Buckman created a six-step protocol for giving unfavorable information to patients. In a review of the literature on Breaking Bad News published in the Journal of American Medical Association, most authors agree that following the SPIKES framework reduces stress on the patients receiving the bad news as well as the physicians charged with delivering the bad news (Table 3-1).
Physicians may have several goals on entering a discussion in which they plan to divulge bad news to a patient: they may wish to gather information from the patient in terms of what they know already of their illness as well as how much they want to know; to provide information to the patient that is clear and within the boundaries of what they desire; to support the patient by responding to emotional needs that arise during the conversation; and to develop a treatment strategy with the help of the patient. These are no small goals, but the SPIKES protocol can assist professionals in realizing them.
Table 3-1.The SPIKES protocol for delivering bad news. ||Download (.pdf) Table 3-1.The SPIKES protocol for delivering bad news.
|Set up the interview ||Advanced preparation, pay attention to the physical setting: sit down, make eye contact, avoid interruptions, and invite patient to ask family to stay |
|Assess patient’s Perception || |
“Tell me how you are doing.”
“What do you understand about what’s happened so far?”
|Obtain the patient’s Invitation || |
“Is it okay to speak freely about the information that I have here?”
“Is there anything that you wouldn’t want to know?”
|Give Knowledge and Information to the patient || |
“I’m afraid that I have bad news for you.”
“The biopsy confirmed cancer.”
|Address the patient’s Emotions with empathic responses || |
“I wish I had better news for you.”
“I can see that you’re upset. Tell me more about what you’re feeling.”
|Set goals ||Summarize the conversation and make a plan to go forward |
Step 1 of the six-step SPIKES protocol (Set up the interview) involves advanced preparation for the discussion and choosing an appropriate physical setting in which it will occur. Mentally rehearse what you will tell patients and anticipate what they may ask or how they may react. Remember that although the conversation that is ahead will be challenging to hear for everyone, it will be important to communicate the information clearly and succinctly to begin preparing patients to plan their future. Consider where the conversation will happen. The space chosen for this purpose should be private, quiet, comfortable, and convenient for everyone involved. Identify the key players that should be present, this includes family or friends whom the patient identifies as being close supports, as well as practical additions to the team, such as nurses, interpreters, social workers, and consultants who know the patient well. Having a supportive colleague present during the discussion may also potentially bolster the comfort level of the provider when the news is particularly bad. In a hospital, the physical setting adds another level of complexity to an already difficult discussion. Finding a space to have a private conversation where the patient can comfortably attend—while maintaining the peaceful, supportive environment required to openly discuss sensitive information—often proves difficult. Seeking out empty family rooms or offices in advance can be helpful. In the outpatient setting, the physical space may not be as much of a problem as the time constraints. It is recommended in this step of the SPIKES protocol to set aside a large amount of time where one does not feel pressured to truncate the conversation in favor of other responsibilities. Many experienced clinicians find that time set aside at the end of a patient-care session is most convenient for this discussion. If possible, providers should hand off their pagers to another colleague and ask staff to hold telephone calls or other interruptions until the conclusion of the bad news discussion.
In addition to the optimal physical setting, physicians should prepare for the conversation by finding out the medical information necessary to answer any anticipated questions. Talking to consultants about specific diagnoses or test results in advance will help when formulating the treatment plan with the patient.
Something else to consider before escorting the patient into the conversation is who should be present and who should be delivering the bad news. There is no single right answer, but the healthcare provider who knows the patient best is the right person in most cases. The use of an interdisciplinary team helps in preventing discrepancies in information presented to the patient, and potentially aids in identification of patient needs. Nurses can also be helpful in acting as a supportive liaison between patients and physicians. Social workers can provide essential services such as talking with patients on how best to communicate with doctors, setting up interpreters, and arranging meetings with key people.
When entering into a discussion, in which sensitive information will be divulged, be mindful of body language and non-verbal cues that could be sending additional information to patients. In addition, be vigilant about identifying what information the patient’s body language is providing to you. Sitting down lets the patient know that there is no rush and making eye contact (though sometimes uncomfortable) assists in strengthening rapport between patient and provider.
