In his role as National Ambulance Director, Peter Bradley states in the foreword of the National End of Life Care Programme for Ambulance Services (Association of Ambulance Chief Executives 2012) that ambulance services are crucial in the delivery of high quality care at end of life. Step 1 of the Pathway outlined in the Programme states the need for ‘open, honest communication’ as end of life approaches. The 6 steps of the Pathway follow the care that ought to be provided for dying patients/relatives who are able to have time to consider advanced care planning. The programme includes the need for good organisation and coordination of service provision, and access to specialist palliative care and post bereavement support. For the ambulance services, the main focus in the Pathway is on ‘rapid discharge home to die’, and this focus makes sense if patients are known to be near their end of life. All too often, paramedics face situations where the patients' death is unexpected, and so, without time to prepare for end-of-life care. For such patients and their families, the End of Life Care Pathway (2012) is simply not appropriate.
“Paramedics …must transition from resuscitators to death notifiers in a matter of moments…this can be very challenging”
From a paramedic perspective, Iserson (2011) emphasises that paramedics need to mentally prepare themselves to cope with this part of their role, and to recognise their own anxieties and feelings relating to this. It is neither clever nor helpful to deny the need for structured emotional support for those delivering frontline services. It would be impossible for paramedics to emotionally prepare for all eventualities, but what can be prepared for is the likelihood that at some point during the day, they will be required to break bad news. Different people have different coping strategies. Developing strategies that are known to work on both an individual and team level can be a tremendous advantage to people working in emotionally challenging roles (Maunder 2008).
As such, there needs to be a mechanism that guards paramedics against emotional degradation, which is a key occupational hazard.
From a medical perspective, “bad news” has been defined as any information which adversely and seriously affects an individual's view of his or her future (Baile et al 2000). Paramedics are often required to inform people that someone who is significant to them has died at the scene. Paramedics have to be sensitive that there may be a gap between what the person understands to be the situation and the reality of what is really happening.
The London Ambulance Service (Dom 2011) has been proactive in offering guidance to paramedics for breaking bad news. It is clear in stating that when it is done incompetently, it can make a situation worse. It reinforces the need for empathetic listening and truthful conversation, conveyed sensitively, and at a pace that is appropriate to the survivor's response to the information.
The London Ambulance Service (Dom 2011) cites Kayes (1996) model ‘10 Steps in Breaking Bad News’ as being useful prompts for delivering bad news. It was originally written from a medical perspective for doctors breaking bad news to patients with terminal medical conditions (see table 1)
| Preparation: be factual with clear objectives in a private setting |
| What does the person know?: ask for a narrative of events; “how did it all start?” |
| Is more information wanted?: “Would you like me to explain a bit more?” |
| Give a warning shot: “I'm afraid it looks rather serious” and allow the person to respond |
| Allow denial: denial is a defence, a way of coping. Allow the patient to control the amount of information |
| Explain: narrow the information gap. Detail will not be remembered but the way you explain will |
| Listen to concerns: what are your main concerns at the moment? Allow space and time for a response. |
| Encourage ventilation of feelings: this allows for empathy |
| Summary and plan: summarise concerns, refer on, give closure |
| Offer availability: offer further explanation, include other healthcare agencies, support groups and family support |
Much of the literature about ‘breaking bad news’ have been written from a medical perspective, and not an emergency care angle. As part of the protocol, doctors are advised to set up an interview with the patient to break the news in person, ask that they may like to bring with them a trusted friend or relative, ensure that protected time is set aside to have an opportunity to give time to the patient when breaking the news, provide guidance on avoiding jargon and using appropriate language, and suggests information on how to pace the conversation to enable the patient to take in the enormity of the news they are receiving, offering time to ask questions, which should be answered honestly and sensitively, concluding the consultation by summarising the conversation and offering factual information on what happens next. This model leaves the paramedic vulnerable as they, for the most part, do not have the opportunity to plan ahead to prepare patients for receiving bad news as recommended in Kaye's (1996) and Baile's (2000) models.
From a paramedic perspective, it would be impossible to have a one-size-fits-all approach with a script of what to say that can be rehearsed or memorised ahead of the event. People's responses to such events are very individual and no two situations are ever the same. What is known is that breaking bad news can be ‘extremely stressful for the…professional involved’ (National Council for Hospice and Specialist Palliative Care Services 2003), and especially so when there is a personal connection with those receiving the information (Maunder 2008).
It is difficult to find academic evidence of the impact of breaking bad news on the emotional wellbeing of paramedics. We were unable to find research to support this, although there is anecdotal evidence in various social media and news articles where paramedics describe this part of their job taking a toll on their health (Kirk 2015). From a paramedic perspective, Iserson (2011) states that paramedics report this area of their work to be the most emotionally difficult part of their job, and that there is need for more education to help with the same.
