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Breaking Bad News
How do doctors learn to deal with the most difficult situations in medicine?

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Gunnery Sergeant Jeffery Hankins knows how tough it is to deliver bad news. A 24-year veteran of the Marine Corps, he has spent the past half decade as a casualty calls officer, assigned to tell the families of Marines killed in action that their loved one has died. He also attends their funerals.

He personally has participated in more than 200 military funerals. He and his fellow casualty officers’ philosophy is that “this is the last thing we will ever do for that Marine or their family, so we do it as if it were our next of kin.”

Last summer, Hankins, 40, found himself on the receiving end of bad news. In a recent e-mail to Edward Miller, dean and CEO of Hopkins Medicine, he praised the compassion and sensitivity with which Hopkins oncologist B. Douglas Smith told him and his wife, Jena, 27, that she had only days left to live.

Jena, the mother of Hankins’ young son and daughter, was diagnosed with leukemia in September 2006. Chemotherapy and a bone marrow transplant at a Michigan hospital near his base led to a temporary remission. When her cancer returned last year, they came to Hopkins for additional treatment. It didn’t work.

In his e-mail to Miller, Hankins marveled at the “courage and good graces” that Smith had “to look us both in the eye and tell us that he was going to cease treatment.

“I could see in his face that this disease had painted him into a corner. His candor, integrity and friendship were and do remain invaluable to me.”

 Two days later, as Hankins held her in his arms, Jena died in her sleep.

“I can’t fathom how Dr. Smith and his colleagues must feel to have hope initially and then lose a patient despite their best efforts,” Hankins wrote. “If only people realize that it’s not the building that makes the hospital. It’s the people who work in it.”

Smith says it is difficult to explain how he summons the strength to deliver grim messages to patients such as Jena Hankins, but he believes it is an essential part of a physician’s role. “I think it’s very important for patients to understand their clinical picture,” he says. “They can make important decisions for their families, for their futures. It gives them an opportunity to reconnect in a meaningful way.”

Traditionally, young physicians did not receive much—if any—instruction in these sensitive matters, Smith says, but “there is more emphasis in current training on the importance of such conversations. Each physician develops his own style for doing it.”

For the past 13 years, the Department of Pediatrics has used a pioneering program to provide more than 300 second-year residents with emotionally draining but enormously valuable experiences that help them develop these skills. They meet with “standardized patients”—professional actors who portray the parents of children who have died. The young physicians learn how to deliver bad news and deal with parents’ anguished responses.

The program, funded by the Cameron Kravitt Foundation in Illinois, was designed by Janet Serwint, professor of pediatrics, after the foundation’s founders, Jason Kravitt and his wife, Beverly, proposed its creation. The Kravitts’ foundation is named for their son, who died at birth in 1982—a searing experience made worse by the insensitivity of staff at the Chicago hospital where their baby died.

“We were appalled at the treatment that we received when Cameron died,” says Jason Kravitt, a prominent Chicago and New York attorney who received his B.A. at Hopkins in 1969. “Beverly and I believed that the best way to help other people with similar experiences was not just to create support groups, but also to train doctors to be sensitive.

“The best way to do that was to start training programs at the most influential hospitals, and Hopkins was the most influential hospital.”

Begun in 1995, the Kravitt Foundation’s pediatric resident training program conducts its once-a-year, day-long sessions each January.

The morning sessions involve two detailed scenarios Serwint devised. In one, a child is found at home without a pulse, a suspected victim of sudden infant death syndrome (SIDS), and rushed to the emergency room. In another scenario, the resident must tell the parents that their child has succumbed to heart problems complicated by a viral infection.

In afternoon sessions, the residents and faculty discuss such issues as organ donation and the importance of spirituality to the parents. Actual parents who have had a child die often attend and participate in panel discussions about their experiences. Jason Kravitt has attended every session for the past 13 years.

“I can give the residents helpful, real advice on what they do well and how to improve, says Kravitt, who now has a grown son and daughter. “The whole day seems less theoretical when someone who has been through such a tragedy participates with the residents.”

Neva Krauss, a 42-year-old, self-described “method” actress who’s been acting since she was 11, has portrayed a shocked and grieving mother for at least six years. “I cry a lot. The resident has to deal with my grief and my husband’s anger at the news,” then counsel them.

This year, Krauss and fellow standardized patient Tom Fox portrayed the parents of a 15-month-old baby daughter who died of heart failure, repeating the scene with four of the 24 residents. Each session took between 20 and 25 minutes of intense interaction. Kristin Arcara was one of the residents who interacted with Krauss.

“I was the second person from my group to participate in this scenario, so I basically knew what was coming next,” says Arcara, “but once I got started, the actors changed their reactions so I just got caught up in it. The interaction felt really lifelike.”
Having a day devoted to death and bereavement, free of clinical responsibilities, permits residents to revisit some of the difficult mortality issues they must address, Aracara says. “I don’t think giving bad news will ever be easy, but I think the way we deliver it will be more effective the more experience we have.”

According to Hankins, the Marine casualty officers also receive training in how to provide the empathy that is so essential to handling the difficult duty of delivering bad news. In his e-mail to Miller, Hankins wrote: “It is said that good can prevail over bad if good is well organized. The physicians at Johns Hopkins are as well organized as one will find.”

—Reported by Neil A. Grauer



Johns Hopkins Medicine

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