Delivering bad news
Program trains professionals in delicate situations

How would you tell a father that his toddler will never walk again? A mother that her little girl’s cancer has spread beyond the reach of chemotherapy? Or a couple in a waiting room that their baby did not make it through emergency surgery? Delivering bad news is one of the most difficult parts of a clinician’s job. But unfortunately, most receive little or no formal training communicating with families in critical situations.

Looking to fill this void, Children’s Hospital Boston has developed the unique Program to Enhance Relational and Communication Skills (PERCS), which provides practitioners with hands-on training in the delicate art of delivering devastating news.

“We spend a lot of time working on improving our clinical procedures,” says Robert Truog, MD, chief of Critical Care Medicine, “but often what families remember is not the details of the procedure, but what physicians said to them and how they said it. Until now, that’s not anything we’ve practiced.”

PERCS is a daylong training session that includes lectures, short films, and most important, a simulation experience where professional actors portray patients and family members dealing with critical care or end-of-life situations. Session trainees must deliver the difficult news while facilitators and peers watch from another room.

“Simulation in general is widely recognized as a way to improve skills in medicine,” Truog says. “We wanted to extend the simulation methodology into the realm of communication skills.”

Trainees typically forget about the observers very quickly as each scenario becomes emotionally authentic, says PERCS Director Elaine Meyer, PhD. “Although you are role playing, you feel very ‘in the moment.’ The situations really pull you in.”

The simulations are designed to integrate the medical aspects of each scenario with issues such as parental guilt, family conflicts and disagreement about care. “We don’t just present straight medical cases,” says Meyer. ”We include the psychosocial issues that clinicians deal with every day.”

For medical trainees, being pushed like this is difficult, but it pays off ultimately. “PERCS is a long, very emotionally exhausting day,” says participant Robert Graham, MD, a clinical fellow in the department of Anesthesia. Graham says he found the day productive despite his years of experience. “Everyone gained something from going through it, no matter how long they’ve been in medicine.”

Following each simulation, participants reflect on the experience with input from the PERCS team, families who have experienced similar tragedies in real life and the actors from the simulation. The feedback offers participants a rare glimpse of how real-life parents may perceive them in a tough situation.

And it’s not just physicians who benefit from the training. Each session also includes nurses, social workers, psychologists and even chaplains. Eighty Children’s staff members, with medical experience ranging from one to 30 years, have been trained so far.

“New hires often tell me that talking to families in difficult situations is one of their biggest fears coming into the job,” says intensive care nurse Christine Roe, RN. According to a survey of PERCS participants, the program has helped most of them reduce that anxiety.

The PERCS philosophy isn’t about teaching a communication technique or a specific way to deliver a message, but about how to build relationships with families. “We know that when clinicians express their humanity,” says Meyer. “Families realize that they’re not walking this path alone.”

A videotape highlighting the teaching philosophy of PERCS has been produced by the Initiative for Pediatric Palliative Care and has been presented at the American Academy of Pediatrics, and the American Academy of Hospice and Palliative Medicine. It will be distributed to children’s hospitals throughout the nation as part of the IPPC’s educational program.