The Welsh Ambulance Service (2016) has been proactive in recognising that there is need to support the health of their workforce and has put in place opportunities for health promotion aimed at reducing sickness levels. Stress is identified as a major cause of ill health, but it is not directly linked to any one aspect of the paramedic role. Statistics relating to the wellbeing of paramedics speak for themselves. In England, figures for the NHS sickness absence rates for paramedics in the first quarter of 2015 showed a sickness rate of 6.78%, the highest sickness absence of all health professionals (NHS Digital 2015). A year later, although the figure had fallen slightly, Ambulance Trusts continued to have the highest average sickness absence rates of all healthcare professionals with an average of 5.79% (Health and Social Care Information Centre 2016). In Wales, the Welsh Ambulance Services NHS Trust has the highest sickness absence of all health professionals in Wales, with a sickness absence of 7.8% recorded in the period 2015–16 (Welsh Government Statistics 2016); and in Scotland, figures released on 31 August 2016 reported a sickness rate of 7.57%, second only to the State Hospital sickness rate of 8.4% in the period April 2015–16 (Information Services Division (2016).
Section 8 of the Health and Care Professions Council's (HCPC) Standards of Proficiency for Paramedics (2014) provides recommendations for establishing protocols for information and support to be given to patients. It states the need for effective communication using language that is clearly understood. It stresses the need for appropriate verbal and non-verbal skills in communicating information, and the need to modify communication to the service user's level of understanding. It is again noticeable that there is no reference to the particular communication skills required for giving bad news despite this being an important part of the paramedic's work, although it is noted that interpersonal skills and communication are key elements of the HCPC education programmes in Higher Education Institutions in the UK.
The National Institute for Clinical Excellence (NICE) guidelines for Major Trauma: Service Delivery (NICE 2016) include recommendations for establishing information and support protocols to be given to patients, and survivors at the scene. These guidelines do not specify what should be included when breaking bad news, but offer information on some of the support groups available to help people deal with the consequences of major trauma.
There is a benefit for having a paramedic tool for breaking bad news that takes into account the unpredictability and immediacy of the role, and the challenging environments in which paramedics are placed when delivering such news. We offer the following paramedic model for breaking bad news, which is based on our experience, and feedback from practising paramedics. The proposed mechanism is abbreviated to ‘MANAGED’ for ease of use. This has been developed as a result of listening to paramedic students and emergency medical technicians undertaking paramedic education at Swansea University. Many of the latter have worked in the field for many years, and they repeatedly stated they felt ill prepared to deal with this part of their work. All stated they had received no formal training in this prior to their course. We have created this model specifically aimed at addressing the key concerns identified by the students in class and in consultation with experienced paramedic colleagues working in the field.
Mentally setting-up and preparing
This arm involves proactively readying for breaking bad news during the day, or mentally adjusting for the role. This should be as routine as with all other areas of preparation at the start of a working shift. Regional Ambulance Trust protocols include use of a leaflet that paramedics must give out stating what happens in the event of sudden death, with guidance on procedures that will be followed for managing sudden death, including information on being contacted by the Police, and Coroner requirements. Paramedics should also know the regional protocol for sudden death.
‘It is true that no protocol can anticipate every eventuality; every notification will differ in some way…It can however, help notifyers prepare for their task and help them.’
Paramedics must ensure that the leaflets are available and know where they are kept in the Ambulance. Such information should be available in different languages if these are the languages used in the local area. There is benefit in knowing the area and the communities served. Familiarity with the equipment and consumables in the Ambulance will further aid paramedics.
Able and confident practice
From a paramedic perspective, Iserson (2011) describes the need to master delivery of care, including resuscitation, with the person in mind. Persons are those witnessing the attempts to save life at the scene. Even when there is little hope of survival, if persons see that all efforts were made to save the casualty or that the care was delivered expertly, calmly and confidently, that in itself can be a comfort to those witnessing paramedic attendance.
We must be realistic in the care provided. Guidance from the Resuscitation Council (2016) is clear:
‘If the healthcare team is as certain as it can be that a person is dying as an inevitable result of…a catastrophic health event, and CPR would not restart the heart and breathing for a sustained period, CPR should not be attempted.’
Yet some persons are further traumatised if they believe nothing is being done to save their loved one – the key skill for the paramedic at this point is to ensure that they are communicating that not attempting CPR does not mean they are not providing care. Ensure that persons know care is appropriate, and includes, for example, excellent pain relief.
