Hard Talks

One of the most emotionally draining elements of paramedicine is the delivery of bad news. This could be a serious diagnosis, catastrophic injury or even death notification. Junior paramedics often feel unskilled or sometimes even unworthy of performing these tasks – but the hard truth is we will all have to do it throughout our career. After a recent teaching session which included this topic, I decided to put together a general guide (there are no hard and fast rules!) to delivering bad news.

When might we have to do this?

• Telling the patient about a significant diagnosis (stroke, STEMI, spinal injury)
• Informing bystanders on scene of significant diagnosis – usually Attendant 2 will do this
• Phone notifications to family, including parents of unaccompanied children
• Providing death notification to family who arrive on scene of a death. Sometimes you will have to provide multiple notifications as more family arrives

What are some barriers or difficulties faced by paramedics having ‘hard talks’?

• Feelings of inexperience, both in paramedicine specifically and life in general
• Uncertainty around cause, diagnosis and outcome (“will the patient survive?”
• Lack of previously built rapport with patient and bystanders
• Uncontrolled environment
• Feeling emotionally or physically unsafe (compared to a hospital environment with security)
• Being physically and emotionally drained, due to patient care/resuscitation
• PPE creating a barrier to connection with patient and family

Standardized approaches

SPIKES (Baile et al, 2000)

BREAKS (Narayanan et al, 2010)

ABCDE (Rabow & McPhee, 1999)

GRIEV_ING (Hobgood, 2005)

10 Step Model (Iserson, 2000)

Paramedics having ‘hard talks’

You will notice a lot of similarities between the above models. If one of them works for you – great! However I think paramedicine is a slightly different venture, so here’s my takeaways from these models.

1. Prepare yourself first. If you have time, doff excess PPE, have a drink of water or a bite to eat. Take a moment for yourself. If things are time critical, take a long deep breath to center yourself
2. Modify your environment. Often you cannot choose where to have these talks. So adjust the lighting, minimize noisy distractions and try to arrange seating for the people you’re talking to.
3. Get your story straight. This is often incredibly hard in a fast paced scene. But ensure you have the basics down – the person’s name, the suspected problem and the plan moving forward.
4. Gather the people you need to talk to. This might involve waiting for someone to arrive or calling someone on the phone.
5. Introduce yourself, your role, and how you’re involved with the patient. Eg “Hi, I’m Sarah, and I’m one of the paramedics who has been looking after Bob.”
6. Figure out who everyone is you’re talking to – are they a random neighbour or a close friend of fifty years? That’s as simple as asking “how are you related to Bob?”. Once you’ve identified everyone, you can work out if anyone needs particular special attention (usually a spouse or parent)
7. Clarify what the bystanders understand. Did they know the patient was sick? Was this a sudden change? You can gently approach this using a question along the lines of “what do you understand about Bob’s condition?” or “how has Bob’s health been lately?”
8. Give a warning shot. This helps people to brace for the impending bad news. I tend to use the phrase “I have to have a hard conversation with you” when delivering a death notification. For patients who are in arrest and being resuscitated, I will usually say “the team is working very hard to restart Bob’s heart right now, but I’m very concerned he is going to die today”.
9. Deliver the news compassionately but directly. Most models suggest using clear language such as ‘dead’ and ‘has died’ to avoid confusion. Eg. “I’m very sorry but the resuscitation has been unsuccessful and Bob has died”.
10. Be present in the moment. It can be terribly overwhelming delivering this news. Reactions from bystanders will vary, but usually involving crying, wailing and collapsing. Very few people will become agitated. Allow yourself to feel – I’ve often formed tears during death notifications.
11. Provide the information you have – but accept that there will be a lot of unknown factors. Diagnosis and cause are often ‘best guesses’ rather than form answers.
12. Thank the bystanders. This is not mentioned in other models, but it is often the bystander who has called Triple Zero (000) and even initiated resuscitation. These people often blame themselves for not calling sooner, or not doing CPR better. Reassure them that their efforts helped – “you did a really good job with CPR and did everything right, unfortunately it’s not always successful” or “your quick call to us gave Bob the best chance”.
13. Explain the next steps. In most cases the police will attend due to the unexpected nature of the death, or in some cases the GP will attend to certify the death. Paramedics will complete a ‘verification of death’ form. Then the patient will either be taken by the Coroner or by a funeral director. Eg. “I need to examine Bob and complete some paperwork to verify his death. We’ve also asked the police to come – that’s routine and they will look after Bob until he can be taken to the Coroner’s.”
14. Allow time throughout the process for questions, but now is a particularly good time to engage with all bystanders to ask if they have any questions.
15. Refer to services – grief is really hard. These people need support. I routinely remind people that their GP, BeyondBlue and local psychology service are available to support them
16. Tidy up after yourself – this isn’t specific to having the hard talk, but it is important. I was recently told how distressing it was for family to return home after a cardiac arrest to find bits of rubbish, evidence of the arrest, all around the room. Each bit of plastic and paper was a reminder. Some were found days later, reviving the distress. Carry a bag in your pocket, and clean up after yourself.

Bottom Line

Death notifications or hard talks are difficult! Experience helps, but compassion is the real key. Think about how you would want the news delivered to you if the roles were reversed. Basic principles include introducing yourself, using the deceased person’s name and being clear in your language. Remember to look after your own welfare.