modicum of trust is built up, then most patients will trust you with their healthcare.

[HERBIE1]

Like was mentioned, we have no idea of tone, inflection, or body language of this student. With anything, be honest, use plain language, explain what is going on, and the basics of why(based on the S&S's, EKG, and PMH, you appear to be having a heart attack) and what you plan to do about it. Remember, depending on the severity and location of the blockage, this could be a potentially fatal event, and the patient and family needs to know the truth and prepare themselves mentally.

Unless this student related this information with a sneer, I see nothing wrong with what he/she did.

[ERDoc]

To reply to ERDoc: Bascially, what WolfmanHarris posted. I ended up explaining to the patient and family why were suspecting he was having a heart attack, and what was going to happen (in terms of our treatment and what might happen at hospital), which is what the student failed to do.

When we talked about it after, the issue seemed to revolve around his mindset which was focused treatment side of things without giving much thought to how his rapport with the patient might effect the situation.

OK, I think I see what you are getting at here. You were concerned because he just said, "You're having a heart attack," and then started to do what he needed to do. He didn't explain what was going to happen. Am I on the right track? If so, then I agree with you. Pts, especially those in pain, want to know that you are going to make them feel better. Telling them that you are going to make their pain go away will go a long way to settling their anxiety, so much so that they may not listen to the rest. It sounds like your student had a good start but didn't finish (I heard the same thing about Kiwi). Using all of the principles/ideas we have already discussed something like, "You are having a heart attack. We have to take you to X hospital. In the mean time we are going to treat you and try to make this pain go away," would be appropriate.

[WolfmanHarris]

Agreed with erDoc. I find the key to assauding anxiety is to immediately explain the treatment plan and progress from here. People have a very incomplete understanding of what a heart attack or stroke, or any other acute condition is, even if they recognize the name. They will recognize it's serious, but beyond that, they might have no idea what that means. Avoid false assurances, but let them know that there is a plan for their care and it's happening right now.

For death notification there has been some research done into this and some papers do exist on pre-hospital death notification, family witnessessing resuscitation efforts and other related topics. The upshot of the various training sessions I've had on death notification has been:

1) Shut off equipment and remove what can be removed without interfering with coroner (i.e. remove BVM, leave ETT). Tidy the scene, place a blanket on the Pt. close their eyes.

2) Remove PPE and recompose physically and emotionally.

3) Have the family sit and remove unnecessary distractions (FD, Police, other crews)

4) Use plain language, say "Died" "Dead." No euphemisms (passed on, left us, etc)

5) Be prepared to field questions.

6) Give family time to process and offer them the opportunity (if applicable, i.e. not a crime scene) to see the Pt. again.

My understanding from the literature and my own experience is that if family have witnessed the efforts, been kept reasonably informed as to progress and are given notification compassionately they will handle it as well as could be expected.

Some exceptions that seem obvious but are worth noting. Pediatric patients, homicides, suicides are going to be particularly difficult notifications and family may not wish to witness efforts (or lack thereof) on traumatic deaths. I can't support that from literature, that is just my personal opinion. Best example I can think of is when I responded to a hanging where the 13 y/o son had found is mom and called. He went to lead us down to her and I redirected him to the living room and kept him on the phone with the dispatcher until a Police officer arrived and took care of him. My thinking, he's seen her once and that was more than enough. Ditto when the husband arrived and asked to see her, we advised that he needed to wait until the Coroner cleared the scene which, while correct, also meant that we wanted her cut down and package before he came down.

The late Dr Robert Buckman, a medical oncologist from Toronto has a series of videos on clinical communication that can be found on youtube. He was a champion for bedside manner and quite an interesting character. Well worth looking at.

Edited March 15, 2012 by WolfmanHarris

[WolfmanHarris]

http://www.ncbi.nlm.nih.gov/pubmed/22401617 - Abstract only, but provides a good example of pit-falls in notification and the importance of adapting.

http://www.ncbi.nlm.nih.gov/pubmed/22372369 - Can't speak to the quality of this paper, can't access full txt. Might be interesting if someone can get at it.

http://www.ncbi.nlm.nih.gov/pubmed/20809692 - Study on prehospital death notification

http://www.ncbi.nlm.nih.gov/pubmed/3942358 - death notification in sudden unexpected death

http://www.ncbi.nlm.nih.gov/pubmed/21063562 - training module for emerg residents in breaking bad news (Full txt available)