It's not fun to tell families (or patients) that there was a complication, that their loved one died, or that their loved one is not going to survive. But it's a fundamental principle of good patient care, especially in the specialties of trauma and critical care.  I didn't become truly comfortable with these conversations until my critical care fellowship. After many years and countless conversations in private rooms, here are my tips on how to develop this skill.

1.  Experience. It's uncomfortable, but you should take every opportunity to participate in these conversations, starting as a student/ trainee.

- As a young resident, I remember walking with my attending to go talk to a family about an intra-operative complication. I'll never forget the sinking feeling in my chest, the shame that I made a mistake. This was a pivotal moment in my training. My attending didn't have to tell me I messed up. But he knew I needed to see how he handled disclosing to the family members. He showed me that this wasn't something that I should allow to crush my self-confidence.

- A few years later, during one of my first trauma rotations, I remember sitting in a small room in the ER as one of my co-residents told a family that their child was the victim of a fatal shooting. I didn't have much experience telling families that their loved one had died. In particular, I didn't have any exposure to telling a family that their loved one died in a trauma bay- a family I'd never met, a family who never had a chance to see their loved one before they died from their injuries. I was initially embarrassed that my co-resident, who was one year younger than me, was more comfortable leading the discussion than I was. But then I realized he had much more exposure to that type of conversation because of his previous trauma rotations. So I took it as an opportunity to learn and prepare myself to lead the conversation the next time.

- Two years later, in the ICU waiting room of the same hospital where I watched my (younger) co-resident tell a family their son died, I sat with the mother of a young man who was critically injured. Thankfully, I had much better news. But still, it's not easy to tell a single mother that her oldest son was shot through the chest, and was laying in the ICU, intubated, with an open chest and abdomen.

2.  Learn from watching experts.

- Everyone has a slightly different style of handling these conversations. I joined my attendings for every conversation I had the opportunity to witness. This included conversations about everything from Code Blue incidents to fatal injuries and end-of-life care. It's important to see different styles, which will allow you to develop your style. Some are more blunt, some are more observant of family dynamics, some are overly talkative. There are some you may choose to not replicate, but it's important to see a spectrum of styles to learn what works for you.

- I've watched my MICU attending talk with the wife of a man who came to the hospital with acute cardiac arrest, requiring emergent coronary angiography and intervention, then therapeutic hypothermia. I learned how to succinctly describe a complex situation and support a wife make a crucial decision without pressuring her.

- I've watched my trauma attending talk to a family of a young male patient who had died on the operating table. I've watched that talk more than once, unfortunately. And it never got more comfortable. But I learned how to convey devastating news while simultaneously expressing compassion.

3.  Practice.

- As a fellow, I would often have a pre-brief with my attending and we would discuss key points for the meeting, as well as the goals of the discussion (ie deciding about proceeding with surgery, deciding about comfort care, etc).

- When I have younger residents who are having family meetings, particularly one's that I haven't worked with before, I have them rehearse their conversations with me before. I did this as a resident and a fellow, and I still do this with my fellows.

4.  Get feedback. Positive feedback is always nice, but true constructive feedback is key to improving.

- I've had nurses and chaplains who have joined me for multiple family meetings, and it's always reaffirming to hear them compliment my interaction.

- My attendings still occasionally joined me in conversations toward the end of my fellowship. It was always helpful to hear feedback about what was well-received and how I could have been more effective.

5.  Once you've practiced, developed your style, and absorbed feedback- don't expect it to always be easy.

- Towards the end of my fellowship, I had a particularly challenging case. I had already had countless family discussions and had become very comfortable with being uncomfortable. For a variety of reasons, I was emotionally overwhelmed with this patient's situation- I sat and cried at the nurse's station for a long time. Then I went and talked to my attending and told her I couldn't have the conversation, that I couldn't stop crying. I was hoping she would take over and lead the conversation- I should have known I wouldn't get off that easily. She reassured me that I wouldn't have to say much- I had already established rapport with the patient's family the day before, and they'd be able to tell from my non-verbal communication that I didn't have good news. It was (and still is) the hardest conversation I've had.

6.  Don't Stifle Your Emotions (within reason)

- Some people would criticize me for expressing emotion when having discussions with families. I do think there has to be a healthy separation, and getting emotionally invested with every case would be paralyzing. I don't cry during the majority of these conversations. However, I'm not a robot, and I still occasionally have patients that affect me on a more personal level. For example, I had one family that came to the very difficult decision to transition their mother to comfort care. Their mother was the matriarch of the family and her children didn't want to disrespect her. She had expressed that she would not want to be kept alive if she couldn't continue to have meaningful interactions and care for the family. I told them that giving them the implicit approval to allow her to die peacefully was probably the greatest gift she could have given them, and I reassured them that they were showing her the ultimate level of respect and kindness by honoring her wishes.  That hit me differently because I could feel their pain as I imagined myself in their position.