How to give bad news

  1. Years ago, my sister lost her newborn son to a birth defect. She knew about the defect prior to his birth, and had been assured that everything would be fine. Unfortunately, within hours of his birth, there were other complications, and an additional undetected defect that meant he had no chance of survival. The problem was that my sister refused to accept that her baby would die within 24 hours.
    What do you do when a patient is in denial and refuses to accept such a grim prognosis? How do you make a patient understand when there is no hope?
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    About FutureNrse

    Joined: Jan '05; Posts: 155; Likes: 44

    16 Comments

  3. by   OBNurseShelley
    Quote from FutureNrse
    Years ago, my sister lost her newborn son to a birth defect. She knew about the defect prior to his birth, and had been assured that everything would be fine. Unfortunately, within hours of his birth, there were other complications, and an additional undetected defect that meant he had no chance of survival. The problem was that my sister refused to accept that her baby would die within 24 hours.
    What do you do when a patient is in denial and refuses to accept such a grim prognosis? How do you make a patient understand when there is no hope?

    You don't MAKE THEM UNDERSTAND, they will soon enough, just let them have hope and support them by answering questions and making them comfortable.
    Miracles DO happen and there's nothing wrong with having hope, sometimes it's all people need to cope.
  4. by   fergus51
    I do think there is something wrong with saying miracles happen when we know it won't. I'm not talking about the kid who has a 5% chance when I say that, I'm talking about the one who has no chance at surviving. Some defects and conditions are not compatible with life, period. In those cases, you just have to be honest in as kind a way as possible. You can't make them accept it, all you can do is make sure the staff is all being completely consistent and honest. If they ask "Isn't there a chance he'll be ok?" and there isn't, the staff better be completely truthful. If they don't accept it, all you can do is inform them of what's happening as it happens and what it all means (ex. "His blood pressure is dropping, that's a sign that he isn't doing very well"). I also think it's a good idea to tell them what you are doing for him (like control his pain, hold him, wash his mouth, etc) so they know you are still caring for him.
  5. by   SmilingBluEyes
    Quote from fergus51
    I do think there is something wrong with saying miracles happen when we know it won't. I'm not talking about the kid who has a 5% chance when I say that, I'm talking about the one who has no chance at surviving. Some defects and conditions are not compatible with life, period. In those cases, you just have to be honest in as kind a way as possible. You can't make them accept it, all you can do is make sure the staff is all being completely consistent and honest. If they ask "Isn't there a chance he'll be ok?" and there isn't, the staff better be completely truthful. If they don't accept it, all you can do is inform them of what's happening as it happens and what it all means (ex. "His blood pressure is dropping, that's a sign that he isn't doing very well"). I also think it's a good idea to tell them what you are doing for him (like control his pain, hold him, wash his mouth, etc) so they know you are still caring for him.
    perfectly stated.
  6. by   BETSRN
    Quote from OBNurseShelley
    You don't MAKE THEM UNDERSTAND, they will soon enough, just let them have hope and support them by answering questions and making them comfortable.
    Miracles DO happen and there's nothing wrong with having hope, sometimes it's all people need to cope.
    I have a bit of a problem with this "miracles happen" thing. You deal with what is happening at that time and nothing else. You give emotional support to the patient by doing what is needed at that time.It is NOT within your scope of practice (or anyone's) to give false hope by saying the above.
  7. by   LPN_mn
    I am sorry I did not read into the post as you did. I don't think that she meant to tell the person that miracles happen. I think she meant that some people do believe in miracles and no matter what you say to them they hold out for that miracle to happen.
  8. by   BETSRN
    Quote from LPN_mn
    I am sorry I did not read into the post as you did. I don't think that she meant to tell the person that miracles happen. I think she meant that some people do believe in miracles and no matter what you say to them they hold out for that miracle to happen.
    They can hold out all they want but it is NOT up to us HCP's to support that hope falsely.
  9. by   KRVRN
    Repetition and consistency is all you can do for parents that just don't believe it. That works if the baby will eventually pass away despite everything you do. It gets ethically hard when you have a bad birth asphyxia baby or something similar with no chance of recovery still sitting on a vent 3 or 4 weeks later.

    Miracles may happen a few days later, but they just don't happen 3 or 4 weeks later like that. At that point we start very heavily speaking in absolutes... "your baby WILL NOT recover, and IS severely brain damaged" rather than saying "his prognosis is so poor that he likely won't have a meaningful life and maybe we should do what's best for him."
  10. by   OBNurseShelley
    That's right, I did not mean to tell the parents that at all, I just meant that sometimes it's ok for the parents to have hope, depending on the situation. Of course there comes a point when they need a reality check about a declining situation.
    I agree about consistanty and telling parents what you're doing and what to expect, for instance a non-viable pre-termer may appear to take a breath or move, when it's born, etc.

