Emergency Room Communication Issues: Dealing with Crisis

Marghani M. Reever and Deborah S. Lyon

The emergency department (ED) is a fast-paced environment dealing primarily with short-term interventions. Because of this setting and the nature of this type of care, the importance of good communication is often overlooked.

Even though the problems of gender gap and setting are real, they are not insurmountable. Some thought given to this subject will be amply rewarded with improved personal comfort as well as patient satisfaction and compliance.

COMMON EMERGENCY SITUATIONS REQUIRING SENSITIVE COMMUNICATION SKILLS

The ED provider will inevitably encounter situations in which sensitive commu­nication skills are important. These situations include such events as fetal death, sexually transmitted diseases, domestic violence, rape, and potentially serious diseases (10,13,15,16). These issues are discussed herein. First, however, thought should be given to the more general aspects of provider-patient communication: process, content, and personality.

PROCESS ISSUES

Men and women communicate differently. Men tend to be more focused on fac­tual issues and tend to be action oriented. (What are the facts, and what needs to be done?) Women tend to focus more on emotional issues and work out solutions through dealing with the emotional aspects (2). Although these statements are generalizations and there is certainly a significant overlap in communication styles between the genders, the stereotypes are, nonetheless, well supported by research (1-6). To optimize communication with female patients, it may be helpful to consciously identify a communication style that is more emotionally oriented than one might embrace with male patients.

The process by which sensitive information is communicated is important and goes more smoothly if the physician considers some basic issues to be addressed (7,8,11-13,15,17-19). The first important issue to decide is who does the telling. Oftentimes in the ED, the physician does not have an ongoing relation­ship with the patient and, in fact, may have never seen her before. However, if sensitive information has to be communicated, it is usually better that it originally come from the physician rather than a nurse or a technician. This dem­onstrates respect for the patient, and for the seriousness of the situation, and bypasses the “I want to speak to the doctor” scenario. Many physicians con­sciously or unconsciously opt out of difficult or sensitive communication sce­narios because they may be time-consuming or because the providers recognize their own inadequacies as communicators. Ultimately, both the provider and the patient are better served by the provider’s making a deliberate effort to learn satisfactory communication skills than simply abdicating communication responsibilities.

It is also helpful, if possible, to have some support personnel in the room with the physician. One study indicates that team-based/family communication is preferable to physician-patient dyad communication (20).

After deciding who does the telling, attention needs to be paid to the setting (21). Standing in the middle of the hallway to inform a woman that she has a sexu­ally transmitted disease is not optimal. The preferred setting would be a room (not a curtained cubicle) that is not a high-traffic area and where there is a place to sit. The physician needs to be at eye level with the patient, preferably sitting. Eye contact is important when talking with a patient. (This is a skill that can be formally rehearsed to improve performance.) The physician also needs to com­municate to the staff that he or she needs uninterrupted time with the patient or family. Attempting to discuss sensitive information while being interrupted by staff or by a pager going off may increase the patient’s anxiety, as well as inspire anger. Uninterrupted time in an appropriate setting is more likely to transmit a sense of care and concern on the part of the physician (22,23). The physician also needs to be conscious of his or her own communication style, including such issues as speed of delivery. Speaking at a slower speed and in a lower tone helps to reduce anxiety. Even though the physician may be feeling enormous pressure to complete the conversation and move on to other tasks, very little time is lost by techniques such as sitting down, pacing the delivery of news, and maintaining appropriate tone and speed of speech. Indeed, time may be saved if patients comprehend information more clearly on the first transmission.

Timing is also important. There is never a good time to present bad news. However, there are bad times to present bad news, such as when the patient or family members have been up all night with no sleep and are fatigued or when a large family group has just arrived and emotions are intense. One cannot always wait for the optimal time, but it is important that this issue be considered. Less urgent tasks such as acquiring consent for autopsy may be deferred until the family has had a chance to recover from the initial emotional blow.

Providing the patient with an opportunity for follow-up questions and clar­ification of issues is also important. If the physician cannot provide this oppor­tunity, it is imperative that the patient or family members have contact with someone who can answer their questions. This allows closure to the current event and allows the patient or family members to know that someone will be there to help when they have dealt with some of the emotional issues of the situation. Many support groups exist to provide patients with information and assistance beyond what the ED can provide. Contact information for national

National Agency Support Services

agencies are listed in Table 30.1.

