To make some extra money, I worked as an internal medicine intern for a short while after graduating early from medical school, while waiting to start my family medicine residency. While covering the medical floors and ICU, one of the duties that I felt very unsure about was to deliver bad news to patients and their families.
On several occasions, I recall feeling totally unprepared to inform an elderly woman that her spouse did not survive the cardiopulmonary arrest that occurred while I was on call. Or the fact that the chest X-ray demonstrated a likely lung cancer in a patient admitted with a cough and bloody sputum.
Admittedly, I probably should not have been the one having those conversations, but it just worked out that way.
Over the years, I became more comfortable with delivering bad news. I watched others do it. I read about it. But I never did receive any formal training on how to do it.
Several decades later, I was asked by the Director of Graduate Medical Education at my hospital to present a series of lectures to the residents. This past month, I presented one of those lectures devoted to the topic of delivering bad news to patients. It gave me an opportunity to review the subject.
I developed my method of delivering bad news by observing my instructors as I completed medical school and family medicine residency training. I don’t recall being taught a consistent method or process to follow.
As I reviewed the subject matter and integrated what I learned with the approach that I had come to follow, I was pleased to find out that there has been an effort to study the subject and several processes have been described and tested.
I think my readers will find this review of the process I taught to the residents to be a useful model to share with colleagues or use themselves in delicate conversations of this nature.
Let’s define the term “bad news” using Robert Buckman’s definition: “any information likely to alter drastically a patient’s view of his or her future.”
Think of these examples:
- A young, pregnant woman is told that she has experienced a fetal demise, her fantasy of a healthy, happy newborn crushed in an instant;
- A middle-aged man with arm pain for several months, discovers he has metastatic prostate cancer causing his pain;
- An elderly woman with “indigestion” and weight loss is found to have pancreatic cancer.
These are life-altering conditions with implications for ensuing disability, loss of autonomy and premature death. Learning of these ailments causes intense emotional responses in most patients, which can interfere with their ability to fully grasp what you’re telling them.
Why is This So Important?
The reality is this: patients want to know the truth. They expect the truth from their doctors. They don’t want to be lied to, or misled.
Patients want to know what their life is going to be like, the constraints that an illness is going to place on their activities and how long they might have to live.
They need to get their affairs in order. And they’re legally entitled to know what’s happening to them because they cannot make informed decisions unless they have all the facts about their medical condition.
Barriers to Conveying Bad News Effectively
There are three major challenges to completing an effective conversation about news such as this:
1. Time constraints
This conversation cannot be completed during a five-minute visit or while rounding briefly on a hospitalized patient. It will require an extended meeting to allow the patient to absorb what is being said, ask questions and reflect. Most physicians are not prepared to take 30 minute break to sit down with their patient and talk this through unexpectedly, so it is a conversation that must be planned and scheduled.
2. Physician Fears and Misgivings
There was a time when physicians believed that patients should be sheltered from the truth about a terminal or disabling illness, believing it will destroy hope and impede healing.
Consider this quote published in the American Medical Association’s Code of Medical Ethics in 1847: “The life of a sick person can be shortened… by the words or manner of a physician… avoid all things which have a tendency to discourage the patient and depress his spirit.”
We’ve certainly dropped this idea that giving bad news should be avoided in order to protect patients. But physicians still have fears about the emotional outpouring that might ensue, fear of being blamed for the bad news, or of having failed the patient in some way.
3. Lack of Instruction
Most of us in medical practice learned how to deliver bad news by watching others do it. We’ve not received formal training. If we had sensitive, empathetic mentors, that might have been good enough.
But, if our instructors were impatient, or not naturally good listeners, or cursed with a low emotional intelligence level, we may have learned some bad habits during our training. Good leaders will be certain that members of their organization present bad news in a measured, empathetic and humane way.
Hospital and medical group leaders need to ensure that our colleagues, department heads, and others have the tools needed to communicate effectively. We should develop educational programs that include much of the information that follows. Taking this a step further, it would be ideal if groups of caregivers, including physicians, could get together and do some role-playing in order to practice having such conversations.
