A Call for Better Death Disclosure Training During COVID-19

Debra L. Beck

June 11, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Physicians rate death disclosures as among the most stressful type of communication they have, but many receive minimal training in how to deliver bad news in a way that best protects both recipient and physician well-being.

With many of these conversations now being done remotely, this lack of mastery is even more distressing.

In a Viewpoint article published online May 27 in JAMA Cardiology, three emergency medicine physicians call for death disclosure training to be paired with cardiopulmonary resuscitation (CPR) courses to ensure all doctors receive at least basic training in this skill.

"Our goal in this opinion piece was to spark a conversation we think is overdue about how to improve training for healthcare providers who are faced with having these conversations, many of them on a regular basis, but who may not have any formal training in how to do this well," said Jason K. Bowman, MD, a chief resident in emergency medicine at Massachusetts General Hospital, Boston.

There is some literature, albeit limited, to indicate that poor performance on this "high-intensity, high-risk procedure" is related to detrimental outcomes for family members and loved ones as well as clinicians, said Bowman in an interview.

Bowman coauthored the piece with Emily L. Aaronson, MD, MPH, assistant chief quality officer at Mass General, and Tammie E. Quest, MD, Emory University, Atlanta, Georgia, a recognized expert in palliative care in the emergency setting.

Nearly all medical professionals serving adult patients are required to undergo training in CPR. Many take the American Heart Association's (AHA) Advanced Cardiac Life Support (ACLS) course.

The AHA also offers a pediatric advanced life support course, which since 1998 includes a module entitled "Coping with the Death of a Child." It includes both a video and written curriculum designed to guide trainees through the basics of how to approach and navigate a conversation with family disclosing the death of a child. No such module exists for the adult course.

Bowman and colleagues point out that, despite the relatively low likelihood of return of spontaneous circulation, the ACLS training includes details on the management of this event, with focused instruction on targeted temperature management and coronary reperfusion. Unfortunately, more likely is an outcome necessitating "empathic death disclosure."

"We don't expect a brief course in breaking bad news will provide mastery any more than the simplified algorithms taught in ACLS or PALS courses provide mastery in cardiac pathophysiology, but it could go far in ensuring some standard in consistency and provide basic tools in this area," said Bowman.

COVID-19 Forces Remote Communications

Breaking bad news is never easy, but COVID-19 has made things much harder, according to Arghavan Salles, MD, PhD, a bariatric surgeon and scholar in residence from Stanford University, Palo Alto, California. In April, Salles traveled to New York City to help care for COVID-19 patients.

"In my normal practice, and certainly during my surgical training, I've had a few patients die, but I would say the biggest difference between those conversations and the ones that I had in New York was that, for my own patients who I take care of, even if they came through the emergency department and I knew them only for a short period of time, most of the time I will have met their family," said Salles.

"With the COVID patients, it's very different. They come in alone, aren't allowed visitors, and then when a really bad turn of events happens, now you have to call their family member and they don't know you at all."

Perhaps even more difficult, she said, is calling families to provide them an opportunity to "say goodbye" to a critically ill patient.

"Under normal conditions, in such a case, you step out of the room to give some privacy, but in New York, we were doing video chats with families in the ICU and the patients are most often not conscious, their bodies swollen, and with tubes coming out of their nose, their mouth, IVs, machines beeping, etc, and you have to stay there and hold this completely inadequate cellphone screen over their face while their family members try to say whatever they feel they need to say in that moment.

"It was very hard to watch and I felt like I was intruding," she added.

Asked if she would have accepted advanced training in death disclosure before going to work in an ICU full of COVID-19 patients, Salles said probably not.

"I probably would have felt like, 'Oh, I've done that before,' not really realizing how different it is in this circumstance."

She agreed that there "are many different ways in which we could improve our training in how to communicate with patients and their families about all sorts of topics."

Bowman and Salles have disclosed no relevant financial relationships.

JAMA Cardiol. Published online May 27, 2020. Viewpoint

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