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

Module 1

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. 

• Full video transcript
• Handout: General Model for End of Life Conversation
• Cue Cards: Starting the Conversation

Reading Assignments

• Chipman, Multi-institutional Study, AmJSurg 2011
• Gries, Family Satisfaction, Chest, 2008
• Lautrette, Communication Strategy, NEJMed, 2007
• Von Guten, Ensuring EOL Competency, JAMA 2000

Module 2

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.

• Video Transcript
• Cue Cards: What the Family Knows
• Cue Cards: Purpose of Meeting ("Warning Shot Across the Bow")

Module 3

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.

• Video Transcript
• Cue Cards: Clear Message
• Cue Cards: Empathy and Support

Reading Assignments

• Bradley, Core Competencies, AmJHospPall Care, 2008
• Heyland, What Matters Most, CMAJ, 2006
• Minichiello, Breaking Bad News, SHM, 2007

Module 4

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.

• Video Transcript
• Explaining Comfort Care
• Explaining Code Status
• Family Decision Making

Reading Assignments

• Diem, CPR on TV, NEJM 1996
• Murray, How Doctors Die, 2011
• Szmuilowisc, Code Status, Palliat Med, 2012
• Von Guten, Discussing DNR, JCO 2003

Module 5

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.

• Video Transcript
• Summarizing Family Wishes
• Sample Follow-up Steps
• Closing the Conversation

Reading Assignments

• Dias, A Patient's Perspective, The Oncologist, 2003

Error Disclosure Modules

Module 1

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. 

• Video Transcript
• Handout: General Model for Medical Error Disclosure
• Mayo Error Disclosure Policy
• UMP Communication Disclosure policy

Reading Assignments

• 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

Module 2

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.

• Video Transcript
• Explaining the Error Introductions

Reading Assignments

• Chan How Surgeons Disclose Medical Errors to Patients 2005 Surgery
Iedema What Prevents Disclosure What Can be Done Joint Commission
• Levinson Review of Surgeon Patient Communication 2014

Module 3

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. 


• Video Transcript

Reading Assignments

• Duclos, Patient Perspective on Adverse Events
• Lazare, Apology in Medical Practice, JAMA, 2006
• Vincent, Understanding, Responding Adverse Events, NEJM, 2003

Module 4

Error Disclosure Module 4: Error Prevention

“As a health system, we need to learn from this event.”

Take ownership for practice improvement. 

• Video Transcript

Reading Assignments

• 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

Module 5

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. 

• Video Transcript
• Summarizing Family Wishes

Reading Assignment

• Strasberg, Severity Grading System, ANN Surgery, 2009