{"id":3033,"date":"2020-10-07T12:35:27","date_gmt":"2020-10-07T16:35:27","guid":{"rendered":"https:\/\/blogs.nejm.org\/general-medicine\/?p=3033"},"modified":"2020-10-08T10:37:58","modified_gmt":"2020-10-08T14:37:58","slug":"we-did-everything-we-could","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2020\/10\/we-did-everything-we-could\/","title":{"rendered":"\u201cWe Did Everything We Could.\u201d"},"content":{"rendered":"<div id=\"attachment_2967\" style=\"width: 135px\" class=\"wp-caption alignright\"><a href=\"https:\/\/blogs.nejm.org\/general-medicine\/wp-content\/uploads\/sites\/4\/2020\/08\/Vivek-Sant-1.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-2967\" class=\"size-full wp-image-2967\" src=\"https:\/\/blogs.nejm.org\/general-medicine\/wp-content\/uploads\/sites\/4\/2020\/08\/Vivek-Sant-1.jpg\" alt=\"Dr. Vivek Sant\" width=\"125\" height=\"150\" \/><\/a><p id=\"caption-attachment-2967\" class=\"wp-caption-text\">Dr. Sant is a General Surgery Chief Resident at NYU Langone Health, Bellevue Hospital, and Manhattan VA in New York, NY.<\/p><\/div>\n<h4>Can we do better when delivering bad news in trauma?<\/h4>\n<p>On a recent trauma call, we had a busy night, culminating in a horrific motorcycle trauma that came in early in the morning. The patient had devastating injuries and ended up dying. The detectives finally tracked down the patient&#8217;s family. I cleaned myself up, put on my white coat, and had the family sit down in a private conference room. I entered with my trauma attending and a consulting specialist and we sat down with them. I told them their loved one had been involved in a terrible accident, and asked them what they knew so far. I filled them in on the rest of the situation, explaining that we&#8217;d done a lot of work to try to save him, but the injuries had been too much, and he had died. We spent as much time as we could answering their questions and being with them as they processed the horrible news, and finally took them to see him. Naturally, they were devastated; I will never forget the wail of sorrow from his widow. While I have delivered bad news before, this experience felt different and far more difficult, emotionally.<\/p>\n<h4>The SPIKES methodology<\/h4>\n<p>Delivering bad news to patients is difficult; but with a methodology and practice, it can be made less difficult. The SPIKES methodology was developed by physicians at the MD Anderson Cancer Center in Houston <a href=\"https:\/\/doi.org\/10.1634\/theoncologist.5-4-302\" target=\"_blank\" rel=\"noopener noreferrer\">(<em>Oncologist<\/em> 2000; 5:302<\/a>), for delivering bad news to oncology patients. Optimizing the following parameters helped improve their patients\u2019 experience:<\/p>\n<ul>\n<li><strong>S<\/strong>etting &#8211; ensure a private, quiet place; sit down, invite other family members, avoid external interruptions<\/li>\n<li><strong>P<\/strong>erception &#8211; assess the patient\u2019s baseline understanding of the situation before diving into an explanation<\/li>\n<li><strong>I<\/strong>nvitation &#8211; provide initial information and offer the option of hearing further details<\/li>\n<li><strong>K<\/strong>nowledge &#8211; warn that bad news is coming, give information in small chunks, and avoid jargon<\/li>\n<li><strong>E<\/strong>mpathy &#8211; address the emotional response with empathy<\/li>\n<li><strong>S<\/strong>trategy &#8211; summarize concrete next steps<\/li>\n<\/ul>\n<p><a href=\"https:\/\/blogs.nejm.org\/general-medicine\/wp-content\/uploads\/sites\/4\/2020\/10\/coupledoctor.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-3036 size-medium\" src=\"https:\/\/blogs.nejm.org\/general-medicine\/wp-content\/uploads\/sites\/4\/2020\/10\/coupledoctor-300x200.jpg\" alt=\"doctor delivering bad news to a couple\" width=\"300\" height=\"200\" srcset=\"https:\/\/blogs.nejm.org\/general-medicine\/wp-content\/uploads\/sites\/4\/2020\/10\/coupledoctor-300x200.jpg 300w, https:\/\/blogs.nejm.org\/general-medicine\/wp-content\/uploads\/sites\/4\/2020\/10\/coupledoctor.jpg 580w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>In retrospect, we had addressed most of these issues as recommended. However, unlike the oncology setting in which this framework was created, or even the surgical context I am used to, the emergent trauma setting presented several unique challenges:<\/p>\n<ul>\n<li><strong>No previously established rapport<\/strong> &#8211; in trauma, providers do not have an earlier visit to establish a bond with the patient or their family; in contrast, rapport in oncology is built over time, and a connection is formed with patients preoperatively, prior to elective surgery.<\/li>\n<li><strong>Traumatic injury is unexpected<\/strong> &#8211; a family member\u2019s death is rarely on the family\u2019s radar since trauma is unexpected. In oncology, patients have been considering their own mortality, and in elective surgery, families know their loved ones are being hospitalized for an operation.<\/li>\n<li><strong>Patients are younger<\/strong> &#8211; trauma patients often are\u00a0younger, where the loss is more unexpected and perceived to be more unfair.<\/li>\n<li><strong>Fewer resources for grief support<\/strong> &#8211; traumas often present on nights and weekends, when the hospital is not as fully staffed with chaplains, social workers, and grief counselors who would otherwise be instrumental in supporting the bereaved family.<\/li>\n<li><strong>No control of the narrative<\/strong> &#8211; various professionals work together to identify and contact family of trauma patients; they may not have training in delivering bad news or accurate updates on the patient\u2019s status. So families sometimes arrive at the hospital without the appropriate foreshadowing of the complete situation and are shocked by the news.<\/li>\n<\/ul>\n<p>We might feel discouraged that some of these aspects are immutable. We can\u2019t control trauma patient demographics nor the unexpected nature of trauma. However, with training and funding, we can better steer the narrative and improve resourcing. And on an individual level, we can soften the blow through a deeper understanding of the specific nature of their pain (\u201cNo one should die so young\u201d) when talking with families.