Death on the table
Anaesthesia 1989; 44: 245-8.
A. K. Bacon
Summary
This describes one way to handle the aftermath of anaesthetic catastrophe. The techniques of how to share bad news, interview
relatives, complete official forms, deal with the legal process and debrief colleagues are outlined. It is hoped that this article will
promote discussion on this topic and improve communication with all those affected by mishaps in the operating suite.
Commentary
Reading this article published in 1989 has been interesting for
both of us. One (DC) had just started primary school and the other
(NR) had been a consultant for two years when it was published. It
was one of those articles I (NR) put in my file of things I might need
to know about. In the days before internet and mobile phones,
most of us had a stash of such reference documents.
Medical students and trainees have much more training in communication skills, including breaking bad news, but how much of this relates to the unexpected death of a loved one?
Much has changed, but the principles of how we manage
catastrophic events remain the same. Dr Bacon’s humanity and
understanding of how we react to a tragic situation still stands
out, even if some of the language used seems of a different
time. He discusses every aspect: sharing bad news with relatives;
completing official forms; dealing with legal process; and
debriefing colleagues. He recognises that the anaesthetist will
feel numb or shattered, and some colleagues are helpful whereas
others keep away ‘as if we can avoid contamination with whatever it
is that person has done’.
He identifies a still-current gap in the curriculum; despite the
inevitability of a peri-operative death at some point in our careers,
he comments that we aren’t taught how to handle these, seeing
this as ‘one of the great taboos of modern anaesthesia literature’.
Is that true now? Medical students and trainees have much more
training in communication skills, including breaking bad news, but
how much of this relates to the unexpected death of a loved one?
His comment that ‘Sometimes none of the medical team feel able
to telephone the next of kin’ remains true, but we may be less likely
to ‘leave it to a nurse to break the news’. Nowadays the GMC make
clear our responsibility to keep people informed, codified in the
duty of candour.
How would we write this paragraph now? Possibly we’d suggest rehearsing the conversation with the team.
The approach is more didactic, telling us: ‘never to impart bad
news over the telephone’ and ‘under no circumstances’ to ‘allow
the surgeon to talk to the relatives by himself’, but ‘deliver the bad
news as a team: surgeon, anaesthetist, nursing staff and other
professionals’ (such as the chaplain - nowadays perhaps the
bereavement officer); get straight to the point; offer sympathy
(empathy nowadays); and give a brief explanation of events.
How would we write this paragraph now? Possibly we’d suggest
rehearsing the conversation with the team. Patients and relatives
may be more likely to be direct with us, ask questions and expect
direct answers. Would we emphasise ‘the heroic efforts made by
the team’? Probably not.
A whole paragraph is devoted to the setting for the conversation,
a room similar in size to a living room with carpets and chairs,
and away from phone interruptions, not one ‘that might have
been a broom cupboard’. The idea that this might be found in an
administrative area of the hospital is interesting. Would we have
such a room available nowadays? The comment that ‘throughout
this article ‘he’ and ‘him’ are used indiscriminately; accidents are
not confined to one sex’ amused us - no journal would print that
now.
For staff, he recommends a short meeting immediately after the
event, and a structured debriefing two or three days later, possibly
using Mitchell’s model. He reminds us that some of us will need
help and we should know how to get this, pointing out the tragedy
of a colleague’s suicide. Dr Bacon’s conclusion still rings true that
‘Each one of us needs to develop an awareness of the vulnerability
of our colleagues’.
Deirdre Conway
Consultant Anaesthetist, Edinburgh Royal Infirmary
Nancy Redfern
Consultant Anaesthetist, Newcastle Hospitals Trust
Tom Boulton, mentioned by Andrew Bacon on page 16, was
Editor-in-Chief of
Anaesthesia from 1973 - 82 and President
of the Association from 1984 - 86. The cover photograph is
Tom Boulton's own copy of the first issue of the journal.
Read his obituary.