CONTENT ISSUES

Content issues might seem more straightforward than process issues, but they may, in fact, be equally difficult when communicating sensitive news. It is impor­tant to use terminology that the patient can understand. The patient receiving unwanted news may hear only a small portion of what is being said and may not understand the implications of certain medical terms (15,24). There is also a ten­dency for patients to nod as though in understanding, thus leading the provider to believe that communication has been successful. The words used by the pro­vider need to be simple and basic to increase the understanding. Do not give too much information too soon. If the patient or family members do not appear to be comprehending the situation, back up, break it down to even smaller portions, and tell it again. The physician may need to repeat the same news a number of times or in several different ways. Open-ended questions (“What do you know about herpes?”) are time-consuming but can provide great insight into what information needs repeating or reframing.

The literature indicates that one of the most important issues in receiving unwanted news is that the physician be honest and direct. More times than not, the patient or family members have some idea that there is a potential for bad news and they need to begin to deal with it on an emotional level. It is important to give hope but not false hope (23,25). Sometimes physicians can be vague when communicating sensitive news. This may be due to their own discomfort and is generally not what the patient wants or needs. One way to compromise between withholding information and overwhelming the patient is to let her guide the conversation by asking her questions such as “What would you like to be told about this problem?” or “Do you have concerns about how this might affect you?” (26).

Many physicians are uncomfortable with their own emotions (7,17,24,27-29). When discussing a sensitive medical issue with a patient or family, the physician often attempts to remain emotionally detached. A number of studies indicate that patients and families are more comforted by a physician who demonstrates some emotion. This allows the family members to feel that the physician is engaged in their situation and cares about them. Even having the physician express sorrow can be very helpful to the patient or family, and it may move the statement “We did everything we could” from the realm of defensiveness to one of shared loss and frustration. The physician’s showing emotion is not seen as a sign of weakness by the patient or family.

Some physicians are very uncomfortable when the patient or family mem­bers have intense emotions. They may attempt either to squelch the expression of the emotions or to remove themselves from the emotional environment. But it is important to allow the patient or family members to express themselves. Becom­ing comfortable with the emotions of others takes practice but allows providers a much broader scope of healing than would otherwise be possible.

The most important skill that a physician can acquire in dealing with sensi­tive news is the ability to listen. By listening, the physician communicates respect, caring, and empathy. In addition, it provides the physician with direc­tion as to where the conversation needs to go. Most people complain more about not being listened to than any other facet of their medical care.

Personality issues

All individuals involved in a communication situation bring aspects of their personalities to the interaction. Physicians need to be aware of their own person­ality type, as well as the type of personality they are dealing with, when commu­nicating sensitive information. The physician, like any other person, has a way of looking at things such as death, the role of the doctor in the treatment process, and appropriate ways of expressing and coping with intense emotion (30). The physician’s perspective affects the communication interaction (7). For example, a physician who believes that he or she represents health and wellness may feel a sense of failure when communicating serious illness or death. For a physician who believes that he or she is a facilitator working with the patient to obtain optimal health, the view of illness or death may differ.

In addition to physicians being aware of their own personality issues and belief systems, it is important to understand that each patient’s personality affects communication. Not all women express their emotions in the same manner, and if a physician waits until the patient expresses her emotion in the manner that is expected, there may be discomfort and misunderstanding for all parties involved. Some patients are prone to anxiety, which may be expressed in several ways such as crying, anger, and pacing. Although it is not possible for an ED provider to know patients the way a primary care provider does, some attempts to identify the patient’s personality type and needs will be rewarded with greatly enhanced communication patterns.

Another factor that needs to be considered is the patient’s social/cultural environment. Having some information about what is going on in the patient’s life may facilitate the communication that will take place. For example, if a woman has been attempting to have children for several years and has experi­enced a fetal death, her reaction may be much different from that of a woman who was not aware of being pregnant and has experienced a spontaneous abortion. If a woman is going through a conflictual divorce, her reaction to any bad news may be compounded by her already fragile emotional state. The level of support that an individual receives from other sources such as family, clergy, and friends will also greatly impact her ability to receive sensitive communication. Even though the ED physician cannot know all these things, it is helpful simply to remember that there is a social/cultural context affecting the transmission and interpretation of information (25).

