Introduction

Delivering bad or unfortunate news to patients is part of the medical profession; after all, medicine is about looking after sick people. Bad news can be broadly categorized as diseases that may be chronic or lifelong, life-altering illness, diseases that significantly shorten life expectancy, and injuries that may persist or being seasonal.

Delivering bad news can be difficult and challenging to any physicians, and special care should be taken to learn these crucial skills. Patients will distinctively remember the day when bad news was delivered to them, and in a way, the physician becomes part of that moment. Having bad news being delivered inadequately can make a patient resentful and may always be bitter towards the healthcare team, which may impede on their health journey, whether palliative or not.

It is found that patients like to be with the physician when they hear the bad news to answer any questions, if they wish to ask. The physician needs to make sure that the language used is clear and easy to understand as well as an environment that reflects calmness, privacy and a safe space. Interestingly, patients have different ways of coping and receiving information, such that some patients want to know everything and others want to know the bare minimum. This behaviour is influenced by different cultures, age, education, gender and so on. Delivering bad news can also put a lot of pressure on the healthcare staff, and it has been found that some physicians are scared of causing a huge emotional reaction and being blamed for the patient’s unfortunate outcome. Some physicians may over-express themselves or too little or be too afraid in sharing their emotions in some instances. Being overly optimistic or withholding information may also damage the relationship between patients and the healthcare staff. Delivering bad news can be very tough, especially when the estimated prognosis has a broad time frame. Hence several frameworks enable bad news to be delivered correctly, in the best possible way and decreases the amount of stress on the patient and the physician.

Before setting up and getting the environment ready, it is essential to “fire warning shots” at the patient that needs a discussion. This includes asking the patient to come back so that results can be discussed and, if possible, to bring a family member with them. Warning shots are vital as it infers that there is bad news and may not be as shocking as if the patient had no warning shots. Imagine a situation where a patient arrives with no knowledge of anything serious going on only to be told that they have cancer that has spread (or even worse with a poor 5 years prognosis such as lung cancer). We want to avoid the 0 to 100 escalation in terms of bad news. Warning shots help the patient ease into the bad news and acknowledging it.

S - Setting

• Before seeing the patient, make sure to read up on the patient’s case and history and mentally rehearse for the upcoming meeting.

• Set up and plan ahead that the environment is private and comfortable. Have tissues or water available.

• Invite other significant people such as family or friends.

• Sit down with the patient if they wish to do so (provide the option). It may be appropriate to be in touching distance if the patient allows it.

• Create a rapport and maintain eye contact (do not look away or chart around).

• Switch anything that may be a distraction off, such as pagers and cellphones.

P - Perception

• What is the patient’s perception, knowledge or what do they suspect?

• Use open-ended questions to assess their perception of the situation.

• Perception is helpful in seeing the patient’s level of comprehension and if there are any misunderstanding or misinformation.

• Do not engage in confrontations and identify any denial or unrealistic expectations of the situation.

I - Invitation

• Find out how much the patient would like to know about their diagnosis and prognosis. This can be a very challenging question and moment in the interview.

• Ask permission, such as ask the patient if they want their results. This helps the patient to be in charge and control the moment, and if they are waiting for someone before hearing the news.

• If the patient declines, ask for another time or date so that results can be discussed. Encourage them if they want to bring their families or friends.

K - knowledge

• Summarize the events leading up to this point.

• Use simple, straightforward and easy to understand information.

• Think of socioeconomic status, culture, ethnicity, gender, age and so on.

• Deliver the news in small, comprehensible chunks and check understanding.

• Give positive aspects such as “has not spread to lymph nodes, treatment is available, good prognosis”.

• It is essential to give accurate facts.

E - emotions

• Assess the emotions of the patient and empathize.

• Validate how they feel.

• Give the patient some time.

S - strategy & summary

• Summarize understanding. Ask them if they have any questions, if they understand everything that has happened and if they have questions to write them down for the next visit.

• Set up a plan to move from there. It is important to let them know that they are not alone and that they won’t go through the treatment alone.

• Offer ways for contacting the team if there are further questions.

• If the prognosis is poor, do not end on “there is nothing else we can do”. There are always things that can be done, such as palliative care and increase the quality of life, pain control, legal advice and so on.

Published 15th February 2021. Last reviewed 1st December 2021.

Reference

Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-11. doi: 10.1634/theoncologist.5-4-302.

Berkey FJ, Wiedemer JP, ND Vithalani. Delivering Bad or Life-Altering News. Am Fam Physician. 2018;98(2):99-104.

Buckman, R. Breaking bad news: the S-P-I-K-E-S strategy. Community Oncology. 2005;2:183-142.

Caresearch authors. Communication Models SPIKES: A six-step protocol for delivering bad news. Caresearch website. https://training.caresearch.com.au/files/file/EoLEss/SPIKES.pdf. Accessed February 5, 2021.

Dr Francine Cheese. Breaking Bad News. Geekymedics website. https://geekymedics.com/breaking-bad-news/. Updated October 4, 2020. Accessed February 5, 2021.

UBC CPD authors. SPIKES protocol for breaking bad news. The University British Columbia website. https://ubccpd.ca/sites/ubccpd.ca/files/SPIKES%20Protocol%20for%20Breaking%20Bad%20News.pdf. Accessed February 5, 2021.