Note on using this video
We try to make each video as authentic as possible, clearly it is not possible to fully depict real life. We aim to design the videos so as to demonstrate plenty of communication skills. You might feel that some points over-emphasised or rather repetitive. Be assured that in real life situations, you will be able to improvise how and when you use these skills, and you’ll be able to personalise them to the individual patient or family member you are meeting with.
Some people want a lot of detail about the Post Mortem Examination, others do not. In this scenario, the family member wanted detail about the processes. There are some pieces of information that should be included in every conversation. Not all of these are included in the sections of the conversation that we recorded. Animated slides detail additional vital points to be included in these conversations.
We did not film what Martin and nurse Christine talked about after Consultant Oncologist Rajnish left the room. However, we know that patients and their family members frequently find that after a sensitive and detailed conversation with a doctor, it can be very helpful to talk it through with a member of the nursing team.
In real life, very detailed information about Post Mortem Examinations might well be conveyed over the course of several shorter conversations. When you are having these kinds of conversations at work, you will make your own judgements about how much to say and when.
Supporting materials
Visit our webpage for supporting materials on good listening skills.
Click this link to download the Debrief in PDF format
Background
The scenario for the conversation sections in the video concerns an unexpected death in hospital, less than 24 hours after admission, and less than 24-hours after a procedure, where the Coroner has decided a Post Mortem Examination is necessary.
Martin McAdam’s mother had locally advanced Stage 3 lung cancer. Her radiation and chemotherapy had finished a month or so ago. She was admitted to the oncology ward feeling unwell. Investigations documented a large pleural effusion, and she had a chest drain inserted from which one litre of fluid was drained. Overnight she became pyrexial, was seen by the medical team, and started on antibiotics. At 08.00 she became acutely unwell, the arrest team were called, and sadly she died. We enter the scene after the conversation has begun, and introductions have been made. Besides Martin, the conversation involves Consultant Oncologist Dr Rajnish Gupta and Christine Smith, Oncology Nurse.
The content of the conversation is based on guidance in the HSE National Clinical Guidelines for Post Mortem Examination Services (2023) (lenus.ie)
Clips
There are three clips in this scenario.
FIRST CLIP
INITIATING THE CONVERSATION
00:13 – 01:11
In this clip... Rajnish thanks Martin for coming along and explains the reason for the meeting. He explains that because Martin’s mother’s death was unexpected, because she was admitted less than 24 hours before her death, and because she had undergone a procedure, the hospital was required to inform the Coroner. He tells Martin the Coroner decided a Post Mortem Examination (PME) is needed. Martin expresses surprise, given his mum was known to have cancer.
SECOND CLIP
SHARING INFORMATION
01:12 – 09:41
In this clip... Rajnish tells Martin where and when the PME will be done and by whom. He gives Martin a choice about how much information he would like regarding the processes during the PME itself. Rajnish provides information in chunks, given at a gentle, steady pace, and observing and responding to what Martin shows with both his talk and non-verbals. Both he and Christine convey empathy, and show their understanding that this is a lot to take in. The sections of conversation in this video are supplemented by animated slides about information that must always be given about the PME process.
THIRD CLIP
CLOSING THE CONVERSATION
09:42 – 10:59
In this clip Martin is given the detailed information booklet about PMEs. Rajnish mentions sources of support, gives Martin some contact numbers, and recommends the family seek practical and emotional support from the hospital’s Bereavement Liaison Nurse. Rajnish assures Martin that Christine will now sit with him and will accompany him to see his mother when he is ready. Rajnish expresses his condolences in a sincere manner.
Communication Skills
FIRST CLIP
INITIATING THE CONVERSATION
00:13 – 01:11
- Firstly, and differently to the recorded conversation sections here, it is recommended that you always refer to Post Mortem Examination, rather than just Post Mortem, (Note: Post Mortem is an adjective, it means after death. An autopsy is a Post Mortem Examination – PME).
- Rajnish begins by ‘telling the story’ of what has happened. ‘Telling the story up until now’ can help bring everyone in the conversation to the same place, and can be more gentle than absolutely immediately stating that the reason for the conversation is that a Post Mortem Examination is needed.
