Mastering Difficult Family Conversations in Surgical Care
“MnSERC - Mastering the Art of Difficult Family Conversations in Surgical Critical Care” is an online self-directed tutorial on end-of-life and error disclosure communications.
This is a research-based curriculum covering 10 modules that were developed by faculty in general and orthopedic surgery departments here, at the University of Minnesota, and at the Mayo Clinic in Rochester. Each module has a 10-minute narrated presentation that provides unscripted video examples of how to lead these conversations. The modules also have key articles, “cue cards,” and other handouts.
The curriculum is free. It can be used for independent learning by students, residents, fellows, or staff. It may also be used by faculty for instructional purposes, e.g. as part of a presentation, or in conjunction with group teaching sessions. Program directors may also require it for individuals who struggle with interpersonal communication skills.
End of Life Modules
End of Life Module 1: Preparation
"Thank you for coming in. I'm here to talk about your mother's care plan."
What you need to do and think about before the conference, and what to say when you walk into the room. Being organized and having a 7-step mental model are key.
End of Life Module 2: Common Understanding
"What do you understand about your mother's condition?"
How to set the stage and deliver some information so you and the family achieve a common understanding of the seriousness of the patient's condition.
End of Life Module 3: Responding to Emotions
"I am so sorry to say this, but your mother is dying."
How to be clear with the family that their loved one is terminal, and then responding to their emotions.
End of Life Module 4: Care Goals and Treatment Options
"It is time to consider changing the goals of care."
How to explain "comfort care," code status, and treatment options when the patient is terminal. How to guide and support the family in their decision-making.
End of Life Module 5: Care Plans and Closure
"We will do everything we can to make sure he gets the best of care."
How to confirm decisions, detail the care plan, and provide continuity of care. Learn how to walk out of the room.
Error Disclosure Modules
Error Disclosure Module 1: Safe and Just Culture
“Thank you for being here. We need to discuss your mother’s care.”
Understanding that medical error disclosure is an ethical obligation and should be seen an extension of informed consent.
• Duclos Patient Perspective on Adverse Events
• Gallagher Three Tough Cases
• Heyland Discussing Prognosis Open Medicine 2009
• Hochberg 2011 Malpractice in an Academic Medical Center
• Singh H Medical Errors by Trainees Intern Med 2007
• West Medical Errors and Resident Distress JAMA 2006
• White Medical Error Disclosure Handbook Clinical Neurology 2014
Error Disclosure Module 2: Explaining the Error
“Unfortunately, things did not go as we expected.”
How to sequence two kinds of “bad news:” the poor outcome, and its causes.
Error Disclosure Module 3: Managing the Relationship
“I am truly sorry. This was my responsibility. On behalf of the whole care team, I apologize.”
How to recognize the signs of a deteriorating conversation; how to rebuild trust.
Error Disclosure Module 4: Error Prevention
“As a health system, we need to learn from this event.”
Take ownership for practice improvement.
• Greenberg, Gawande, Patterns of Communication Breakdown, JACS, 2007
• Iedema 100 Patient Stories BMJ 2011
• Rogers and Gawandee, Errors in Liability Claims, Surgery 2006
• Vincent Why People Sue Doctors Lancet 1994
Error Disclosure Module 5: Care Plans and Closure
“Let’s review what we decided to do, based on today’s conversation.”
Don’t leave the room before you clarify next steps and avenues for further conversation.