Week 10 - Breaking bad news

Question 1

Why is it important to tell patients bad news?

Answer 1

• To maintain trust
• To reduce uncertainty
• To prevent unrealistic expectations
• To allow appropriate adjustment
• To promote open communication
• Most patients wish to know their diagnosis and be informed about the progress of the treatment and disease
• Doctors find it easier to treat and care for patients if they know their diagnosis
• Lack of information can increase patient uncertainty, anxiety, distress and dissatisfaction

Question 2

What are the implications for patients if bad news is not delivered well?

Answer 2

It can have an impact on:

• Doctor-patient relationship
• Emotional well-being
• Adjustment to and ability to cope with the illness, for patients and their relatives

Question 3

What is the SPIKES model for breaking bad news?

Answer 3

• Setting and listening skills
  — Break the bad news face to face
  — Avoid informing relatives first
  — Ensure privacy and no interruptions, allow enough time
  — Find out who the patient wants present
  — Introduce yourself and any colleagues (ideally no more than 3 staff)
  — Sit down, eyes on same level
  — No physical barriers (e.g. no computer in the way)
  — Have tissues available
  — Listening mode – silence and repetition
• Patient’s perception
  — What does the patient already know?
  • Before you tell, ask
  • Start consultation with general question, e.g. “what have you been told about all this so far”
• Invitation from patient
  — Don’t assume the patient will want to know everything
  • E.g. Ask “how much information would you like me to give you about your diagnosis and treatment?”
  — If the patient declines information at any point, respect this
  — Allow for denial and offer opportunity for further discussion
• Knowledge
  — Give a warning shot
  • “I’m very sorry to have to tell you this”
  — Direct patient to diagnosis:
  • Give information in small chunks
  • Give patient time to consider and ask questions before continuing
  • Check understanding
  — Avoid jargon, align language with patient
• Empathy
  — “How are you feeling?”
  — Acknowledge connection between news and emotion
  • “I can see this news is very upsetting for you”
  — Validate/normalise emotion
  • “I can understand why you feel that way”
  — Listen to patient’s concerns
• Strategy and summary
  — Summarise the main discussion topics and check understanding again
  — Discuss strategy, agree on next step
  — Be optimistic, but avoid inappropriate/premature reassurance
  — Signal closure, give opportunity to ask questions
  — Offer future availability
  — If the patient is still distressed ask if they would like a member of the healthcare team to remain, someone to be contacted or to be left alone