Protocol for the Communication of Bad News in Prehospital Emergencies ^†

Abstract

The communication of bad news, particularly in situations of an unexpected death, is one of the most difficult tasks for health professionals. It is important to be aware of the words used and the way the loss is conveyed, as these can mark the family forever, influencing grief management. The communication of death should therefore not be an improvised act, but rather, the health professional should have knowledge about the most adequate communication approach for each situation. In the chaotic and often violent prehospital environment, no protocols with the aim of guiding professionals to carry out this communication were discovered.

1. Introduction

Bad news can be defined as any information involving a drastic and negative change in a person’s life, as well as the future perspective of destroying hopes and dreams [1,2,3].

The communication of bad news is one of the responsibilities included in the daily life of health professionals, however, it continues to be mentioned as one of the most difficult skills to practice and is a frequent object of study in several professional contexts [4]. Thus, bad news is painful not only for the relatives who experience it, but also for the health professional who observes those who experience it. This can give health professionals a feeling of helplessness and a sense of failure [5,6,7].

Unexpected death is a sudden event for which there is no preparation. Unexpected death requires, from the health teams, competence in the management of the dying process and family grief. The experience of loss and bereavement of a relative is a moment of developmental crisis for the members of a family, thus, after the death of a loved one, the family should become the center of care; it is one of the most painful experiences for a human being [6].

Communicating a death during the initial contact with a family in a context where there was no possibility of creating an interpersonal relationship—as it happens in the prehospital environment—is one of the greatest communication challenges for health professionals [1,8].

As advocated by several authors [9,10,11], communication should not be an improvised act; health professionals must possess and develop knowledge about the most appropriate communication approaches to each situation. Assertive communication reduces anxiety and conflicts of emotions, which makes it an important therapeutic tool for the health professional–family relationship.

Studies carried out in hospital settings have highlighted the benefits of training health professionals in the communication of bad news. This training also helps to improve and increase the professionals’ confidence to discuss issues about death, communication of death, and end-of-life care [9,10,12].

It is in this context that protocols emerge as fundamental guidance tools, since they describe important considerations, in the sense of alleviating the aforementioned feelings for the family that receives the news, as well as for the health professionals who transmit it [13].

Several protocols have been developed to support health professionals in the communication of bad news, but none have answered the needs revealed by the families of sudden death victims [1,14], which require orientations on how to give bad news when there are several people present [15] and present the news in a chaotic and violent environment as it happens in the prehospital environment [1,16].

In this sense, there is an urgency to establish a protocol for the communication of bad news in a specific context as the one of a prehospital emergency, where the effort and the preparation of the health professionals become a requirement to minimize the negative impact of the experience on those who are present.

2. Materials and Methods

The question of this study is: how should the communication of bad news in situations of sudden death be performed by the emergency team in the prehospital environment?

The purpose of this study is to contribute to improving the communication of bad news, particularly in situations of an unexpected death, through the implementation of a protocol designed for the prehospital emergency setting.

The specific objectives outlined are:

• Map the state of the art on strategies used in the communication of bad news in a sudden death context.
• Understand the experiences of sudden death victims’ relatives during the process of bad news communication in the prehospital environment.
• Understand the professionals’ experiences during the process of bad news communication in the prehospital environment.
• Construct and validate a protocol for the communication of bad news adapted to the prehospital emergency context.
• Develop professionals’ communication competencies in the communication of bad news in a prehospital emergency using a high-fidelity simulation program.
• Evaluate the efficiency of the protocol developed for the communication of bad news in prehospital emergency situations.

To achieve the previously-mentioned objectives, it is necessary to divide the methodological process into five distinct phases, each corresponding to a study.

In the first phase, a Scoping Review will be carried out to map the strategies used to communicate with the families of sudden death victims, the results obtained with their application, the context in which they occurred, and the role of each professional, according to the guidelines recommended by the Joanna Briggs Institute.

In the second and third phases, respectively, a study will be carried out on the experiences of the professionals, and another on the experiences of the families of sudden death victims, during the NMC process, in a prehospital context. These are two qualitative phenomenological studies, according to Giorgi's methodology. The choice of participants will be through the ‘snowball’ method, and in-depth interviews will be carried out.

In the fourth phase, the intent is to build a protocol through the Delphi Method, based on the results of the studies previously developed. The panel will be composed of 30 experts in the area under investigation.

In the fifth phase, the validated protocol will be tested with health professionals. For this phase, an instrument will be built and validated to analyze the self-confidence resulting from the training using a simulated practice of the implementation of the protocol for CMN, applied in the form of a methodological research study.

3. Results and Discussion

The knowledge translation regarding the impact of the protocol application program on the practice of a high-fidelity simulation will be based on the evidence produced and the authors’ experience in this field.

It is expected that this protocol will bring advantages to professionals in the prehospital emergency area, in the sense that they will feel more prepared and confident to face the moment of bad news communication, without a tendency to avoid this responsibility. This advantage is also argued to be the focus of nursing care, without the anguish and nervousness that is usually associated with bad news communication. It is also expected that the communication of bad news will consider the needs of the family who must to deal with a moment that can change their lives forever, making it less painful and allowing them to feel more supported and understood by the emergency team.

4. Conclusions

This project aimed to design a study that will contribute to the development of scientific evidence on the communication of bad news in the prehospital environment, especially in situations of sudden death. The results of the study are expected to reflect the reality of this issue and contribute to the recognition of the skills that need to be developed by prehospital emergency professionals, in particular nurses, who should participate in this process, considering it as a moment that precipitates an important transition in the lives of the relatives who receive the news.

This study aims to create a deeper knowledge of this issue, which will also contribute to the nurses' role in the prehospital environment and lead to the provision of more competent and humanized care to the population they serve.