- Rajnish checks Martin’s understanding at points:
“I assume you knew she had the procedure?”. Questions like this can give the family member the opportunity to answer more than the question itself, and here Martin does so: “Yeah I knew, I thought the drain was going to help”. - Notice that Rajnish could have started talking again in the pause after Martin has said “Yeah I knew”. Because Rajnish does not come straight in, Martin can take this as an opportunity to say more, and he does. In some circumstances, leaving short periods of silence after a someone has answered a question gives the person space to say more should they wish to.
- Using clear concise language and a calm tone of voice, Rajnish explains that in cases of sudden death in hospital, the hospital team is required to contact the Coroner. Often, it is helpful to the relative to mention that this is legally required.
- Rajnish goes on to tell Martin that the Coroner’s opinion is that a PME is needed, whilst in our script, the word used is ‘warranted’, the words ‘needed’ or ‘necessary’ may be easier for the family member to follow. Martin is clearly shocked, Rajnish and Christine keep their gaze on him, and stay quiet, giving him time to react to this news. They leave time and opportunity for Martin to speak, and he does so “Why would they do that? Surely they knew that Mum had her cancer?”.
- Leaving space for the other person to talk whilst staying attentive to them is important in sensitive and information-heavy conversations. If the person does add further talk, this gives you more information on their perspective and emotional state. You might find it difficult to leave space like this: in information-heavy conversations, staff can often feel the urge to focus on the information that they need to deliver, and to focus less upon the perspective and state of the person they are talking to. But, there are good reasons for pacing, leaving space, and carefully fitting what you say to how the person is responding.
SECOND CLIP
SHARING INFORMATION
01:12 – 09:41
- After confirming that the Coroner did know about Martin’s mother’s cancer, Rajnish tells him more about why a PME is required.
- One of the challenges Rajnish faces here is to explain to Martin that one reason for the PME is that the Coroner “needs to know if there was something related to the procedure that may have contributed to the death.” It is important to explain this, but it is also a challenge. This is because the family member, understandably, might take this as meaning a medical error has definitely occurred.
- Several aspects of Rajnish’s communication work to reduce this misinterpretation. First, he explains PMEs are conducted after any death shortly after a procedure. This supports an understanding that this is – although a rare occurrence – a routine matter. Then he explains to Martin that he has looked at his mother’s medical notes and noted there had been no difficulties in the procedure, and that it had been effective in removing fluid and reducing his mother’s breathlessness. Thirdly, Rajnish’s tone is calm and steadily paced, he does not come over as flustered nor as if he is trying to avoid this sensitive matter.
- [2.31] again, Martin is given space to give his perspective. He confirms that his mother had seemed better after drainage of the effusion, then goes on to explain why her death feels such a shock.
- Rajnish offers condolences in a sincere tone, Christine notices Martin becoming tearful and offers him a tissue. He is given time to calm a little before the next part of the conversation. The task of giving detailed reasons for and information about PME is a challenging one. Having an additional member of staff present, as here, has advantages that include being part of the emotional support available.
- [3.05] Rajnish signposts what he needs to tell him about the PME. He then explains that in terms of the actual procedures, he can give a lot of information or “I can just give you the important points.”. Martin is given time to consider, and says “Actually, I would like to know what’s going to happen.”
- [03.34] An animated slide explains the following, an essential part of these conversations not included in our video-recorded conversation...
Before the PME, a family member must identify their deceased relative’s identity to a member of An Garda Síochána.
To ease the family member’s anxiety, it is important to explain that this is a routine part of the Coroner’s investigation. This could be worded something like: ‘Something we need to tell people in your situation is that you will need to formally identify your Mum to a member of An Garda Síochána. This can feel alarming, but I want to assure you that it’s a routine part of the process’. - [03.48] Rajnish signposts for Martin what information he will give and in what order. In conversations that are information-heavy and where the person is in stressful circumstances, it can be helpful to: ‘Tell them what you are going to tell them, tell them, then tell them what you have told them’.
- In the video, Martin is told he can stay on the ward with his mother as long as he wishes. Rajnish could alternatively say something like ‘for a while’, in case the PME needs to commence soon.
- Rajnish chunks up information: where the PME will happen, who will perform it and when. He emphasises the rules and regulations that govern PME procedures, and that PMEs are done with full care and respect for the deceased.
- Moving to details of the actual procedure, Rajnish explains the pathologist will look at the outside and the inside of Martin’s mother’s body. When talking of samples, whereas our video script is: “they often take samples”, a more accurate wording would be to say that ‘they always take small samples of tissue to examine under the microscope, and they may take samples of fluids too’.