Furthermore, patients may have mental health issues in addition to their presenting complaints, and the mental health issues can sometimes overshadow the physical ones. Two categories of mental illness are of particular concern to the ED physician caring for women. The first is schizophrenia. Patients with this diagnosis often have difficulty establishing ongoing relationships and thus may receive most or all of their health care in the emergency setting. These patients’ noncompliance with prescribed care regimens and their disordered and often disruptive thought processes can be extremely frustrating. Obviously, every effort should be made to establish a connection with a mental health profes­sional. It may also be of some help to have the consultant to whom the patient will be referred for ongoing care of the problem actually come to the ED and begin establishing a relationship with the patient. This may make it easier for her to muster the trust necessary to continue her care regimen in a conventional fashion.

The second mental health disorder of particular significance to women’s caregivers is borderline personality disorder. This Axis II disorder is three times more common in women than in men (31) and often goes undiagnosed. It is not amenable to treatment, but the highly disruptive effects of a borderline “acting out” can be contained if the provider is alert to the possibility of the diagnosis. Women with borderline personality disorder are extremely seductive, although this may not be enacted as sexual behavior. They may be victims, ceaseless care­givers, lost newcomers, or any other role calculated to win sympathy and special treatment. They are often excessively flattering regarding their current care situ­ation, while being vituperative in their denunciation of the previous caregiver who somehow failed them. Underlying all actions of patients with borderline personality disorder is the insatiable need for attention. Even though initially interactions may be gratifying to providers who are being told that they are mar­velous, borderline patients inevitably become disillusioned when interactions fail to escalate to what their fantasies lead them to expect. At this point, they may become angry, vengeful, and abusive. And at this stage, the special efforts that physicians may have exerted on these patients’ behalf will inevitably be used against them.

The point of mentioning borderline personality disorder is not to discour­age genuine care on the part of ED providers. Certainly, there are patients with extraordinary problems worthy of extraordinary care measures. Providers should be alert, however, to patients dressed seductively, those who describe out­rageously inappropriate behavior on the part of previous caregivers, or those who actively campaign to elicit sympathy. Providers are particularly cautioned to pay attention to their own interaction style and how that may change from patient to patient. If one finds oneself taking extraordinary measures on behalf of a patient whose needs at face value do not merit such effort, it is best to disen­gage quickly. Such a patient is best managed by a team approach with the active involvement of a mental health professional, and the physician should never allow the patient to manipulate him or her into being alone w ith the patient for any portion of a physical examination. Once a borderline patient has been identified, it is best to have chaperonage even for interviews to help contain inappropriate self-disclosures or solicitations.

Unfortunately, the seductive behavior patterns of borderline patients, along with their explosive interaction patterns, tend to make them frequent victims of rape, domestic violence, and battery. Awareness of the patient’s underlying personality disorder in no way lessens the tragic nature of these situations or diminishes the need for provider concern and compassionate care. It is vital, however, that providers protect their own interests as well as those of the patient.

SKILLS FOR SPECIFIC SITUATIONS

Fetal Death

Emotional response to a fetal death may be influenced by several factors. Gesta­tional age of the fetus is highly likely to play a role. Generally, the more advanced the pregnancy, the more intense the grief reaction. This is true not only because of the expectancy of a live birth but also because of the amount of planning the mother and family have done to welcome a new baby. The more preparation that has been made, the more difficult it is to move on emotionally. Life experiences of the parents may also play a part. Young parents who have experienced very little grief in their lives are likely to respond with greater difficulty to a fetal death than older parents who have had other grief experiences. On the other hand, a woman who has undergone an extensive infertility workup to become pregnant is more apt to experience an intense grief response than a woman whose preg­nancy was unintended. Social support is important in helping a mother deal with a fetal loss. Women who have a high degree of social support are more likely to be able to handle the situation better than women who are socially isolated.

The most difficult area to evaluate with regard to grief experience is the importance of the pregnancy to the mother. The issue of planned versus unplanned pregnancy may have an effect on the emotional response. If the preg­nancy was unplanned and consideration was given to terminating the preg­nancy, feelings of intense guilt may result. Even if the mother felt somewhat ambivalent toward the baby, guilt may result. If the pregnancy was planned and anticipated, the emotional response to the loss is likely to be significant. Each woman is different, and her grief will be acknowledged, felt, and expressed in a unique way. Providers should be aware that a broad spectrum of emotional responses may occur and that many full-blown grief reactions occur after the patient is sent home from the ED. Every effort should be made to ensure both adequate medical follow-up and availability of appropriate emotional support. Most communities have fetal loss support groups, and every patient should be given this information for possible further reference.