The S-P-I-K-E-S Protocol to Deliver Bad News
So what are the steps? I’m going to outline the steps following the SPIKES protocol. Each letter in the word SPIKES represents one step of the process:
- Emotional response
- Strategy and Summary
There have been other approaches developed for delivering bad news. For example, the ABCDE method was described by Rabow and McPhee. But they generally follow a similar approach.
Let me go through each step individually.
There are several components we should address under this preparation phase. We should go through a mental rehearsal of the conversation we hope to have with the patient. We should plan to have this conversation in a private setting where we can sit down face-to-face with the patient and have good eye contact.
This setting must be free of distractions so we should leave our telephone and pager outside the room or put them on “do not disturb” mode. We should be prepared to have sufficient time to have this conversation. This is not a conversation that will occur in five minutes during rounds or in a semi-private room with another patient in the room in the hospital setting.
The next step is to assess the perception that the patient has about her illness and the pending conversation. You could say we should “ask before we tell.” Ask the patient, “What is your understanding of your medical situation?”
If you’ve had a conversation with the patient about testing that was going to be done or the consultation that was going to be arranged, and you explained what the expected outcomes of that test or consultation would be, then the patient should have a pretty good understanding of the potential implications.
But if you’re a hospitalist encountering a patient for the first time, or an emergency room physician who has no personal relationship with the patient, it’s going to be a little different. You’ll need to determine the perception by the patient of their situation.
Do they know that they might have a terminal illness or one which is going to seriously affect their long-term living situation? Did they know that coming into this meeting today you were going to provide them the results of the testing and explain any bad news that might be coming?
The next step is to understand whether the patient is ready to proceed, and how they want to proceed. Do they want every detail, or a short summary of the illness, with a focus on the treatment? You’re seeking an invitation to provide the information and answer questions. You want to be sure that the patient is prepared to do so. If your patient says that they really aren’t prepared emotionally to hear the results, then you might need to stop and regroup later.
The patient might want to have a family member present with them. Or he might not have been aware of what was coming. And, is the patient ready to receive both the medical knowledge and the plans for dealing with the bad news going forward?
The fourth step is imparting the knowledge or the information. The most important advice here is to take… your… time.
Do not rush through this conversation.
This is the most lengthy part of the interaction, explaining in layman’s terms exactly what is going on. Is this a terminal illness? Is this an illness that is going to severely impair the patient’s daily activities, ability to work, ability to travel?
This part of the conversation should start with a warning, something like, “I’m sorry but I’ve got bad news for you today.” Be sure to use non-technical terms. Provide the information in small bites. Pause frequently, and assess the patient’s response.
And don’t use euphemisms, like referring to a “growth”, when you should use the term “cancer.” Use terms like “very serious,” limited “life expectancy” and “death,” if necessary. But be gentle and patient at the same time.
Is the information sinking in? Are they grasping what you’re saying? Be sure to provide reassurance as you go. Tell the patient, “Yes, this is a serious condition, but we’re going to be here to help you along the way. We’re not going to abandon you.”
The fifth step is the emotion phase. How is the patient responding to the news? Observe the patient. See what emotions have been elicited. Is the patient sad, angry, or in denial? Acknowledge that there has been a strong emotional response, and try to reflect back what that emotional response is. Use terms like, “I see you’re very sad” or “I can see you’re very upset” or “You seem to be angry.”
Then try to connect the emotional response to the underlying reasons. It may seem obvious that since they received bad news, they should be angry or upset. But it’s the interpretation of the news that drives the emotional response. Find out, if you can, what fear is driving the emotion. Then help the patient connect meaning to the emotion.
Consider using observations such as, “You look angry. What is it about this news that makes you so angry? Tell me more.”
The patient may state that they had plans coming up for a trip and they’re angry because now they won’t have a chance to travel.
