Breaking Bad News: A Mnemonic to Help

You, your partner, and a team of first responders have spent 30 minutes trying to bring a 38-year-old father of three back to life. Unfortunately, the resuscitation was not successful. His family is in the other room waiting for word on how he is doing—you can hear sobbing and angry voices. No one from the EMS team has spoken to them about the status of their loved one. It is up to you to inform his spouse and teenage children he succumbed to a presumed cardiac arrest. 

Dreading the thought of breaking the bad news, you’ve stayed involved in patient care and put off the inevitable interaction with family. Even after time of death was established, you’ve continued to busy yourself by packing up equipment. Understandably, you are at a loss for why your treatments did not work. You grapple with a sense of failure. Struggling to answer your own questions, how can you answer those asked by survivors?

Telling survivors their loved one has died is the most important and difficult duty of a paramedic. The average number of death notifications a paramedic provides annually varies. Regardless of the number or frequency, it is never easy. 

This difficulty lies in many causes. A paramedic may have a sense of failure, be at a loss for words or have no idea how to convey the message, be intimidated by the emotional displays of survivors, or be overwhelmed by personal experience. From an educational standpoint, there is little to no in-depth training on what to do after a resuscitation is stopped. Tradition has left learning this task to on-the-job training. Fumbling through the process is not good for paramedic or survivor. 

Breaking bad news is an aspect of medicine that has been researched for decades—so much so, it has its own acronym, BBN. Researchers have compartmentalized BBN study into four categories: 

• Provider discomfort/reluctance; 
• Quality of message or delivery; 
• Survivor wishes for how to receive news;  
• Educational models. 

Few BBN studies have evaluated paramedics. Instead, BBN research has focused on doctors. Physicians have to share news not only of death but also of debilitating and terminal diseases. Despite this emotionally burdensome responsibility, doctors get little formal training on it.¹ 

Several mnemonics have been created to aid physicians in formulating and delivering bad news. SPIKES, BREAKS, and GRIEV_ING (see sidebar) are memory aids to support clinicians. Many of these steps are useful but likely not applicable for paramedics in a prehospital setting. SPIKES, for instance, is geared for conveying a terminal illness prognosis to a living patient.² BREAKS can be used to deliver bad news to a patient or survivors.³ GRIEV_ING is the most applicable to prehospital clinicians.⁴ However, these are all cumbersome and not completely relatable to paramedics. 

For physicians, “medical education has placed more value on technical proficiency than communication skills.”⁵ The same can be said about paramedic training. Effective communication requires the messenger to know the intentions and goals of the message. BBN requires more than memorizing an acronym. Communications of this nature require a well-prepared clinician with an empathetic delivery. 

SPIKES, BREAKS, and GRIEV_ING are built off the ABCDE model promoted by University of California, San Francisco physicians Michael Rabow, MD, and Stephen McPhee, MD.⁶ The ABCDE memory aid consists of advanced preparation, building a therapeutic environment/relationship, communicating well, dealing with patient and family reactions, and encouraging and validating (reflecting back) emotions. This article will examine the foundational elements of Rabow’s and McPhee’s ABCDE framework, which encompasses the necessary components of what to say and how to deliver a death notification. The following are adaptations to the ABCDEs for practical applications to the prehospital setting.

The ABCDE Mnemonic

Advanced preparation—Preparation should begin before the next opportunity to break bad news happens. Just as you might visualize or dip into a skills room at the ambulance base to prepare for intubation, imagine yourself having to communicate the death of a loved one. Work on a script that is rehearsed but dynamic to fit the situation. On scene, once the futility of resuscitation is realized, begin preparing the family. Do not make your first contact when you need to deliver the message. Find time midway through resuscitation to step away to address the family; foreshadow the likely outcome. 

Building a therapeutic environment/relationship—For many, including myself, it is easier to approach survivors with a sterile, clinical manner, yet this is unhelpful. Research suggests such an approach is not desired by those receiving bad news.⁷ Balance compassion and sympathy with some empathy. Position yourself at eye level with the person or group. If possible, sit or kneel to reduce the need to awkwardly balance, which can be distracting. Assess receptiveness to touch. Gently placing your hand on a shoulder or forearm may be reassuring and comforting. Often family and friends are not only present for themselves but create a therapeutic environment. If possible, have these important people summoned early. Rabow and McPhee consider this part of advanced preparation.

Communicating well—This is the backbone of the BBN skill. Fumbling for words or phrasing something incorrectly can ruin the whole process. Struggling in this aspect steals confidence and may affect future performance. Therefore, utilization of frameworks and practice will allow you to communicate more effectively. Use the patient’s name and speak politely of them. One lesson learned in paramedic training is to avoid euphemisms. Be direct; say “dead” or “died.” Also state this in your first sentence. Chances are that the receiver of bad news won’t hear much else for several minutes. Pause and wait for a question or invitation to continue talking. You may need to repeat your message or confirm what they heard. Let survivors ask questions and do not hesitate to say you don’t know the answer. It’s not a good idea to speculate or draw conclusions and express them as absolutes. 

