Breaking Bad News

Breaking bad news is an important skill required of doctors. It is virtually impossible to shy away from, therefore it is necessary to have a method of effectively communicating bad news to patients or their relatives. Bad news can take the form of diagnosing a patient with a life-threatening condition or informing families that their loved one has died. Getting it wrong can be frustrating for both yourself and those whom you broke the news to.

Here, we provide a framework proposed by Baile et al. (2000) named SPIKES which offers a six-step protocol for breaking bad news effectively. You can use this framework in any interview scenario where you have to break bad news to a patient or their relative, or equally in your future medical career.

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Privacy is important. Not only for enabling you to have the discussion without any interruptions, but ensures that your attention is undivided. Ways to achieve this include:

• Take them to a quiet room where you will not be disturbed. If you feel putting a sign up is necessary then feel free to do so.

• Turn your pager and phone on silent so you don't get disturbed inadvertently.

• Ensure that yourself and the patient/relatives are seated to put them more at ease.

• Maintain eye contact throughout to establish rapport.

• If you are breaking bad news to a patient, ask if they would like other people there to for emotional support.

First, discuss the medical findings leading up to the current discovery to assess how the patient views the situation. Based on this, you can direct the conversation towards what the patient will understand. It also lets you know if the patient is in denial about their condition. Things to ask them may include:

• Reasons for conducting a scan

• Asking: "Did someone explain to you what the results might show?"

• Asking: "What do you understand about your condition so far?"

Patients have the autonomy to find out as much information relevant to them as they wish. The majority of them will want full information about the details of their condition. Nevertheless, still let them decide for themselves how much they would like to know. Ways of expressing this may be:

• "Would you like me to explain your diagnosis to you?"

• "How would you like me to present the information to you?"

There can sometimes be a lot of information for patients to process so in order to make this as smooth as possible consider implementing these tactics:

• Avoid technical words where they are not absolutely necessary e.g. instead of "the cancer has metastasised" you could say "the cancer has spread". However, don't be patronising.

• Give them information in small chunks.

• Check that they have understood what you have said at regular intervals.

• Repeat important points if you must.

• Listen to what the patient has to say in response - reinforce those which align with medical facts and stress relevant medical information if their understanding seems to be inaccurate.

This can vary dramatically from silence, to tears or even anger. The important thing to remember is to show that you have acknowledged their emotions and respond empathically without giving false hope. Way to navigate this include the following:

• Look at their facial expressions and body language to assess their emotions

• Don't be afraid to allow silence to fill the space is appropriate

• Allow the patient to express their emotions and respond to how they react e.g. by showing you understand the reason for their emotions

• Ask them how they're feeling if their emotions haven't been clearly expressed

Before you do this, confirm the patient is ready for any treatment plans for the future. The main strategy here is to explain to the patient what is curable and incurable, as well as identify any coping strategies of the patient. Important things to consider include:

• Inform the patient of the next steps; while explaining the steps invite any questions they may have.

• Signpost people or places they can access for more support such as support groups.

• Understand the specific goals the patient has (such as symptom control) as this will help you frame what is possible to accomplish.

• Summarise the main points as they may not have taken everything in due to shock.

References

1. Baile, W., Buckman, R., Lenzi, E., Glober, G., Beale, E., & Kudelka, A. SPIKES – a six-step protocol for delivering bad news: Application to the Patient with Cancer. Oncologist 2000; 5(4):302-311.