We spend hundreds of hours teaching our students how to approach the sick and/or injured patient. But what about the relative left behind when someone passes away? What do we teach them about the management of breaking bad news? To expand further on that, how many of our paramedic students have ever seen or been around a deceased person—outside of a funeral—and just how many witnessed a deceased patient during clinical placement either post-resuscitative efforts or during a welfare check?
Multiple paramedic programmes provide communication courses within their programme structure, with Griffith University offering a course called Human Skills in Medicine, which is a core foundational year education course across all Griffith Health Medical and Paramedic programmes. However, like most other communication courses, it is not specific to paramedicine, but aimed more broadly across key medical courses. It does however provide valuable learning within the area of breaking bad news, which has been leveraged into contextualised scenarios, tailored to enhance student learning experiences within our paramedicine programme.
The approach developed around breaking bad news within our students' training is very simple and follows these areas:
The scenario
The scenario that we have been using now, which has the best and highest impact on our students is: ‘92-year-old female patient, not alert and unresponsive’.
Our students receive only this information when they are dispatched to the case, outside the simulation lab room. On arrival, the students are met by the patient's husband, who informs them of what happened: ‘I woke up before my wife this morning, pottered around for about 20 minutes, came back into the room with some tea, as she really likes a nice cup of tea when she wakes up, but I couldn't rouse her. That is when I called the ambulance. We went to bed around 10 pm last night and I woke up at my normal time of 7 am. You know we have been married for 68 years this year’. Upon examination, it is obvious that the patient is deceased, and has been for some time, as there has been a 9-hour window since the husband last saw the patient alive.
The other part of this scenario is an environmental factor that provides significant challenges to the students. ‘Eddie the Jack Russell Terrier’ is a devoted little dog who loves his owner and refuses to get off the bed. Every time the students do anything to assess his mum, Eddie goes up and investigates. The husband won't remove dog and if the students remove the dog, he jumps right back up on the bed. If they put him outside, he gets back in the house and jumps back up on the bed. The point here is that the students need to manage what is wrong with this patient and manage the environmental factors thrown in by Eddie.
Eddie also plays a part with the husband when he is sitting down to hear the bad news. Again the students need to manage the situation with Eddie, this time in the arms of the deceased patient's husband, when they break the bad news.
Once it is established that the patient is deceased, the husband now becomes the students' next patient, as there is nothing more that can be done for his wife.
No training or prompting is done prior to the ‘breaking bad news’ part of the scenario, as the way in which the students perform this aspect plays a big part in the debriefing. We also involve another academic staff member to act as a daughter or son, to receive the call from the students, telling them that their mother has just passed away. Again, we don't provide any training on how they break this news to the son or daughter, as this also plays a major part in the debriefing of the scenario. How the students speak/communicate to both the husband or daughter/son will affect how the husband responds or how the daughter/son responds to the news. If the students communicate well, the husband and/or the daughter/son will respond well. However, in most cases, the students do not really know what to say, and the people in the roles of husband and/or daughter/son have been told to respond in an extremely blunt, short or shocked way; effectively in the way they would have responded if they were communicated such news in the way the students delivered it.
Low cost
Our low-cost approach focuses on how we present the patient, the way in which that information is delivered to the students and the overall factors (environmental, verbal and physical appearance) that are used. For example, we use an extrication manikin as our deceased patient, dressed up with appropriate clothes and a wig. Our patient passed away in their sleep, obvious death, so no need for an expensive high-fidelity manikin, as they have no breath sounds, no heart sounds, fixed and dilated pupils and asystole in all leads. Other than the asystole, these manikins naturally present this way, because there are no electronics in them. So when a student listens for heart or breath sounds or looks at the fixed drawn-on pupils, the results are as they would find them in reality. As far as the asystole goes, with so many monitor simulator devices on the market now, it is pretty easy to replicate this as well. If you've got a broken manikin laying in a back room, not being used and gathering dust, this would also be perfect for this type of scenario.
