Breaking bad news

Breaking bad news requires very delicate communication skills: you must show compassion, sensitivity and tact, while also being clear and straightforward with your patient, avoiding the temptation to play down or obscure painful truths. The SPIKES protocol (Baile et al. 2000) is widely used and is a very helpful way to structure the consultation.

Setting

Ensure you are in a comfortable and confidential room where you will not be interrupted

Perception

Outline events that have led up to the present situation
- Ask them what they already know/expect
- If possible, gently encourage the patient to say what the diagnosis is:

‘Could you tell me what’s happened so far?’

‘Do you have any ideas as to what the problem might be?’

‘Is there anything you have been worried about?’

Invitation

Check if the patient
- Wants to know the result now
- Would like a family member/friend to be present

‘I do have the result here today. Would you like me to explain it to you now, or would you prefer to have a family member/friend present?’

Knowledge

Giving the diagnosis

Build up to the result – give a warning shot
Chunk the diagnosis (stepped approach)
After every statement you make, pause and wait for the patient to respond (silence is the best thing at this point – there are a million thoughts going around in their head)
If the silence is very awkward, you can ask a question about what’s going through their mind or how they are feeling

‘As you know, we took a biopsy and, unfortunately, the results are not what we wanted.’ PAUSE AND WAIT

‘I’m very sorry to tell you it is a cancer.’

Explaining

DO NOT launch into explanation – during the knowledge stage and afterwards, the patient must lead the consultation – only answer questions they ask (they will not remember anything else you say)
Chunk and check any requested explanations

Emotions and Empathy

Acknowledge and reflect back their emotions (including body language)
Don’t try to solve their problems or reassure them, just listen and summarise/bounce back their concerns and expand on them (it shows you are listening and conveys empathy)
If there is a lot of silence, you can ask cautiously about their feelings

‘I can see this news is a huge shock.’ PAUSE AND WAIT

‘I imagine this news must be making you very anxious.’ PAUSE AND WAIT

‘How are you feeling about hearing this news?’

‘This must be extremely distressing for you. How are you feeling right now?’

‘There must be so much going through your head right now. Would it help to talk about it?’

Strategy and Summary

Agree on a plan
Summarise concerns

Communicating during the consultation

Breaking the news

Stepped approach (wait for a sign of approval from the patient before moving on from each step):
- ‘I’m afraid it’s not good news, Mrs Smith.’ PAUSE AND WAIT FOR PATIENT TO ASK
- ‘Unfortunately the lump is a problem.’ PAUSE AND WAIT FOR PATIENT TO ASK
- ‘Yes, I’m so sorry to have to tell you, it is a cancer.’ PAUSE AND WAIT FOR PATIENT TO ASK
Next: Don’t say anything until the patient speaks. This can feel difficult and take a long time but it’s the best approach to take from this point onwards in the consultation. But if the silence really is too prolonged, you can try gently moving the discussion forwards to the patient’s feelings. (See above under Emotions and Empathy stage.)

Responding to cues/questions

Cues can be verbal or non-verbal. They may be subtle and the only manifestations of much stronger feelings – the ‘tip of the iceberg’
Dealing with a cue
- Bounce it back (you must show you have recognised it)
- Empathise
- Explore the content of the cue, e.g. ‘Would it be OK if I asked more about that?’
- In general, don’t try to solve problems – it may well be that you can’t. Concentrate on listening sympathetically and encouraging the patient to open up.
e.g. ‘I’m dying, what does it matter?’
- ‘I think I can imagine why you might feel like that. But sometimes it can still be helpful to talk about everything that’s going through your head right now.’ PAUSE AND WAIT
- ‘I’m so sorry – this news must be devastating for you. I can’t imagine how difficult this must be for you right now.’ PAUSE AND WAIT FOR PATIENT

Don’t start giving information until it is requested

Patients have such pressing concerns that they can find it difficult to listen to what you’re saying. You need to address their concerns out first.
Prompt if you need to, e.g. ‘You must have so much going through your mind right now. Would it help to talk about it?’
Summarise back and expand on all their concerns