Do Nurses have to give Bad News and How?

ErinS, BSN, RN · Jan 18, 2011

I work as a hospice nurse and while I do not give initial diagnosis, I often am giving additional bad news. Such as, yes your baby is dying. Yes your wife's cancer is progressing. No, your husband will not be here for his birthday. Also, on occasion I am the first person who has discussed a diagnosis of being terminal. For example, an oncologist will tell a patient they have pancreatic cancer and hospice will be called. Then I go in, and I am the first person who has mentioned that to qualify for hospice you are expected to live 6 months or less. So yes, we give bad news all the time. It just is not a diagnosis.

Flo., BSN, RN · Jan 18, 2011

I don't break the news of the terminal disease / accident. But I do reinforce the gravity of the situation. Like "The majority of people diagnosed with xyz have a long and difficult course." or "now would be a good time to tell your mother anything you feel needs to be said."

dthfytr, ADN, LPN, RN, EMT-B, EMT-I · Jan 18, 2011

"Thick skinned? Oh maaaan, I just wasted 30 years! They told me I just had to be human!

Theoretically, the doctor should be the one giving bad news, and the nurse could always refer people to the doctor for answers. In reality, some doctors have all the tact of fresh skunk roadkill. My point of view comes from the ER, but should help you. In a teaching hospital sometimes I'd take a resident by the hand and go to the family room.

Starting with what the family already knew, I'd give a brief rundown of the events that occurred since, for instance, EMS picked up their loved one. CPR, breathing tube, shocked 75 times, iv and drugs, when we'd done everything there was to do and no response from the patient, no signs of life etc, the Dr concluded there was nothing to gain by continuing and your loved one was pronounced at 0715.

This is the method I learned in the ACLS book, answers the family's questions before they're asked, and seems most compasionate overall to me. It also helps prepare the family if they're to see the deceased still intubated, iv'd, and the inevitable mountain of trash on the floor. I make it a point to leave the trash, supply carts, etc to reinforce that great effort went into the event. Blood gets cleaned up always before viewing.

Short question, long answer. Hope it helps, and good luck with nursing school. If anybody has a better suggestion I'm open to suggestions. :up:

niteowlrn29 · Jan 18, 2011

The time that I had to do it was when a patient was on hospice care in the hospital so the loved ones knew what was happening but its still very hard to call the family. In one occasion I had already spent some time with the family and got to know them a little bit. But I called and said, I'm calling you to let you know mrs. sos and so passed a few minutes ago. They were okay but it's partly because they expected it. Its not easy at all to tell family or a patient bad news. I just try to be empathetic.

steelydanfan · Jan 18, 2011

Bad news, yes every day, bad labs, yes he is NOT responding to treatment, no your mother has not woken up from her hepatic coma.

We do not make prognosises, but we do PREPARE people every day. Such is the ART of nursing.

nurse2033, MSN, RN · Jan 18, 2011

I was a medic before RN and have given bad news many many times. RNs aren't usually the ones but you could be. You have to start by preparing them with something like "I'm afraid I have some bad news". This will get their attention and allow them to prepare, you can't leave them waiting though and must press on immediately with the news. Just say it like it is, "your Grandpa has died" or whatever.

lenoxat325 · Jan 18, 2011

Thanks for all of the advice

highlandlass1592, BSN, RN · Jan 18, 2011

I've had to do it frequently. It really depends upon the facility you are at. I work in critical care, so it's not uncommon to have to tell family their loved one isn't going to survive. It also taught me how to have end of life discussions....exploring what family members may want for their loved ones. At one facility, they had specially trained nurses who helped with this situation.

I think one thing that is important is honesty and compassion. A person can tell when you really don't care. I've cried with so many families, it's not funny. A few years ago, when I lost my husband I was especially sensitive to losing patients. I'll never forget one gentleman, in his 70's..been married for 35 years. He lost his wife after having surgery...I had just lost my husband two weeks earlier. He just kept saying "I never got to say good bye" I bawled with him, offered him all the comfort I could, stayed with him for quite a while. Told him I understood some of his pain, I had lost my husband suddenly and I had never gotten to say goodbye either. He appreciated the time I spent with him, going over the details, what would happen next. I took extra time preparing her for viewing and he really appreciate that too. He sent a card to my supervisor thanking me.