Sexually Transmitted Disease

Communicating the presence of a sexually transmitted disease should be straightforward and matter-of-fact, without expression ofjudgment. Most patients accept this information without significant emotional reaction, particularly in an urban medical environment. However, for some patients, notification of a sexu­ally transmitted disease such as herpes is devastating. All patients should be approached with the consideration that they may have an intense emotional reac­tion to the news. Additionally, there has been a dramatic increase in the diagnosis of pelvic inflammatory disease (PID) (10). Women with PID are often not told that it is the consequence of an untreated sexually transmitted disease. This leads to social embarrassment as well as a high likelihood of reinfection if sexual partners or behaviors are not modified. Because of its social and medical consequences, the diagnosis should not be made without careful consideration of a differential diagnosis, and the patient should be informed of the etiology of PID, so that she can make informed decisions regarding her lifestyle habits.

Domestic Violence

Domestic violence is more prevalent than many would like to acknowledge. The most likely medical arena in which domestic violence will be discovered is the ED. It is very important when discussing the possibility of domestic violence with a woman that the spouse or partner not be in the room. Most victims of domestic violence are unlikely to acknowledge the problem without some probing. One of the barriers to communication between a physician and a victim of domestic vio­lence is the failure of the physician to ask directly about possible abuse (32). Addi­tionally, providing messages to patients that they are worth caring about has been found to be an intervention that is effective in overcoming barriers to women receiv­ing much-needed help (33). This is a situation in which the ability to communicate sensitively is very important.

One of the convenient ways many providers find to have a private conversa­tion with a woman is to establish a standing policy that there will be no family members present in the examination room when a pelvic examination is being conducted on an adult. This allows for an opportunity to talk with the woman without making her partner suspicious. If the partner is reluctant to leave the room, this may be a warning sign.

Questions regarding abuse should be frank and explicit. Many abused women do not consider being slapped or punched by a partner to be abnormal, so specific questions should be asked about the etiology of injuries. Many women also collude to hide abuse, either because of fear of retaliation or because of a genuine desire not to see the partner harmed. If there is a high index of suspicion that domestic violence is occurring but the patient refuses to acknowledge it, information regarding shelters and victims services should be provided in such a way that the woman can secure it for future use. Consideration should be given to making this information available in the waiting room or in the women’s bath­rooms. Some women will use this information at a later date even if they are not prepared to do so at the time of presentation. Additionally, each state has spe­cific laws regarding suspicion or knowledge of domestic violence. All providers should be aware of the law in their state.

Rape

Rape or attempted rape is one of the most difficult situations that a woman may experience. The reaction is often far more severe than even that to aggravated assault, in part because rape threatens the deepest sense of self and personal control that most women possess. Research shows that about 12.4% of the esti­mated 12 million American women who have experienced a completed rape will develop chronic posttraumatic stress disorder (PTSD) (34). Upon the arrival of law enforcement officials, the patient is often drawn into what feels very much like a second assault: first, by having to repeat her story in detail and, then, by being subjected to the most meticulous and invasive medical examination imaginable. The ability to communicate with a rape victim in an empathic and sensitive manner is of vital importance in this situation.

In some cases, it is believed that litigation is absolutely not under consid­eration and the patient just wants a medical evaluation that is briefer and much easier on the patient and the staff. However, some patients subsequently change their minds and the best time to collect evidence is immediately after the assault, so if there is any potential for litigation, evidence should be col­lected immediately and following the standard protocol. The patient may be very poorly suited to make this decision immediately following an assault. It is the job of the provider, in this case, to be the patient’s advocate in assessing the opportunity for improving litigation outcome versus the immediate cost to the patient.

Careful communication with the victim is vital. As with any severe emotional trauma, patients who are victims of rape may not be able to hear or understand information or instructions. It is important that all information be presented often and in many different ways, so that the patient can absorb it. The patient should be informed of what is to happen next at each phase of the examination, and when­ever possible, she should be given choices about her examination and treatment. This begins to restore some sense of control for her. Particularly if the protocol involves plucking hair or scraping nails, the patient should be allowed to do this herself rather than have medical providers virtually reenact her assault. Psycho­motor retardation is common in sexual assault victims and can be maddening to busy providers, but the patient must be allowed to move at her own pace.

