Tips for Bad News Bearers

A Critical Clinical Skill

Learning Objectives
After this session, you will: Recognize the challenge of sharing bad news effectively Be able to describe an effective six step process for sharing bad news--SPIKES Be committed to improving your skills in breaking bad news to patients

What is Bad News?

Any news that seriously and negatively alters the patients view of his or her future.

The Goal
Help the patient and family understand the condition Support the patient and family Minimize the risk of overwhelming distress or prolonged denial

Why is it a critical skill?

The Patients Perspective
Patients often have vivid memories of receiving bad news Negative experiences can have lasting effects on anxiety and depression Can facilitate adaptation to illness and deepen the patient-doctor relationship

Why is it a critical skill?

The Physicians Perspective
High degree of difficulty + Physician anxiety =

High risk of performing poorly

What do patients want?

For themselves more time to talk and show feelings From the doctor more information, caring, hopefulness, confidence a familiar face
Strauss 1995

What do you do?

What have you found helpful in making bad news visits go as well as possible?

There are several models of breaking bad news.

Buckmans S.P.I.K.E strategy (2005). It describes much of the emotional issues that one should consider when delivering bad news and discusses an easier way to remember the important facts when delivering bad news.

S
P I K E S

etting up the interview erception of the patient re their illness nvitation from patient to share info nowledge and Information conveyed motions responded to empathically ummary and Strategy for followup

1. Setting up the interview

Anticipate the possibility of bad news, and arrange a follow-up visit after significant scans, biopsies etc. Avoid telephone Private setting, sitting down Turn off beeper, no interruptions Ensure adequate time

1. Setting up the interview

Lab reports, X-rays present Support person present , if desired Review the condition, basic prognosis and treatments before the visit HOPEFUL TONE

2. Perception

Assessing the patients

ASK then TELL Important if the patient is not well known to you OR if visits to consultants have occurred Assess the Gap between what the patient knows and the diagnosis What have you already been told about might

be going on? What is your understanding of why the CT scan was ordered?

Obtaining the patients

3. Invitation

Preferably before the visit Easier if patient is well- known Listen to patient cues Are you the sort of person who likes to know

all the details of your condition? Would you like me to discuss the results of the CT scan with you?

Giving

4. Knowledge and Information

Align yourself with the patients understanding and vocabulary Start with a warning shot: Im afraid that

the scan shows that the problem is fairly serious.

Give diagnosis simply, avoid euphemisms or excessive bluntness Provide information in small chunks Check frequently for understanding

Giving

4. Knowledge and Information

Check for knowledge or experience with condition Allow for pauses, use repetition Will usually want basic but clear information re treatment plan and prognosis BUT Tune into patient readiness to hear more, and know when to stop

Balancing Truth and Hope: The Skillful Use of Indirect Language S Healing et al 2006

It looks like. not You have. there are tumours in the liver not you have tumours in your liver

Emphasize on maintaining the relationship as well as communicating the news

Respond to

5. Emotions empathically
Observe for and allow emotional reactions Kleenex handy, use of touch N aming the feeling I know this is upsetting U nderstanding It would be for anyone R especting Youre asking all the right questions S upporting Ill do everything I can to help you
through this.

6. Summary and Strategy

for follow-up Summarize discussion Clear follow-up plan re: referral, tests, next contact (in <48 hrs) Provide written summary or brochures Refer to community resources Invite support person for next visit if not present

6. Summary and Strategy

for follow-up

End on note of hope and partnership AFTER: document well assess your own reaction

Six Steps for Breaking Bad News

S etting up the interview P erception of the patient re their illness I nvitation from patient to share info K nowledge and Information conveyed E motions responded to empathically S ummary and Strategy for follow-up

Discrepancies in Ratings
Patients rated the following much higher than doctor and nurses: receiving bad news in a quiet, private place arranging a follow-up visit soon to review with patient and family inform patient about support services
Girgis, Behavioural Medicine 1999

Follow-up
Please take a handout outlining the SPIKES steps in sharing bad news Try out one or two of the suggestions next time you have bad news to share

The task of breaking bad news is a testing ground for the entire range of our professional skills and abilities. If we do it badly, the patients or family members may never forgive us; if we do it well, they will never forget us.
Robert Buckman