In Step 2 of the SPIKES protocol (Perception), the goal is to assess the patient’s perception of what has thus far occurred to bring everyone together. Introduce yourself and state your role, and invite everyone else in the room to introduce themselves and state their reason for being there. This is a good time to acknowledge any time constraints that you might have. For example, “I have thirty minutes to meet with you before my next meeting.” Start then by stating the goals of the meeting, such as, “I asked you here today to discuss Mr. Green’s recent test results and how this affects the plan for the future.” An excellent rule of thumb at this point of the conversation is “before you tell, ask.” Find out what the patient and family know and what they want to know. Some patients may choose less-than-full disclosure in regard to their medical conditions, and you cannot know without asking. Some cultures protect their members from bad news by relaying this information to family instead of the patient; these issues must be explored early in the interview to ensure that this is truly the desire of both the patient and the family.Cultural differences in medical care and in discussing bad news are explored in more detail later in this chapter.
Once it is determined that everyone in the room wants to participate in the ensuing discussion, invite the patient to speak freely about their understanding of their experience thus far. Studies have shown that satisfaction in family meetings increases as the proportion of family talktime goes up. Attempt to minimize interruptions and actively listen to what patients and families describe. Invite them to participate freely in the information exchange and to dictate how much information is divulged at this initial meeting. Active listening ensures that nothing is left out of the conversation simply due to over-estimating what the patient and family already know. Step 2, when patients are invited to express what they already know, is a great time also to correct any misinformation that the family or the patient may harbor. It is also a good time to assess whether the patient or their support group are engaging in any sort of denial about their condition. As examples, wishful thinking, unrealistic expectations of treatment or omitting important details of medical care might surface during this time of the interview.
The purpose of Step 3 of the protocol (Invitation) is to obtain the patient’s invitation to the clinician to talk further about what he or she knows about the patient’s condition. Ideally, one would have previously asked the patient when ordering a test that might result in serious news how they would want to receive bad news if the need should arise. Do they want to tell their family on their own? Or would they prefer to let everyone hear together and be able to ask questions of the provider as the news is divulged? When asking the patient for an invitation to speak, ask also if it is okay to speak freely in front of family in the room. Most patients indicate during research studies that they want as much information as possible about their illness, though they may not express their full desire to providers (and they may not retain the details of what has been shared if they have a strong emotional response to the news).
Step 4 (Knowledge) is the actual process of giving information to the patient. If the news is bad, many clinicians are advised starting with a “warning shot;” this may lessen the shock that follows disclosure and may facilitate processing of the information to follow. The warning shot may be prepared earlier in the process as well. For example, it can be provided when the office calls a patient to set up an appointment, as in: “Is there anyone that you’d want to bring with you to this appointment? I’m afraid we have some serious things to discuss.” The separation in time between the warning shot and the actual disclosure may ease the patient into the coping process.
Once the patient has been told that it is not good news, follow the “Ask, tell, ask” procedure. In Step 3, the patient was asked how much information they wanted to know. Use Step 4 to actually tell them that information in small quantities. Reevaluate the patient’s verbal and non-verbal cues throughout the discussion and ask if it is okay to proceed with the conversation. Use nontechnical words, but be sure to use words that will allow the patient to clearly understand what you are telling them when they are ready. For example, instead of telling a patient that there is an “invasive mass” in their liver, one might say, “There is a large cancer in your liver” (not a “tumor”). Instead of “metastasized,” use “spread.” Instead of “dyspnea,” say “shortness of breath.” Excessive bluntness must be avoided (“There is nothing we can do to treat this cancer”) to keep patient’s feeling engaged in the conversation and to avoid inciting a feeling of isolation and anger—but one should try to gage what additional information is given by soliciting what additional questions the patient and family may have.
A good rule of thumb along the lines of “ask, tell, ask” is to give at most three pieces of information at a time before checking for understanding. Repeat information as much as is necessary for the patient and their family. Asking the patient to summarize periodically what you have shared with them thus far can be helpful in checking to see if information is being received.