Dealing with patient and family reactions—A common barrier to breaking bad news comfortably is the fear of how family will respond.⁸ Violence is possible but unlikely. There are cultural considerations where survivors can be expressive in their grief. Provide space for your own safety. Do not prevent emotional expressions. Some survivors may be despondent and make suicidal comments; be prepared to evaluate these and provide resources if such utterances seem legitimate. Be aware the well-known five stages of grief popularized by Elisabeth Kübler-Ross are not experienced in any particular order.⁹  

Encourage and validate (reflect back) emotions—Allow survivors to talk (or not talk). Answer questions to clarify what you know and do not know. Help them process the news and work through the initial shock of a loved one dying. As space permits, invite survivors to observe your treatment. If survivors were not present to witness resuscitative efforts, consider allowing them to view and touch the deceased. Of course this must be consistent with local requirements and law enforcement considerations. 

Conclusion

Decades of research have solidified the notion that BBN is difficult and uncomfortable. Despite this knowledge, even scenario-based training for physicians is rare. Therefore, it is unlikely to be incorporated into paramedic education soon. While on-the-job exposure to this function of clinician duties is less than ideal, it is present reality. Muddling through death notifications, hoping they become less difficult, will probably disappoint. Repeated attempts with poor technique only ensure loss of confidence and a continued sense of failure. 

Being a part of death is extremely difficult. Clinicians’ distress comes from performance in resuscitation, their own issues with death, and anticipation of survivor reaction. These factors make breaking bad news stressful. Prepare yourself with the basic components of the ABCDE mnemonic. which easily incorporates basic principles of effective death notification. But rather than just learn an acronym, embrace the basics of communications for this task. Be prepared to tailor your approach and message to the situation. Fret less over actual words (except to use dead or died) and focus on the humanity of the deceased and survivor. Your conduct speaks louder than the words you choose. The ABCDE structure emphasizes actions and promotes open behavior.  

Sidebar: Memory Aids for Breaking Bad News

SPIKES

• Set up discussion
• Perception of patient
• Invitation to converse
• Knowledge sharing
• Empathetic emotions
• Strategy/summary

BREAKS

• Background
• Rapport built
• Explore knowledge
• Announce news
• Kindling emotions
• Summarize

GRIEV_ING

• Gather everyone
• Resources to help
• Identify yourself and patient
• Educate on events 
• Verify death
• [pause]
• Inquire about questions
• Nuts and bolts (discuss logistical tasks)
• Give contact information 

References

1. Hobgood C, Harward D, Newton K, Davis W. The educational intervention “GRIEV_ING” improves the death notification skills of residents. Acad Emerg Med, 2005; 12(4): 296–301.

2. Marschollek P, Bąkowska K, Bąkowski W, Marschollek K, Tarkowski R. Oncologists and Breaking Bad News—From the Informed Patients’ Point of View. The Evaluation of the SPIKES Protocol Implementation. J Cancer Educ, 2019 Apr; 34(2): 375–80.  

3. Guven R, Kuday Kaykisiz E, Onturk H, et al. Breaking Bad News in the Emergency Department: How Do the Patients Want it? Eurasian J Emerg Med, 2018; 17(3): 97–102.

4. Hobgood CD, Tamayo-Sarver JH, Hollar DW, et al. (2009). Griev_ing: Death notification skills and applications for fourth-year medical students. Teach Learn Med, 2009 Jul; 21(3): 207–19.

5. Monden KR, Gentry L, Cox TR. Delivering Bad News to Patients. Proc (Bayl Univ Med Cent), 2016; 29(1): 101–2.

6. Rabow MW, McPhee SJ. Beyond breaking bad news: How to help patients who suffer. West J Med, 1999; 171(4): 260–3.

7. Martins RG, Carvalho IP. Breaking bad news: Patients’ preferences and health locus of control. Patient Educ Couns, 2013; 92(1): 67–73.

8. Hobgood C, Mathew D, Woodyard DJ, Shofer FS, Brice JH. Death in the field: Teaching paramedics to deliver effective death notifications using the educational intervention “GRIEV-ING.” Prehosp Emerg Care, 2013; 17(4): 501–10.

9. Maciejewski PK, Zhang B, Block SD, Prigerson HG. An empirical examination of the stage theory of grief. JAMA, 2007; 297(7): 716–23. 

Aaron Florin, MSHS, NRP, SPO, CADS, is a paramedic and field training officer with Allina Health in Minneapolis, Minn.