Law enforcement officials often have their own agendas regarding report­ing of sexual assault. They may push for access to the patient before she has been fully evaluated or before she is emotionally able to communicate with them. Again, the provider may need to serve as the patient’s advocate in controlling access to her.

Potentially Serious Diseases

Patients do not often receive first notification of a serious or life-threatening dis­ease in the ED. However, they do sometimes come to the ED shortly after receiv­ing the news. Kubler-Ross, in her book On Death and Dying (35), discusses the five stages of grief (anger, denial, depression, bargaining, and acceptance) and notes that patients may move often and at varying speeds back and forth through each of these. It is expected that patients given the news that they have a serious dis­ease will begin to traverse these stages almost immediately. The ED physician is unlikely to know where a particular patient is in her grief process. It is therefore in the best interest of the patient and the provider to consider consulting the treating physician early in the patient’s ED assessment, regardless of her presenting complaint.

If the ED physician is the first person to share the news of a serious or life­threatening disease, the following process should be considered. Never lie. Acknowledge that a limited knowledge base about the problem exists and provide enough information to get the patient to the next level of care. It is impor­tant for the ED physician not to overstep his or her knowledge base, although the patient or family may press for such information. For example, if a patient says she has been told that she has pancreatic cancer, she should not be told that she has only 6 months to live. The information may or may not be true and will not be helpful regardless. As much optimism should be expressed as the situation will allow, along with the repeated emphasis that prompt treatment by the best qual­ified specialist is vital to the patient’s emotional as well as physical well-being. If possible, the patient should be associated with the next level of care before leav­ing the ED. This connection is potentially the most important thing that the ED physician can do for the patient.

Other Communication Issues

When a patient receives serious news, there is almost always some fol­low-up needed. If there is follow-up medical treatment, an appointment should be made before the physician ends the communication, if possible. If there has been a death, the patient or family will need to know what to do next. Many times, the patient or family is in emotional shock and can only understand the most basic of instructions. Some people have never dealt with death before and have no idea as to the process of dealing with funeral arrangements, hospice care, do-not-resuscitate orders, or other complex instructions. It should be the ethical commitment of the medical staff to ensure connection to someone who can direct the patient or family through whatever process is necessary. The worst thing that can happen to a patient is to feel that she has been abandoned.

Patients also benefit from having access to support opportunities (36). If a social worker is assigned to the ED, he or she should be involved as soon as possible. There are many groups that have been developed to help with specific traumatic situations. They include such organizations as support groups for those who have lost a spouse or a child, cancer support groups, and support for victims of domestic violence. These support groups also help the patient get answers to all her ques­tions regarding her situation. If possible, all ED personnel should have a laminated information card with basic information regarding available support services. The ED staff can then be prepared to make prompt, appropriate referrals.

Another aspect of communicating sensitive information is dealing with support persons and family members. Much of the literature regarding commu­nicating bad news revolves around how much should be told and to whom. When possible, ask the patient. She not only has the right to know what is going on with her health but also has the right to decide who else has access to that informa­tion (37). Extended families may improve a patient’s support structure, but there is also a higher potential for conflict and chaos. A clear understanding of the patient’s desires can allow safety in the minefield of such conflicts. On the other hand, the litigation fears inherent in modern medicine often inhibit warm com­munication with needy family members. The physician is well advised to temper confidentiality concerns with good judgment in deciding who is informed of dif­ficult news. If the patient has no support system, the physician may do well to inquire if he or she can contact the hospital social worker or a member of the clergy to be involved in the situation.

SUMMARY

The ED is a particularly difficult environment for learning or maintaining good communication skills. It is also, however, a place where those skills are most highly valued. Attention to the more global aspects of patient care is essential to ensure compliance, continuity, and patient satisfaction. The skills necessary may not be intuitive, and almost certainly were not taught or emphasized in medical school, but can be learned if they are valued by the caregiver. Many sources are available from which to learn these skills, including textbooks, references cited here, and good mentoring from a clinician respected for his or her ability to com­municate. Such effort will be amply rewarded by generally shorter, less conflictual patient interactions and by better patient compliance with prescribed therapy. Resources are available for patient support and should be liberally used.

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