Most importantly, help the patient and family find hope. If the hope is no longer in the form of a cure, assist the patient in changing the therapeutic goal or the “hope object.” Hope objects will be addressed in more detail later in this chapter. Sometimes patients may have to deal with strong negative emotions (see next section) after hearing bad news before they are able to see hope. But just because there is no treatment for their cancer, one can potentially be hopeful for a good quality of life moving forward or for other important personal or family outcomes.
Step 5 in the SPIKES protocol (Emotions) is to respond humanistically to the patient’s emotions. Most people find this to be the most difficult part of giving bad news. Although one can hypothesize how a patient might react to life-altering news, the range of emotions is endless. Following your disclosure, wait for the patient to react. Begin by acknowledging and if possible naming the emotion (“I see that you’re sad, Mr. Green.”). It is helpful also to identify the reason for the emotion. “I imagine that you feel this way because you were hopeful that the treatment was going to work.” Legitimize the emotions that you have identified (“Most anyone hearing such news would feel [sad, angry …]”). Rather than trying prematurely to reassure, try exploring the emotion so you fully understand it (“Tell me about the most difficult part …”). Let the patient know that you have connected their emotion to the feeling behind it with a statement to reflect your understanding. “I would probably feel the same way if I were you.” It is important to allow the patient sufficient time to express their fears and emotions. Listen carefully and do not interrupt. Allowing patients to talk freely about what they are experiencing and feeling will improve how you both feel about the value of the conversation.
An approach to responding to patient emotion. ||Download (.pdf) An approach to responding to patient emotion.
|Acknowledge that emotion is being expressed ||“I can see that this is upsetting to you.” |
|Legitimatize the normalcy of the emotion ||“Anyone receiving this news would be devastated.” |
|Explore more about what is behind the emotion ||“Tell me more about that …” |
|Empathize with the emotion if you genuinely feel it ||“I can imagine that this feels disappointing.” |
|Explore strengths ||“In past circumstances, what has helped?” |
Empathy is defined as being able to personally imagine what the patient is feeling and experiencing. (see Chapter 2). Empathy can be a very powerful tool in building trust and relationships with patients if done correctly; empathic statements made by the physician are associated with increased family satisfaction. However, if an empathic response is done without sincerity or when a patient is not ready to accept another’s compassion, it can end up being harmful to a therapeutic relationship. For instance, if a patient is silent at the conclusion of the divulgence of bad news, they are not clearly expressing any emotion to the physician. In this case, it is helpful to explore what the patient is thinking and feeling prior to offering an empathic response. Sometimes the feelings of the provider can provide a clue as to how the patient is feeling, but this is not always accurate. If a physician is feeling anxious while anticipating a response from a patient after having given bad news, this may represent the physician’s own response and not necessarily a guide to how the patient is feeling (countertransference).
Addressing a patient’s emotions during the conversation may help mitigate anxiety in both provider and patient, prevent depression later in the course of the illness, and improve overall satisfaction with the interaction. Patients report less distress when they feel that their physician detected and addressed their concerns. Although identifying and responding to emotional cues requires focus, experience, and time, clinical interactions may actually take longer when emotional cues are missed.
Physicians often want to respond empathically to a patient’s visual cues and feelings, though sometimes physicians may also be experiencing feelings such as hopelessness and perhaps guilt at not having detected the disease earlier. Providers may fear that responding empathically may be construed as evidence of inadequacy, mistakes, or failure. Before expressing empathy, clinicians should try to be sure that they are responding to the patient’s feelings and not their own. Clinicians’ feelings and reactions are important, but unless they relate directly to the patient’s experience, they should be explored in other settings with trusted colleagues.