Notice survivor response
Noticing survivor response and assessing the situation involves actively listening to what the person is saying or asking. Observe if persons appear to have understood the enormity of what has just occurred. The questions they ask can provide information of their understanding. Although factual and unambiguous information will be required, there is benefit in repeating the words used in their questions gently back to them before stating factually what has happened, if the words they use are appropriate. This can facilitate their coming to terms with taking in the information, and also provides very first information at the relative's level, using a language that they use and understand.
As an example, if the relative uses the words ‘he has passed away?’ it would be sensitive to say gently ‘yes, he has passed away…pause… he has died.’
This is not to be confused as replacing the need for factual information, but simply the gentle starting point leading to factual knowledge. Remember the way the words are said, and the words that you use, should not be underestimated. Using everyday language where possible helps to convey difficult information. for example, if the person has comfort from thinking their relative or significant other is in heaven, simply nod and agree.
Soto and Cooke (2013) state:
‘Survivors may not be able to remember specific details related to an event that may be lasting for paramedics, but can and do remember in remarkable detail, the exact words they heard, feelings they felt and images they witnessed at the time they learned of the death of a loved one.’
Similarly:
‘The way the news is broken can stay in the memory of survivors for the rest of their lives. The exact words used, the tone of voice and the expression on the face of the person who delivered the news.’
This is where compassion, sensitivity and empathy shown towards persons is much needed.
Accurately and sensitively giving information and knowledge
Be factual, truthful and clear; mindful that the way information is conveyed is as important as what is said. Ensure the survivor is in no doubt that their relative or significant other has died. If possible, add that the patient was not conscious, or that pain or anxiety was alleviated quickly, or anything else relevant to that particular situation that can help make the news more bearable to hear. Be honest, stay calm, and quietly give the information in a caring manner.
Give time for person's response and hear their story
Show that you care. Listen. It can help survivors cope with the enormity of what has happened if they are simply able to give their story and know that they are being heard. This also provides the opportunity to obtain more information on events leading up to the call out for Ambulance support.
Attend to people's emotions and signpost to support before exiting the scene
Respect the person's grief, and if possible, offer a private area or screen the person from the public to maintain his or her dignity in grief until further help (e.g. until professional support or another family member is called or arrives).
Professionally deal with the practicalities associated with that particular situation.
Signpost the person to further support and help, as appropriate, by giving the information leaflet detailing the regional protocol of what happens next in the event of sudden death, ideally written sensitively in their first language.
In addition, verbally inform the person of what will happen next.
Ensure that the person is supported by a significant other if possible, before leaving the scene.
Debrief
Straight after leaving the scene, try to find an opportunity to complete a Personal Debrief Prompt.
Debriefings should be costed as a crucial part of the paramedic role. They provide the option for paramedics to talk about their work with others who understand the role and include the opportunity to:
Debriefings provide an opportunity to give and receive feedback of own performance with peers, and learn from experienced mentors (Iserson, 2000)
From a pragmatic viewpoint, this may not be done on the day events occur, but all members of a team should know that there will be an opportunity at some point in a working week where team members will be able to touch base for such debriefings.
One criticism to such a suggestion may be that paramedic teams work shifts, and that it would be impossible to get all members of a team together at any one time. The challenge is to work around that, and consider offering debriefing meetings when there is cover for those attending by another team – the point being that the groups attending the debriefings have opportunity to meet together regularly for such emotional support, and that this is seen as part of their work.
The HCPC's standards of proficiency for paramedics (2014) state the need for paramedics to:
‘recognise the need to engage in critical incident debriefing, reflection and review…..[and] understand the importance of maintaining their own health.’
There is a need for recognition that witnessing and attending to traumatic dying and death is at the very least harrowing, and although it is true that some people cope by simply getting on with the job, it is unrealistic to expect that when people ‘switch into their role’ they completely ‘switch-off their emotion’ – we may deal with situations more effectively when we are experienced and trained and educated to do so, but over time, and without adequate support, that wall of emotional protection can crack.
| Personal debrief prompt | |
|---|---|
| What went well? | e.g. you kept the situation calm |
| What could have gone better? | e.g. traffic or environmental factors |
| Are there issues here we need to remember for future situations? | e.g. moving a consumable to an easier place to locate in the ambulance |
| Have I learnt something from this experience? | Pertinent to that particular experience/situation |
It is obvious that adequate staffing levels are necessary to provide best practice. That in itself can be a coping strategy to help deal with this challenging part of the job. When paramedics know they have done all that they could have done; have had time to break bad news to the standard; were able to provide the support to the survivors who witnessed their care, then they have peace of mind and are able to function more effectively in their role. There is clearly need for a national strategy for breaking bad news for paramedics, including the provision of adequate structured emotional support for paramedics to maintain their own well-being in order to do so.