Death and Dying

Breaking bad news

Geriatricians frequently break bad news. No matter how old and frail the patient, the news can always come as a devastating blow. Equally, news that may seem bad may be taken well—someone who has felt unwell for ages may welcome an explanation, even if it means a terminal diagnosis. Sometimes they will have been expecting worse (‘I’ve had a stroke? Thank God it isn’t cancer’).

▶Each case needs to be considered individually and carefully modified as reactions become apparent.

Who should be told bad news?

Information about a patient’s diagnosis and prognosis belong to the patient, and that individual has a right to know. The paternalistic tendency to ‘protect’ a patient or their relatives from bad news is now largely obsolete, but some patients and relatives still believe this exists and this may need to be corrected
Very often, fears that an older person will not cope with bad news are unfounded. They may not have asked questions because they are not culturally used to quizzing doctors, but will often have an idea that something is wrong. Anxieties about remaining family members (particularly spouses) can be addressed once everyone knows a patient’s diagnosis and management plan. Open dialogue may ease distress
Equally, there are some older people who simply do not wish to know details about diagnosis and prognosis, preferring to trust others to make decisions for them. It is inappropriate to force information on such patients and crucial to identify them. Approaches range from blunt questioning—‘If you turn out to have something serious, are you the sort of person who likes to know exactly what is going on?’ to a more subtle line—‘We have some test results back, and your daughter is keen to talk to me about them. Would you like to know about them too?’ The response to this is usually informative—either ‘Yes, of course I want to know’ or ‘Oh, well I’d rather let my daughter deal with all that’
Well-meaning relatives (usually children, who are more used to challenging authority) may be more proactive in seeking information than the patient, and then try to shield their relative from the truth, believing that they would not be able to cope. In such situations, try to avoid giving information to relatives first—explain that you cannot discuss it with them without the patient’s permission. Be sympathetic — these wishes are usually born from genuine concern. Explore why they don’t want news told, and encourage reality—the patient knows that they are unwell and must have had thoughts about what is wrong. Point out that it becomes almost impossible to continue to hide a diagnosis from a patient in a deteriorating condition and that such an approach can set up major conflicts between family and carers. Be open—tell the relative that you are going to talk to the patient, and promise discretion (ie you will not force unwanted information). A joint meeting can be valuable if the patient agrees. They may be right, and the patient does not want to be told, but establish this for yourself first and always get permission from the patient before disclosing details to anyone else

HOW TO … Break bad news

Make an appointment and ensure that there will be no interruptions
Ensure that you are up to date on all the latest information—about the disease itself and the latest patient condition. (Have you seen them that morning?)
Talk in pleasant, homely surroundings away from busy clinical areas
Ensure that you are appropriately dressed (eg not covered in blood from a failed resuscitation attempt)
Suggest that family members or friends come along to support
Invite other members of the MDT (usually a nurse) who are involved in the patient’s care
Begin with introductions and context (‘I am Dr Brown, the doctor in charge of your mother’s care since arriving in the hospital. This is Staff Nurse Green. I already know Mrs. Jones but perhaps I could also know who everyone else is?’). It is sometimes useful to make some ‘ice-breaking’ non-medical comments (eg ‘How was the journey?’), but do not be flippant
Establish what is already known (‘A lot has happened here today—perhaps you could begin by telling me what you already know?’ or in a non-acute setting ‘When did you last speak to a doctor?’)
Set the scene and give a ‘warning shot’. (‘Your mother has been unwell for some time now, and when she came in today she had become much more seriously ill’ or ‘I’m afraid I have some bad news’)
Use simple jargon-free language to describe events, giving ‘bitesized’ chunks of information, gauging comprehension and response as you go
Avoid euphemisms—say ‘dead’ or ‘cancer’ if that is what you mean. Avoid false reassurances and platitudes
Allow time for the news to sink in—long silences may be necessary; try not to fill them because you are uncomfortable
Allow time for emotional reactions, and reassure in verbal and non-verbal ways that this is an acceptable and normal response
Encourage questions
Do not be afraid to show your own emotions, while maintaining professionalism—strive for genuine empathy
Summarize and clarify understanding if possible. If you feel that the message has been lost or misinterpreted, ask them to summarize what they have been told, allowing reinforcement and correction. Complex medical terms are usefully written down to take away and show to relatives or look up
Someone should stay for as long as is needed, and offer opportunity for further meeting to clarify questions that will come up later
Document your meeting carefully in the medical notes

Bereavement

Common experience in older people—causes huge psychological morbidity. A quarter of older widowers/widows develop clinical anxiety and/or depression in the first year.