- [05.21] Rajnish now introduces a topic that must be covered in these conversations: possible retention of organs for further specialist examination.
- Rajnish and Christine are monitoring Martin’s nonverbal communication, Christine offers reassuring touch, and Rajnish paces what he says slowly.
- He moves in a stepwise manner towards two important and sensitive matters: first, that if organs are retained, this means beyond the person’s funeral date, and second, what happens to retained organs after completion of specialist examinations. Stepwise movement towards the most sensitive aspects of a topic can help steer the conversation towards the most sensitive matters whilst making it less likely that the person on the receiving end experiences sudden, severe shock or distress.
- [05.41] An animated slide explains part of the organ retention procedures not included in the video-recorded conversation: that the family must be informed immediately if an organ has been retained. A consent form must be completed by them as soon as manageable after the PME to indicate their wishes for management* of the organ. They may also be given an option of waiting until examination of the organ is completed before making this decision. In this case, they will be contacted by the designated healthcare worker from the hospital once the organ examination is finished (usually 8-12 weeks). *Note: Simply put, ‘management’ means whether the organ will be buried or cremated, and whether the hospital or the family organise this.
- With “it is a lot to take in Martin”, Rajnish conveys his understanding and builds rapport.
- Rajnish now explains the role of the undertaker. Perhaps rather than saying “they are very familiar with the whole process” as is scripted in our scenario, a more accurate alternative would be to say they will have ‘some familiarity’. Rajnish goes on to say that the family’s undertaker will communicate with mortuary staff, and help the family make funeral arrangements.
- [07.38] Rajnish explains that finalising the written report of the PME can take months. He raises the possibility of an inquest, explaining what this means. He also offers to go through the report with the family when the Coroner is ready to release it. The information is delivered at a steady pace, and in chunks.
- [08.26] acknowledging again what a lot of ground has been covered, Rajnish asks Martin “Is there anything you would like me to go through again?”. Martin responds “I think I’ve followed a lot of it but [if] you wouldn’t mind just going over the main points, just in case I missed something”. Checking a person’s understanding and their retention of information is quite a tricky part of this kind of conversation for at least two reasons. First, people might not recognise what they have not followed or retained. Second, people (all of us!) don’t always feel comfortable admitting that we might have missed something. In our scripted scenario, Martin manages to articulate a request for the key points to be gone over again. There are alternatives that can be helpful. In particular, rather than asking the other person if they would like the key points summarised (which may seem like putting the burden on them), you could just go ahead and do so after giving a reason - something like: ‘I’ve covered a lot of ground, so I’ll just go over the key points again’. You could also use phrases that rule out the implication that the person might have failed to understand or listen, and that instead emphasises your role: something like ‘Just in case there were things I didn’t make clear enough’.
- Another communication skills point to make from this part of the scenario is about the recommendation that we ask patients and relatives questions like: ‘is there anything you would like to…?’ and ‘do you have any questions?’. We now know from research that avoiding the word ‘any’ can work better for encouraging someone to come up with points or questions. Alternatives include ‘some things’.
This is because using the word ‘any’ can encourage a negative response. (Notice how we can use ‘any’ for the negative: ‘I don’t have any pain’, but not for the positive: ‘I have any pain’). - Besides the key points Rajnish summarises in the scripted conversation section, other points that must be included are a reminder that before the PME, a family member will need to identify their deceased relative’s body in the presence of a member of An Garda Síochána and that this is a normal and routine part of the of the Coroner’s investigation. Another point that must be included is to emphasise that the deceased relative’s body, any parts of their body, even the smallest part of tissue will be treated with dignity and respect. And you can explain that if organs are retained for specialist examination, the family will need to decide and sign an authorisation and consent form which documents whether the organ(s) will be buried or cremated, and whether the hospital or the family (via their undertaker) will arrange this.
- A booklet and contact details of support organisations are given to Martin, he is encouraged to use the emotional and practical support of the bereavement liaison/link person.
THIRD CLIP
CLOSING THE CONVERSATION
09:42 – 10:59
- A common way of suggesting that a conversation might be coming to its end is to talk about what happens next. Rajnish does so by handing over the booklet, and saying that Christine will sit with Martin, and then accompany him to see his mother when he is ready.
- Rajnish ends the conversation by offering his condolences.