    Anyway, I still stay you never MAKE SOMEONE UNDERSTAND, you simply give them the facts and let them cope in their own way.
  11. by   FutureNrse
    Quote from BETSRN
    They can hold out all they want but it is NOT up to us HCP's to support that hope falsely.
    I don't think she meant that she supports it either. I think she meant that if a parent has false hope, there is no need to beat it out of them. You've given them the facts, that there is no hope, the parent chooses to believe otherwise, so you leave it at that. The childs imminent death will be the turning point when the false hope fades. There is no point in making a parent accept the death until it happens. You've told them the truth, and that's all you can do.
    Did I get it right?
  12. by   OBNurseShelley
    Quote from FutureNrse
    I don't think she meant that she supports it either. I think she meant that if a parent has false hope, there is no need to beat it out of them. You've given them the facts, that there is no hope, the parent chooses to believe otherwise, so you leave it at that. The childs imminent death will be the turning point when the false hope fades. There is no point in making a parent accept the death until it happens. You've told them the truth, and that's all you can do.
    Did I get it right?
    Yes, that is what I meant, they will come to terms with the imminent death and eventually death on their OWN TERMS. It's the statment, "MAKE THEM UNDERSTAND" that hit a button for me. It's similar to dealing with a teenager, you can't MAKE THEM UNDERSTAND anything, you have to hope you've given them all the CORRECT information and they will choose to understannd on their own time.

    Thank you for clarifying my statement.
  13. by   FutureNrse
    Quote from OBNurseShelley
    Yes, that is what I meant, they will come to terms with the imminent death and eventually death on their OWN TERMS. It's the statment, "MAKE THEM UNDERSTAND" that hit a button for me. It's similar to dealing with a teenager, you can't MAKE THEM UNDERSTAND anything, you have to hope you've given them all the CORRECT information and they will choose to understannd on their own time.

    Thank you for clarifying my statement.
    You're welcome I'm just glad that I got it right.
    Your initial post showed me that I was looking at the problem the wrong way, probably because of the circumstances involved with me sister. She has never come to a point of understanding, and in fact is now mentally and emotionally damaged to an extreme that I fear is permanent. Maybe that was already starting to happen from the moment she heard that her son would not live. I just assumed that her reaction was normal, but considering how she is now, 4 years later, I'd say that her initial reactions probably weren't the norm either. I know everyone greives in thier own way, but with her, it was like she didn't hear anything that was said.
    After all this time, I'm fuzzy on some details but one example is that the baby was missing a valve related to his digestive system, and she could not understand why they couldn't do a transplant. His liver was destroyed, and again she wanted a transplant, and there were a host of other things as well. Now, I understood why she asked about transplants to begin with, seems like if somethings broke, you get a new one, right? But when the whole surgical team sat us down and explained why none of these things could be done, I could see thier point.
    My sister, on the other hand, started trying to find loop-holes in what they said, and started thinking up outlandish ideas on how to fix each thing. So, how do you explain to a normally intelligent woman that even though the afterbirth LOOKS like liver, you cannot cut off a piece and use it as a liver?
    So, I guess my question was aimed at this type of behavior, but I think your answer still applies. The understanding will come when they can accept it.
  14. by   OBNurseShelley
    Quote from FutureNrse
    You're welcome I'm just glad that I got it right.
    Your initial post showed me that I was looking at the problem the wrong way, probably because of the circumstances involved with me sister. She has never come to a point of understanding, and in fact is now mentally and emotionally damaged to an extreme that I fear is permanent. Maybe that was already starting to happen from the moment she heard that her son would not live. I just assumed that her reaction was normal, but considering how she is now, 4 years later, I'd say that her initial reactions probably weren't the norm either. I know everyone greives in thier own way, but with her, it was like she didn't hear anything that was said.
    After all this time, I'm fuzzy on some details but one example is that the baby was missing a valve related to his digestive system, and she could not understand why they couldn't do a transplant. His liver was destroyed, and again she wanted a transplant, and there were a host of other things as well. Now, I understood why she asked about transplants to begin with, seems like if somethings broke, you get a new one, right? But when the whole surgical team sat us down and explained why none of these things could be done, I could see thier point.
    My sister, on the other hand, started trying to find loop-holes in what they said, and started thinking up outlandish ideas on how to fix each thing. So, how do you explain to a normally intelligent woman that even though the afterbirth LOOKS like liver, you cannot cut off a piece and use it as a liver?
    So, I guess my question was aimed at this type of behavior, but I think your answer still applies. The understanding will come when they can accept it.

    Sorry to hear your sister is not coping well. Hang in there and support her the best you can.

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