Bad docs giving bad news badly
Based on the monotony of my usual speech, it probably doesn’t surprise you that I had to remediate my standardized patient assessment on “giving bad news.” I mean, in my defense, it was a forced awkward situation with an actor, with whom I was supposed to act as well. The whole situation was suboptimal. Even so, I still wouldn’t consider myself an authority on how to carry out these types of difficult conversations. Therefore, whether it is out of shame and personal growth, I bring to you in this week’s BrainWaves episode some helpful tips on how to do this well. With the help of Dr. Mike Rubenstein.
As part of my remediation for the standardized patient experience, I was encouraged to learn the SPIKES method:
S–Setting up the conversation: As a boy scout, I learned from an early age the importance of being prepared for whatever I would encounter. Leading an emotionally jarring conversation about a patient’s health is no exception.
P–Perception of the patient: This is your chance to survey the landscape and determine a patient’s or their family’s readiness to receive bad news. How much do they know? Are they prepared to hear bad news, or are they expecting more optimism from you?
I–Invitation: Now, the original authors of the manuscript (mind you, it has been cited nearly 1500 times) use invitation for the ‘I’. They recommend obtaining an invitation from the patient to deliver the upsetting news. My approach would be slightly different, and my ‘I’ would be ‘Information’. As in, what kind of information is appropriate to share here? Some patients want the full details of every chest x-ray and lab test, and others want
a general overview of what is going on. Most…they want a blend of the two. And I don’t know how better to tell you how to conduct yourself in this regard, other than you should have gotten a general understanding of this after having met with the family in prior occasions during the patient’s critical illness. The real challenge comes when you only just met the patient, or the patient was perfectly healthy until quite recently.
K–Knowledge: This is the part where you give the knowledge to the patient. It is probably best here to be sensitive, to be brief, and not to sugarcoat it. You need to be brief because after the first 10 seconds, the patient or their family will shut down and stop listening. And it’s best not to sugarcoat it because you don’t need to use more words than are absolutely necessary. Plus, honesty helps build rapport with your patients. You won’t get anywhere by inappropriately qualifying your own statements, or by feigning ignorance. Tell them what you know, tell them what you think, and recognize that you may not be 100% right but that this is your medical opinion.
E–Emotions: Address the patient’s emotions. At the simplest level, this can be accomplished with statements of recognition. “I can see that this has upset you.” “I can see that this news is confusing.” These kinds of elementary statements can quickly open up that dialogue you need to keep the conversation going. But always know that silence is golden, and sometimes people need a moment to process this heavy information.
S–Summary & Strategy: This is my favorite part, because up until this point you’ve served the role of the antagonist. The messenger of maladies. Here you have the chance to redeem yourself as the person responsible for the treatment and comfort of the patient. But first, you must sum up all that’s been said and ensure the recipient of this information comprehends it. Only then can you discuss options moving forward. “Is palliative chemotherapy an option?” “How can we manage her secretions?” “Should we place a gastrostomy tube?” “Can we make your father more comfortable using medications?”
All this SPIKES stuff being said, I should tell you that none of this is mentioned in the episode. This page is meant to give you something I hope you might learn from, as I have. Consider this to be “textbook-learning” in contrast to what Mike and I describe as “practice”. So take a listen on your own time, and let us know if you have any other thoughts or experiences you’d like to share.
- Baile WF, Buckman R, Lenzi R, Glober G, Beale EA and Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5:302-11.
- Fallowfield L and Jenkins V. Communicating sad, bad, and difficult news in medicine. Lancet. 2004;363:312-9.
- Ptacek JT and Eberhardt TL. Breaking bad news. A review of the literature. JAMA : the journal of the American Medical Association. 1996;276:496-502.