LRH · EMERGENCY DEPARTMENT
Conversations
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Not yet ready for clinical use. Shared for feedback and practice only.
Communication is always situational — these are starting structures, not scripts to read verbatim. Use your judgment and your department's policies.
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LRH · EMERGENCY DEPARTMENT

Conversations

Cognitive aids for the hard conversations — the ones where structure buys you calm. Starting frameworks, not scripts to read word for word.

01Consultant Crucial Conversation 02Code Status Conversation 03SPIKES — Delivering Bad News 04Debrief — After the Event

01Consultant Crucial Conversation

WHEN A CONSULT IS BEING REFUSED OR RESISTED
De-escalate the emotion first, then solve the clinical problem. A structured approach built on tactical empathy — you cannot problem-solve with someone whose guard is up.
⚠ LOCALIZE THIS CARD: set the escalation chain to your site (ED director, on-call CMO / administrator, transfer center). EMTALA obligations are federal, but who you call and how you document a refusal are local.
1 · UNCOVER THE EMOTION
  • Goal — neutralize hostility before the clinical problem
    Label the emotion out loud, or run an accusation audit (name the worst thing they might be thinking, so it loses its charge).
    “It sounds like this call is coming at a terrible time — or that you feel this consult shouldn't be coming to your service.”
2 · VALIDATE THE PERSPECTIVE
  • Goal — acknowledge their situation without agreeing to the refusal
    Tactical empathy and mirroring. You are not conceding; you are showing you understand.
    “It sounds like you're completely underwater right now, and adding another complex admission feels impossible. If I were in your shoes, I'd probably be frustrated too.”
3 · CONFIRM UNDERSTANDING — GET “THAT'S RIGHT”
  • Goal — get a “that's right” so the defensive guard drops
    Pause and listen until they confirm with “That's right” or “Exactly.” Don't settle for “You're right” — that's usually a brush-off to end the call, not real agreement.
4 · SHIFT TO COLLABORATIVE PROBLEM-SOLVING
  • Goal — make them invested in the solution
    Calibrated, open-ended questions — “how” and “what,” not “can you.” They put the problem back in front of both of you.
    “Based on where things stand, how can we safely get this patient what they need right now?”
    “What would it take for us to manage this patient together tonight?”
5 · FRAME THE ESCALATION / EMTALA BOUNDARY
  • Goal — state the consequence of inaction without a personal threat
    Bounded force and loss aversion: name the boundary, anchor the shared cost, and keep them in control of the way out.
    “It seems like we're stuck. This patient needs [X], and because of EMTALA I have to either escalate this to [ED director / CMO] or document a formal refusal. I really don't want to do that, and I know neither of us wants an administrative review. Is there any other way we can solve this right now?”
6 · EXECUTE INSTITUTIONAL PROTOCOL
  • Goal — follow through cleanly if they still won't engage
    Document the facts objectively in the record (what was requested, the clinical need, the response — no editorializing). Notify executive leadership / the on-call CMO. Initiate transfer or the escalation protocol per policy.
Sources: Framework adapted from Never Split the Difference (Chris Voss) — labeling & accusation audit, tactical empathy & mirroring, triggering “that's right,” calibrated questions, and bounded force / loss aversion. Consult-refusal and transfer obligations per EMTALA (42 U.S.C. §1395dd); follow your institution's on-call and escalation policy for the specifics.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment.

02Code Status Conversation

STARTING THE CONVERSATION IN THE ED
A brief, values-based goals-of-care conversation — make a recommendation, don't hand over a menu. Best done early, before the crash.
⚠ LOCALIZE — Dr. Lawson's one-pager: the originating site's graphics and CPR-outcome references are in “CPR images and one-page review with references” (Dr. Lawson, Dec 2025). That link is an external download — for true offline/bedside use, self-host the graphics (image or PDF) in this conversations/ folder and link them locally.
1 · SET UP
  • Sit down, quiet space, the right people present. Ask permission to open it.
    “Would it be OK if we talked about what we'd do if you became much sicker — so we're on the same page ahead of time?”
2 · ASSESS UNDERSTANDING — ASK · TELL · ASK
  • Start from what they already know, then fill the gap in plain language — no jargon, small chunks.
    “What's your understanding of how sick you are right now?” … then … “Can I share how I'm seeing it?”
3 · EXPECT & NAME EMOTION
  • Silence is a tool. Respond to emotion before facts — a wish/worry statement lands better than more data.
    “I wish things were different.” · “This is a lot to take in.”
4 · MAP WHAT MATTERS
  • Values before interventions — the answers here drive the recommendation.
    “If time were short, what would matter most to you?” · “Are there abilities so important that life without them wouldn't be worth living?”
5 · DESCRIBE CPR HONESTLY
  • Avoid “do you want us to do everything?” — it's unanswerable. Describe what CPR actually is and, for a seriously-ill patient, what it realistically achieves. Use Dr. Lawson's CPR-outcome graphics to show, not just tell.
    “If your heart were to stop, CPR means chest compressions, a breathing tube, and shocks. For someone as sick as you are, it rarely gets people back to the life they had — and often the opposite.”
6 · ALIGN & RECOMMEND
  • Tie it back to their values and make a recommendation — patients and families consistently want one. Offer a time-limited trial when the path is genuinely uncertain.
    “Given what you've told me matters most, I'd recommend we focus on [comfort / this treatment], and I wouldn't recommend CPR. How does that sound?”
7 · PLAN & DOCUMENT
  • Enter the code-status order, complete a POLST/MOLST or your state form if appropriate, document the discussion and who was present, and tell the team out loud so the plan travels with the patient.
Sources: Communication structure per VitalTalk (REMAP; Ask-Tell-Ask; NURSE statements — vitaltalk.org) and the Ariadne Labs Serious Illness Conversation Guide. Local CPR-outcome graphics and references: Dr. Lawson, “CPR images and one-page review with references,” Dec 2025 — linked here (self-host locally for offline use). Best-practice content is a draft for departmental review; confirm your final references on this card.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment.