They may be more worried and upset about the impact of this news on other members of their family, rather than the direct effects on themselves. Or, perhaps the patient has lived through a loved one’s illness and are fearful about the effects of treatment (hair loss, other side effects) or uncontrolled pain.
Link the Emotion to the Meaning
It’s important that you identify both the emotional response and the meaning that’s driving it. Then acknowledge both. Be empathetic, acknowledge their concerns and their emotions, pausing frequently to allow them to vent.
At this stage, they must get their emotions under some level of control before we can proceed to the next step of the process. If someone is completely distraught, and crying uncontrollably, they’re not going to hear what you have to say.
Give them a few moments. Wait to see if they can compose themselves enough to answer your questions. Verify that they understand what you’ve said, and move forward with the conversation, answering questions slowly and deliberately.
Be sure to validate their emotions and their concerns as you go. But, again, do not downplay their condition. Don’t say “Don’t worry, everything will be OK” in a way that whitewashes what is going on.
Once they seem to have accepted the reality of the situation, and are composed enough to proceed, move to the final phase of the discussion.
Strategy and Summary
This final step is designed to verify that they’ve heard the information. You might ask them, “What is your understanding of what we’ve just talked about?” Are they able to clearly articulate what you’ve conveyed? Are they using euphemisms that you may have used like, “I have a tumor”? Or are they being realistic and accurate with their assessment?
Be sure that if this is a terminal illness, that is understood. Be prepared to describe what is known about the course of the illness. You can explain that the condition may result in their death at some point, but you’re going to be there to help them and not let them be suffer needlessly. Describe some of the support that will be available to them.
Provide a brief overview of the steps that will be taken to address their diagnosis. Then ask them to reiterate the plans that you have discussed. Explain decisions that might need to be made. Once they’ve heard about them, give them a chance to express their initial thoughts. But a final course of action should be discussed later, after they have fully digested the information that has been provided.
You might ask. “Is there a direction that you’d prefer to follow, or would you like to come back later and discuss the treatment options again in more detail?”
If the patient is too distraught to finish this part of the process, then it’s best to stop, circle back to the beginning of the SPIKES protocol and reiterate some of the information.
If necessary, stop completely and reconvene later in the day or the next day with the patient, perhaps with a family member present. Then reiterate the plan, including when you’re going to meet next.
Let’s quickly recap the six steps of the SPIKES protocol.
First, you’re going to address the SETTING. In setting up, you’re going to rehearse mentally, make sure you have a private setting where you’ll be sitting eye-to-eye with the patient, and that distractions are going to be eliminated.
Second, you’re going to assess the patient’s PERCEPTION of what’s going on and any recall of previous conversations leading up to this meeting.
In the third step, you’re going to look for an INVITATION by the patient to proceed. That means they’re ready to proceed and they’ve told you how much detail they want to have during this conversation.
The fourth step is imparting the KNOWLEDGE that needs to be delivered, starting with, “I’m sorry to tell you that I have bad news” and avoid using jargon. Give the information in small bites, pause frequently and reassure as you go.
During the fifth step, you must address the EMOTIONS evoked in response to the news. You should observe the patient, acknowledge their emotions, clarify them, connect them to the meaning that the news has to that patient, and validate them.
The sixth and final step is to elicit their SUMMARY of what has been discussed and outline the STRATEGY for moving forward while reassuring them. Then set a particular time and place when you’re going to follow-up with them.
This process seems to be a little bit too “cookbook” for some. But after using it a few times, it becomes second nature. The six seemingly discrete steps start to blend into one another, so that this conversation can be done in a very responsible and effective manner. This will enable you to convey the news to the patient and prepare them for the next steps in their treatment.
You may find it useful to watch some videos, demonstrating poor examples of giving bad news and more effective examples. Below are two such videos:
Does this approach seem useful? Does it generally follow the process you’ve developed to convey bad news?
Please add you’re thoughts in the Comments. I will respond to them all.
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Thanks for joining me.
Until next time.