Compassion is really important in these situations. Honestly, no one is usually trained in how to approach these topics but we are all usually trained in how to "do everything" to try to keep someone alive. I really think that is a shame. Learning how not to be afraid to discuss end of life issues is really a skill all healthcare providers need to develop. For a long time, on my unit, when we withdrew care...many of my peers wouldn't take those patients. I always did. I feel it is a privilege to make sure someone's last hours on this earth are the best I can make them. It takes a toll on me but it's a bill I'm willing to pay.

Not sure if that was what you were looking for, I think I drifted a bit. Sorry

mentalhealthRN · Jan 18, 2011

Legally giving a prognosis or diagnosis is not within the scope of practice for any nurse-- (well except an NP) The only place that is hard to avoid is LTC as the docs are not always there to give the news. However in acute care in should always be a doc/provider.

BluegrassRN · Jan 18, 2011

I work nights, and if my patient takes a turn for the worse or flat out dies and is not a code, I am the one to call and break that news to the family. If the patient codes suddenly, I am in the room helping, another available nurse will call the family.

In my facility, docs typically give bad prognoses, and will call the family if death is not imminent; but at night, when things can change suddenly, it's up to the nurses to keep the family informed and to break bad news.

It's not easy. I usually don't beat around the bush, because no one wants to hear a long drawn out story ending with "your husband is dead." I typically say something like "This is BluegrassRN from X hospital, and I'm taking care of your husband tonight. I am very sorry to tell you that he has passed away." I usually give them a little breakdown of what has happened, and then ask them if they would like to come up to be with him before the funeral home arrives. I ask them if there is someone I can call for them: a pastor, a family member, someone to be with them. I ask them if they have any questions. That's about it. It stinks to have to do it over the phone, but sometimes it happens that way.

If the patient is going down hill fast, or we are actively coding, I'll call and say something like "This is BluegrassRN from X hospital. I am calling to tell you that your husband has taken a turn for the worse. His breathing is much more labored/his heartrate and rhythm have become unstable/he is becoming more confused and less alert." I will give them my honest opinion of what the future holds "We may need to transfer him to the ICU/I fear that he will not be with us much longer."

In the event of a code, I usually say something like "We are currently working very hard to keep your husband alive right now. His condition deteriorated very fast/he had a sudden rhythm change at 3:15 this morning, and despite all our efforts his heart stopped. We are in the process of doing chest compressions and coding him as we speak. Are you able to come up to the hospital right now?"

It helps to have a spiel, a script of sorts. That way you don't use too many words, and you don't stumble over your words. I always ask if they have someone with them or if I can call someone for them; I always ask if they are planning on coming up to the hospital right now; I always ask if they have any questions; and I am always honest. If someone asks if they should come up, I am honest. "If it is important for you to be present if your husband dies, then you should come up now, because his condition is quite serious and I'm not sure he will pull out of this."

It's an uncomfortable conversation to have, but it is so important for the family to understand what is happening.

NurseInTexas12 · Jan 18, 2011

Yes, I give bad news every day. I always ask the patient if the doctor has discussed their diagnosis with them before I mention a new diagnosis to them, and they usually say yes. However, even after they say yes, there are many times each week where it's clear as day that I am the first one to tell them they are having a miscarriage, have an ectopic pregnancy, have an STD, have cancer, etc.

How do you do it? You do it with compassion and caring. You make sure all of their questions are answered. You help them understand what their diagnosis really means. Then you go get the doctor, let them know it's not cool that they didn't explain everything to the patient before sending you in, and then you get them to the bedside to speak with the patient.

It's just part of the job in some units, but it's also an opportunity to really be there for your patients and to make their sad experience a little better.