“One of the residents that I was working with was yelled at once by somebody else because he had cried while giving a family bad news. I think everyone knows when you’re giving them bad news; it’s not like a big secret. You maintaining a great deal of composure doesn’t change that fact. I think that we’re allowed to be human. If we force ourselves not to be human or have any degree of human emotion, that’s obviously not putting us on the path to wellness and certainly if we force other people not to be human that’s not putting either them or us on the path to wellness.”
—Ilene A. Claudius, MD
Breaking bad news to patients and families is a fact of life for an emergency physician. More than 300,000 patients die in emergency departments each year from either traumatic or nontraumatic cardiopulmonary arrest, and an even greater number are diagnosed with a new life-threatening or life-altering illness, such as cancer, stroke, or traumatic brain injury.1 We stand at the front lines for these patients and families when they are first confronted with death or their own mortality. It is up to us at these moments, not their specialists or family physicians, to comfort and support them in a time of need. While intensely fulfilling at times, this type of demanding emotional support can also be incredibly draining in an environment that never sleeps and never stops moving.
Why debriefing is so important
Sometimes it can feel impossible to find the line between professional composure and our personal humanity. In order to deliver the most compassionate and effective patient care, we must create some emotional distance between ourselves and our patients. Contrarily, total avoidance of any kind when coping with death is one of the major reasons that emergency physicians become disillusioned and ultimately leave the field.2 Debriefing after a resuscitation or stressful event can help us to walk this line and maintain a balance that allows us space to express and process our emotions while still providing excellent care to our patients. Even better, debriefing helps us to identify systems issues, improve as providers, and strengthen the bonds between residents, attendings, nurses, and other ED staff.
How to debrief on your next shift in 7 steps
The following guidelines have been adapted from the 7-step Mitchell Model of Critical Incident Stress Debriefing [PDF]. However, even before starting the debriefing process, try to be mentally prepared ahead of time. Make an attempt to grab all of the staff members involved as early after the event as possible, as it may be more difficult to gather everyone at a later time. Although people may be sad or angry, try not to allow emotions to overwhelm or alter the facts of the event. Consider the power dynamics of the group and ensure that all participants have an equal voice.
1. Set ground rules
Introduce everyone and explicitly describe the purpose of the debriefing session. Set ground rules and create a safe environment for discussion.
2. Present facts first
Very briefly summarize the timeline of events. Excessive detail is actually discouraged as the primary purpose of this phase is to help get everyone talking. It’s often easier to talk about what happened than how the event impacted them. The typical question here is, “Can you give our team a brief overview of what happened in the situation from your viewpoint?”
3. Elicit thoughts
This phase is a transition between facts and emotions. It’s easier to talk about thoughts rather than the more painful aspects of the event. The typical question to ask is, “What was your first thought or your most prominent thought once you realized you were thinking?”
4. Open up about reactions
This is the heart of a Critical Stress Incident Debriefing. Anger, sadness, frustration, and other emotions may emerge. The common trigger question is, “What is the very worst thing about this event for you personally?”
5. Discuss symptoms
In the symptoms phase, the group begins to move away from emotions back to thinking. Encourage participants to think about any cognitive, emotional, or behavioral symptoms related to the event.
6. Teaching and learning
Normalize the symptoms discussed in the previous phase. Also take this opportunity to teach the group about any pertinent topics, such as breaking bad news to families and developing personal resilience strategies.
7. Re-entry and closure
Use this time to solicit questions or allow participants to make any final statements. Closure is important, especially for more junior residents. Provide information for where to turn for more support if needed.
Want an even better solution?
If you are an EM resident, join us on May 15, 2017 at the 16th annual Essentials of Emergency Medicine (EEM) Course where residents from all over the country will be coming together for the first-ever Resident Wellness Consensus Summit (RWCS) in order to innovate real-world solutions to physician wellness issues just like this one. The Consensus Summit is jointly sponsored by EEM, Emergency Medicine Residents’ Association (EMRA), and ALiEM. Sign-up on the EMRA site where there is a significant discount for EM residents at only $189, which is <20% of the total registration price!]
Featured podcast with Dr. Ilene Claudius
Listen to Dr. Ilene Claudius, the ever-popular pediatric emergency medicine expert on EM:RAP, talk about her residency experience and the secret ingredients that made it so great, including community, personal fulfillment, and staying human.