When giving bad news to a patient or family, generally avoid apologizing unless you have clearly made a mistake that you are ready to acknowledge. Apologies can be mistaken for admissions of guilt or of error on the part of the clinician. Though we may feel like we need to apologize for being the bearer of bad news, apologies can be problematic to physicians for many reasons. Patients may confuse an apology as an expression of pity or can change the emphasis of the conversation from the feelings of the patient to the feelings of the physician. “I’m sorry” may also limit further exploration of the patient’s feelings. A good surrogate expression for “I’m sorry” as proposed by Quill is an “I wish” statement. “I wish I had better news for you” allows the physician to walk in the patient’s shoes while acknowledging that the news is unlikely to change.
Compassion can take many forms. For instance, empathy can be shown by giving recommendations in light of what the physician knows of the patient’s beliefs, goals, fears, and medical situation. For example, “From what I know about your ideals, Mr. Green, I would recommend switching to a hospice plan of care. This will allow for you to have the best possible quality of life for whatever time you have left.”
Factors that improve attentiveness to and empathy for the patient during this difficult discussion include older age, female gender, and personal experience on the part of the physician. One study illustrated that physicians who had personally experienced life-threatening illness were more attentive to the emotional needs of the patient than those who had not. The same study concluded that older physicians give more emotional support to patients than their younger counterparts. Female physicians spend more time giving bad news to patients than male physicians.
Step 6, the final step of the SPIKES protocol (Set goals), is to summarize the conversation and to engage with the patient in creating a clear plan for the future. This step is essential in decreasing a patient’s anxiety and level of uncertainty. At this point into the conversation, the patient has heard a lot of information that affects them very personally. Ask, first, if the patient and family are ready for a discussion about the plan. If they are not, briefly review the conversation to that point and ask for further questions about what has been said. Most likely at this point patients will be eager to plan for and discuss the next step. Present the possible treatment options in small bits and elicit patients’ values and preferences as it relates to the possible treatment options. Clearly state each option and make a recommendation based on your medical expertise and experience as well as your knowledge of the patient’s values as to which one you think would work best. Work together to come up with a decision; shared decision making with the patient relieves some pressure for the physician should the treatment not be completely successful. Referring patients to support groups within the community has also shown some benefits in those with terminal illnesses. There has been some evidence to suggest that patients who share experiences with supportive physicians and a group of peers with similar experiences have improved quality of life, experience less pain, and cope more effectively with terminal illnesses than those who do not attend support groups.
Some providers might consider briefly writing down the diagnosis and possible treatment plans for the patient to look up when they feel ready. In some studies, physicians audio-recorded these consultations, so that patients could take them home; however, reliving this experience may contribute to poorer mood and increasing rates of depression for patients. Schedule a follow-up appointment with you and other appropriate consultant(s) for the patient before he or she leaves your office. They may not feel up to completing these tasks while they are processing their bad news.
Patients are not likely to ask about prognosis during this initial discussion. In one survey of over 30 patients newly diagnosed with cancer, only 1 patient asked for a specific prognosis. Studies have shown that patients value qualitative estimates of prognosis far more than quantitative assessments. Doctors consistently overestimate survival in terminally ill patients, especially those who have a short life expectancy. Patients may vary in their desire for prognosis disclosure over the course of their illness as well; at their first visit, they may be more interested in information about their disease and possible course of treatment, with curiosity regarding prognosis revealed at later visits. If a patient desires some information at the time of the initial discussion, provide an average range of survival with caveats that they may lie also outside of that range in either direction. “The average person with your condition will live (3-6) months. Some will live longer, and we will do our best to try to have you be in that group, but also some may live shorter, so you should get prepared just in case.” Clinicians need to be aware if they tend to be optimists or pessimists in their prognostication, but the inclusion of the possibility of being outside the expected range helps compensate for that to some degree.
It has been generally agreed upon by clinicians and researchers in this area that the SPIKES protocol assists both patients and physicians in breaking bad news. Most guidelines are based on expert opinion with little evidence about the best method for breaking bad news. Remember that all guidelines recommend tailoring the interview to the patient, and that each discussion will be different, depending on differences between patients. Not every conversation surrounding unfavorable information will require all six steps, but when it does, the steps of the SPIKES protocol should generally be done in sequence.