Our bed setup is often a converted stretcher or hospital bed borrowed from within our school, with clothing and wigs from our collection of outfits and other items we have gathered over the years to dress up our manikins.
Our star actor, Eddie the Jack Russell Terrier, costs us a bag full of soft chewy dog treats, which we place under the sheets, in and around key areas on the manikin, so that he goes sniffing in key areas when the students assess the patient. Hiding the dog treats under the blanket also keeps Eddie's interest up through the day of scenarios and, being a very food-motivated dog, keeps him wanting to stay on the bed. We also hide dog treats in the response kits just in case he does get on the ground.
The facilitator generally plays the part of the husband, with a second academic playing the part of the daughter or son.
High impact; simple learning outcomes
The high impact of this scenario comes directly from how the students manage the overall scenario based on:
These four areas provide some very simple learning outcomes in an area to which the students have very little, if any, exposure prior to starting their careers as paramedics. The main learning outcomes within the scenario are as follows:
The scenario itself takes only about 25–30 minutes to complete, as we try to do it in real time; however, the debriefing session can take 45 minutes to an hour, which is when every student in the room benefits from the high impact of this scenario.
Solid debriefing
The debriefing is the real learning opportunity for every student, whether or not they played a direct part in the scenario. This is where we completely unpack what has happened and highlight the following:
The key areas we have found in this scenario that the students struggled with all relate to one of two areas:
This debriefing enables us to unpack what communication style was used; whether it was effective; how the students changed their communication style/method if it wasn't effective; and the overall reaction to and management of the shock communicated back at them when they broke the bad news to the daughter/son.
By not instructing the students about how to actually break the bad news, and allowing them to try their own methods first based on their experiences and what they had already learned in the Human Skills for Medicine communication course, we were able to see/get a more natural reaction from them if they communicated to both the husband and the daughter/son in a way that invoked a sharp/blunt or shocked response. Unpacking those responses provided clarity around why they occurred in the way that they did and then cleared the way to provide examples of different methods and word choices for breaking bad news. This has resulted in in-depth learning experiences that have stuck with students through the rest of the programme.
Eddie the Jack Russell Terrier is there purely as a distraction and he does a very good job, physically getting in the way and forcing the students to work around this issue. During the debrief, students provided feedback on how a real physical environmental distraction like Eddie challenged them to approach their treatment plan via a modified avenue, which accommodated the dog as part of their normal clinical approach. A common remark from having Eddie in this scenario was that:
‘So many scenarios say there is a dog or a cat or some other form of environmental distraction in the scenario; however it is only there in make believe, so you just say we would put it in another room and move on with our scenario. There is no real impact and no real challenge within a scenario that way. A real animal provides a much more authentic approach to what we will be doing when we graduate’.
As a result of the very nature of what this scenario covers, Eddie also becomes a ‘support puppy’ during the debrief for students who are saddened by the history or have had a recent older adult family member pass away. Also included as part of the debrief was peer support. Any student who needed assistance either after or during this scenario, had immediate access to support.
Conclusion
Overall, we have found that adding this simple aspect to a very common area of practice, not previously taught within a paramedic student education pathway, enables our students to be better prepared when they first encounter or are required to perform this exact scenario in the real world.
No one taught me how to break bad news to a patient's loved one; I sort of just watched what others did, probably said the wrong thing more than once, but eventually found my way. Also by providing the opportunity for students to make mistakes in a controlled learning environment—in particular when breaking bad news—they can make those mistakes or practise bad communication methods in the classroom instead of with Joe Public, the very first time they need to do it.
In the current era of paramedic educational training, where the field of paramedicine has shifted from a job into a profession just like medicine, nursing and other registered allied health professionals, it is our duty as paramedic clinical educators to teach more of these less sexy ‘soft’ skills. This will enable our future paramedics the opportunities most of us never had back when we started. There is also an expectation from the public that we know how to do this correctly and do it well.
If you take one thing away from this article, remember this: you are going to be the first person to tell someone their loved one has passed away. How would you like that news passed on to you when the time comes?