<\/p>\n<h4>Resilience in the face of delivering bad news<\/h4>\n<p>Delivering bad news is tough. Delivering bad news in trauma is tougher still. And this takes a toll on healthcare providers as well. Thirty minutes after we talked to our patient\u2019s family, wails of sorrow still ringing in our ears, we headed to the OR to take out another patient\u2019s appendix. New patient, fresh game face, another battle to fight \u2014 with the same sense of purpose and urgency.<\/p>\n<p>What strategies do you use for delivering bad news in the emergent trauma setting?<\/p>\n<p>&nbsp;<\/p>\n<p><a href=\"https:\/\/resident360.nejm.org\/\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-full wp-image-926\" src=\"https:\/\/blogs.nejm.org\/general-medicine\/wp-content\/uploads\/sites\/4\/2017\/03\/genMedRes360Ad540x250.jpg\" alt=\"NEJM Resident 360\" width=\"540\" height=\"250\" \/><\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Can we do better when delivering bad news in trauma? On a recent trauma call, we had a busy night, culminating in a horrific motorcycle trauma that came in early in the morning. The patient had devastating injuries and ended up dying. The detectives finally tracked down the patient&#8217;s family. I cleaned myself up, put [&hellip;]<\/p>\n","protected":false},"author":1305,"featured_media":3036,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2,3],"tags":[49,19,1536,1537],"class_list":["post-3033","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-about-residency","category-cases-and-rounds","tag-art-of-medicine","tag-communication","tag-delivering-bad-news","tag-trauma"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v17.1.2 (Yoast SEO v20.8) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>\u201cWe Did Everything We Could.\u201d - Insights on Residency Training<\/title>\n<meta name=\"description\" content=\"Dr. Sant discusses some techniques that can help physicians with delivering bad news to patients\u2019 relatives.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2020\/10\/we-did-everything-we-could\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"\u201cWe Did Everything We Could.\u201d\" \/>\n<meta property=\"og:description\" content=\"Dr. Sant discusses some techniques that can help physicians with delivering bad news to patients\u2019 relatives.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2020\/10\/we-did-everything-we-could\/\" \/>\n<meta property=\"og:site_name\" content=\"Insights on Residency Training\" \/>\n<meta property=\"article:published_time\" content=\"2020-10-07T16:35:27+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2020-10-08T14:37:58+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/blogs.nejm.org\/general-medicine\/wp-content\/uploads\/sites\/4\/2020\/10\/coupledoctor.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"580\" \/>\n\t<meta property=\"og:image:height\" content=\"387\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"author\" content=\"Vivek Sant, MD\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"Vivek Sant, MD\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"4 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2020\/10\/we-did-everything-we-could\/\",\"url\":\"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2020\/10\/we-did-everything-we-could\/\",\"name\":\"\u201cWe Did Everything We Could.\u201d - Insights on Residency Training\",\"isPartOf\":{\"@id\":\"https:\/\/blogs.nejm.org\/general-medicine\/#website\"},\"datePublished\":\"2020-10-07T16:35:27+00:00\",\"dateModified\":\"2020-10-08T14:37:58+00:00\",\"author\":{\"@id\":\"https:\/\/blogs.nejm.org\/general-medicine\/#\/schema\/person\/8f8952abc8435c26c55463d54d32bd3c\"},\"description\":\"Dr. Sant discusses some techniques that can help physicians with delivering bad news to patients\u2019 relatives.\",\"breadcrumb\":{\"@id\":\"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2020\/10\/we-did-everything-we-could\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2020\/10\/we-did-everything-we-could\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2020\/10\/we-did-everything-we-could\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/blogs.nejm.org\/general-medicine\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"\u201cWe Did Everything We&nbsp;Could.\u201d\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/blogs.nejm.org\/general-medicine\/#website\",\"url\":\"https:\/\/blogs.nejm.org\/general-medicine\/\",\"name\":\"Insights on Residency Training\",\"description\":\"Observation of residents across diverse medical specialties\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/blogs.nejm.org\/general-medicine\/?s={search_term_string}\"},\"query-input\":\"required name=search_term_string\"}],\"inLanguage\":\"en-US\"},{\"@type\":\"Person\",\"@id\":\"https:\/\/blogs.nejm.org\/general-medicine\/#\/schema\/person\/8f8952abc8435c26c55463d54d32bd3c\",\"name\":\"Vivek Sant, MD\",\"description\":\"Vivek is completing his chief residency in General Surgery at New York University. Growing up in the Boston suburbs, he developed a love for the outdoors, from hiking in the White Mountains to exploring the shores of Cape Cod. From an early age, he enjoyed tinkering with gadgets and discovering how things work. He received his Bachelors degree in Electrical Engineering and Computer Science at Harvard University and completed medical school at Columbia University College of Physicians and Surgeons. During his surgical residency at NYU, he developed a fitness app for the Apple Watch to track rowing workouts, which is used by more than 1000 users worldwide. After his third year of residency, he took a year off to participate in the Texas Medical Center's Biodesign Innovation Fellowship, where he went on to cofound a medical device company that is developing a novel neurostimulator device. He is passionate about surgical innovation and endocrine surgery, and he plans to pursue fellowship training in this area. 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