How does one speak the unspeakable?

“Where is she?” he asked. He tells me it is their twenty-fifth wedding anniversary and that they were celebrating with a motorcycle ride to a favorite lake. But, now she is not with him in the Emergency Department and he needs to know where she is. I explain that we are reaching out to emergency responders for information. At his request, we pray together for her.

This is not the way life is supposed to be, I think. The EMTs say that a deer jumped in front of their motorcycle. The passenger died at the scene while the driver briefly lost consciousness before being airlifted to our hospital. While hurting with road rash and a broken hip, he is now fully alert and distressed. He asks person after person about his wife. No one wants to tell him that she has died. What to do? What to say?

Just outside the room, away from the patient’s hearing, I caucus with the patient’s ED doctor and several other team members to strategize. Certain questions are now key: are we absolutely positive that the woman pronounced dead at the scene was actually this man’s wife, that her identity is certain? (I remember another time when an injured motorcyclist’s passenger was his girlfriend, not his wife). And, is he physically stable enough to hear such difficult news? Together with first responders, our hospital team has confirmed identities and relationships, and the doctor says that the patient is now out of danger of dying. He looks at me, shakes his head and says, “I can’t do this. Will you tell him?”

Being a chaplain means that we are often confronted by the challenge of delivering difficult news or helping to facilitate conversations about end-of-life issues alongside doctors, nurses and other healthcare professionals. Our training is to work collaboratively with others in the context of people’s grief in all of its stages. Our calling at such times is to bring compassion and honesty both to the bedside and to caregivers who often hurt alongside patients and their families.

Over time, I’ve come to understand that one cannot and should not rely upon a script to ease suffering. Yet, certain ways of approaching are better than others. Paramount to this process is the PAUSE. Here are some suggestions for supporting patients, their families and staff while addressing difficult circumstances:

Giving Bad News – Seven Empathic Pauses*

Physicians are usually the first persons to deliver bad news. And often it is a repetitive process that involves a whole team. Whoever the bad-news-bearer is, it is not an easy task. Never should the process be treated lightly, and ideally, it should not be rushed.

Often the bad news must be phrased and then rephrased, again and again. Professional chaplains assist doctors and staff with this process.

When presenting difficult news to patients and family members, it is important to think ahead not only about what will be said, but how to say it. Here are some basic guidelines for speaking “hard truths”:

1. Pause to strategize with the care team. Before approaching the patient and family, take time to ensure that someone will be alongside to support during and after bad news is delivered.
2. Pause with the patient and family to identify what is understood and what isn’t. For example, “What is your understanding of what is happening?” Listen carefully for indicators of poor comprehension and/or underlying fears that may be impeding an ability to fully hear what is actually happening.
3. Pause, then empathically caution the patient and/or family that they will now hear something that is upsetting. For example, “I am sorry that I must tell you something that will be difficult to hear.”
4. Pause again so that the patient and/or family can compose their emotions and prepare themselves for what they are now about to hear. And then, deliver the news with short, simple sentences. For example, “Your mother’s heart is very tired and weak; it is struggling ... the poor blood-flow is now affecting other parts of her body. Her kidneys and lungs are shutting down...She is dying.”
5. Pause to allow time for each person to take in and start processing the bad news.
6. Pause to allow time for persons to verbalize their questions and fears. Then, answer them compassionately and honestly. If there are no clear answers, say so clearly.
7. Pause to acknowledge emotions and to assure non-abandonment: “This is a hard time. No matter what lies ahead, I want you to know that I am here to walk alongside you, to support you in whatever way feels right for you. If I am not here, one of my colleagues will be available...” Utilizing and affirming a team approach is more helpful than making promises that we might not be able to keep.

In these encounters two values are essential: honesty and kindness. When we are with persons traumatized by bad news or hard choices, we join with them in a journey. The reality may be so horrific that it exceeds our imaginations. Yet, we must speak honestly: “Your son was killed this morning,” “You have Stage 4 terminal cancer,” “We’ve exhausted all treatment options,” “You are dying.” When death is imminent or has just happened, it is no time for sugar-coating truth. Saccharine euphemisms can contribute to avoidance rather than acceptance of reality, and may mask kindness rather than reveal it.

Thus, before we speak, God calls us to listen inwardly, seeking the Abiding Source of healing and hope. We let the Sacred One’s empathy rise from our hearts to our eyes, ears, and lips and face. Listening, seeing, speaking and emoting, we convey hope. We move forward in incremental baby steps alongside care recipients, allowing the ultimate outcome to reveal itself without anyone or anything being rushed.

The motorcyclist looked up as I re-entered his space, followed by the doctor and several other team members. They circled his bed, one reaching out to hold his left hand as I gripped his other hand. Collectively we paused, then I spoke, telling him that his wife did not survive the accident. His tears flowed freely. Mine too. He then squeezed my hand, hard, and said, “Thank you for telling me. I know that wasn’t easy for you. But, thank you!”

He then asked that I lead us all in a prayer of gratitude for the wife who had blessed his life for twenty-five years. In that moment I glimpsed the silver of his Silver Anniversary.

* The Seven Pauses are excerpted from Becraft’s book, "A Bamboo Grove for the Soul: A Storybook of Spiritual Resources for Caregivers," which is now considered required reading for Crisis Ministry students at Walla Walla University and in other training programs. The book serves as a bridge-builder among healthcare professionals, educating regarding the principles and practices of spiritual care while sharing practical approaches to self-care. Becraft is a semi-retired Board Certified Chaplain, educator, missionary and pastor who has published numerous articles in both English and Japanese during a 45 year ministerial journey.

"I laughed and cried from cover to cover." - an emergency department nurse

Click on the following link to obtain your copy: "A Bamboo Grove for the Soul: A Storybook of Spiritual Resources for Caregivers"