03SPIKES — Delivering Bad News

DEATH NOTIFICATION · SERIOUS DIAGNOSIS · BAD OUTCOME
A six-step structure for breaking bad news — the point is to go slow, follow the patient, and respond to emotion before you keep talking.
S · SETTING UP
  • Private space, sit down, tissues within reach, phone silenced. Have the right people present and know their names. Take a breath before you go in.
    “Is it OK if we sit down together? I want to make sure we have a few minutes.”
P · PERCEPTION — ASK BEFORE YOU TELL
  • Find out what they already understand, so you meet them where they are.
    “Before I go on — what's your understanding of what's been happening?”
I · INVITATION — HOW MUCH DO THEY WANT?
  • Ask permission and gauge how much detail they want right now. People take news in at different speeds.
    “Are you someone who likes all the details, or would you rather I give you the big picture first?”
K · KNOWLEDGE — THE NEWS ITSELF
  • Fire a warning shot, then say it plainly — no jargon, no euphemisms (“passed,” “we lost him” are unclear; say died). Small chunks, then stop and let it land.
    “I'm afraid I have difficult news.” … (pause) … “Despite everything we did, his heart could not be restarted, and he died.”
E · EMOTIONS — RESPOND WITH EMPATHY
  • Stop talking. Observe the emotion, name it, and let silence do the work. A single empathic statement matters more than any explanation right now.
    “I can see this is devastating.” · “Take whatever time you need.”
S · STRATEGY & SUMMARY
  • Only once they're ready: what happens next (seeing the body, belongings, autopsy/medical examiner, who to call), and make sure they aren't left alone. Offer a contact and chaplain/social work.
    “You don't have to decide anything now. I'll stay with you, and here's what we can do next when you're ready.”
Sources: Baile WF, Buckman R, et al. “SPIKES — A Six-Step Protocol for Delivering Bad News,” The Oncologist 2000;5(4):302-311. Empathic-response language per VitalTalk (NURSE statements). For a death notification specifically, the GRIEV_ING mnemonic (Hobgood, Acad Emerg Med 2005) is a useful ED-specific companion.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment.

04Debrief — After the Event

SAME SHIFT AS THE EVENT
A short, structured team conversation after a code or critical event — a few minutes, at the bedside or a quiet corner, before everyone scatters.
1 · WHY DEBRIEF — PURPOSE
  • A debrief is not a performance review and not an incident investigation. It's a few protected minutes for the team to compare what each person saw, surface what the system enabled and inhibited, and carry one or two concrete things into the next case.
  • Anyone on the team can call for one. Short beats perfect — five focused minutes now is worth more than a perfect session next week.
2 · STATE THE BASIC ASSUMPTION
  • Open by saying it out loud: we start from the assumption that everyone here is intelligent, capable, cares about doing their best, and wants to improve. (Adapted from the Center for Medical Simulation's Basic Assumption.)
  • Saying it first changes the conversation that follows — curiosity about why things happened, instead of judgment about who did them.
3 · REVIEW THE CASE — WHAT DID YOU SEE?
  • Review the case timeline together — if the team ran a card in this manual, open its SUMMARY (case timeline) and read the timestamps aloud as the shared record of what happened when.
  • Then go around: “What did you see?” — each role saw a different case. Let everyone add to the shared picture before anyone evaluates anything.
4 · PLUS / DELTA / PLUS — ENABLED & INHIBITED
  • PLUS — what enabled us? Name the specific things (behaviors, tools, communication, environment) that enabled the team's performance.
  • DELTA — what inhibited us? Name what inhibited performance — framed as conditions and systems, not blame. “The pulse ox was on the BP-cuff arm” invites a fix; “you missed the sat drop” invites defensiveness.
  • PLUS — what do we take away? Close on the takeaway: anything to communicate or escalate? Key saves or key learning? Missing or broken equipment to report? Pick one or two deltas at most to act on, name who owns each, and stop there.
Sources: The Basic Assumption is adapted from the Center for Medical Simulation (Boston, MA) — harvardmedsim.org; the enabled/inhibited framing draws on debriefing-with-good-judgment and plus/delta conventions from the simulation-education literature. Locally drafted — refine with your simulation/education leads.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment.
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