▶The grieving process is amenable to positive and negative influences, so awareness of those at risk can help target care.

Normal stages of grief

Not linear—often go back and forth between stages.

Shock/denial: lasts from minutes to days. Longer if unexpected death. Resolves as reality is accepted
Pining/searching: feel sad, angry, guilty, vulnerable; urge to look back and search for the dead person; restless, irritable, and tearful. Loss of appetite and weight. Poor short-term memory and concentration. Resolved by feeling pain and expressing sadness. May be hampered by social or cultural pressures to behave in a certain way
Disorganization/despair: feel life has no meaning. Tend to relive events and try to put it right. Common to experience hallucinations of the deceased when falling asleep (reassure that this is normal). Resolves as adjust to the new reality without the deceased
Reorganization: begin to look forward and explore a new life without the deceased. Find things to carry forward into the future from the past. May feel guilt and need reassurance. Period of adjustment
Recurrence: grief may recur on anniversaries, birthdays, etc.

Abnormal grief

Hard to define as everyone is different (both individual and cultural variability) and the process cannot be prescribed. In general, weight is regained by 3-4 months, interest is regained after several more months, and the beginnings of recovery have usually been recognized by 2 years.

Risk factors for abnormal grief

These include:

Sudden or unexpected loss
Low self-esteem or low social support
Prior mental illness (especially depression)
Multiple prior bereavements
Ambivalent or dependent relationship with the deceased
Having cared for the deceased in their final illness for more than 6 months
Having fewer opportunities for developing new interests and relationships after the death

Although older people are generally more accepting of death than younger people, they commonly have a number of these risk factors (eg an 80-year-old man who has cared for his demented wife for 3 years prior to her death, is likely to have had an ambivalent relationship as well as being her carer. He may have limited social support and opportunity for alternative social contacts).

▶Older widowers have the highest rate of suicide among all groups of bereaved persons

HOW TO … Promote a ‘healthy bereavement’

Identify those at risk of abnormal grief (see ‘Risk factors for abnormal grief’, p.640)
Encourage seeing the body after death if wished
Encourage involvement in funeral arrangements
A visit by the GP after death to answer questions, or a meeting with the hospital team can be very helpful
Good social support initially is crucial and professional/voluntary groups (eg CRUSE at www.crusebereavementcare.org.uk) or counsellors can be helpful if family/friends are not present
There needs to be permission for ‘time out’ and reassurance that they are experiencing a normal reaction
As time goes on, setting small goals for progressive change can structure recovery

For the confused, older patient, repeated explanations, and supported involvement in the funeral and visiting the grave have been shown to reduce repetitive questioning about the whereabouts of the deceased.

Palliative care

Death is inevitable. Physicians should acknowledge their limitations, not seeing every death as a personal or system failure. Society has a misperception that medical technology can always postpone death—this should be addressed, and death portrayed when appropriate as a natural and inevitable end.

Palliative care is concerned with the holistic management of a patient in whom death is likely to be soon and where curative treatments are no longer possible. It aims to help the patient (and relatives) come to terms with death while optimizing the quality of the time left. It involves an MDT approach, with attention to relief of physical symptoms and to social, psychological, spiritual, and family support.

Traditionally used in cases of incurable cancer (where a diagnosis has often been made and a prognosis given), the approach is valuable in many other situations. Death from, eg end-stage heart failure is as predictable as death from cancer, yet application of palliative care measures is less frequent. Discussing impending death with a patient is often difficult for doctor and patient, but it allows the goals to shift from hopeless (patient cure) to realistic and achievable (planning a good death). With the complexity of illness in older people, deciding when death is inevitable can be difficult and there is often a degree of uncertainty—not least about timescale—but the rewards to the patient and carers are many.

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