Breaking Bad News BBN Points to consider: 1 Breaking bad news requires both verbal & non-verbal communication skills, so be aware of your gestures, facial expressions, tone of voice, & indeed be wise in choosing your words. 2. SPIKES protocol is used to deliver the bad news a S: Setting up interview P: perception |: Invitation K: Knowledge E: Empathic response S: Strategy and Summary The Protocol: 1- Setting up the interview: b. Introduce yourself Gather patient information Explain to the patient (reason for coming) When setting down: i. Keep eye contact as appropriate. ii. Keep your chair at the level of the patient chair. ii, Make sure that the tissues are there. Ask the patient if he wants someone else to be with him/ her or NOT? i, Do you want your “brother, sister, son.. etc to be here with you? 2- Asses the patient Perception: Goal: To know the patient idea about what he thinks he has, to determine where he is standing now. Hence, unrealistic expectations and/or denial can be assessed after delivering the bad news. Also, to determine the proper way of delivering the information for this particular patient. Determine what the patient knows about his medical condition, and what he is suspecting. |. What have you been told about your condition so far?” OR “I want to make sure we're on the same page; what have other doctors told you?” ii. What is your understanding of why we did the MRI?” OR “When you first had (symptom), what did you think it might be?”3- Invitation “obtaining the patient invitation”: Goal: Obtain the patient’s permission. While many patients increasingly want to have details about their disease and diagnosis, some patients do not and this should be respected and appropriately managed. a. Obtain permission: i. “Would you like me to tell you the full details of your condition or is there someone else you would like me to talk to?” ii. "Would you like detailed information about your condition? Or do you prefer me to give a general idea about it?” b. Ifthe patient does not want to hear all the details, offer to discuss these details with a family member. Also, tell the patient that you are available whenever he wants to discuss any details in the future and that you respect his wishes. 4- Knowledge “giving knowledge and information about the patient”: Goal: To tell the patient the diagnosis in an appropriate way. 2. Give a warning shot! i. “Unfortunately I've got some bad news to tell you” OR “I’m afraid the test results shows that the problem is fairly serious” OR “I’m sorry to tell you. b. Avoid medical jargons: i. Use non-technical words such as ‘spread’ instead of ‘metastases’ il, Remember: patients may not understand the word ‘malignancy’. So use the word ‘cancer instead. «Provide information simply and honestly: i. DO NOT SAY: "you have cancer", as itis likely to leave the patient isolated and angry with a tendency to blame the messenger (you). ii, Use: “It looks like...” NOT “You have...” ‘And “there are tumors in the liver...” NOT “you have tumors in your liver...” 4. Give information in small chunks, and stop periodically to check patient understanding: i. ask, encourage questions and allow time: “Do you understand so far? Do you have any questions?" 5- Empathy “to explore emotion” Goal: To respond to patients’ emotions with empathy. a. Observe for any emotion on the part of the patient. This may be tearfulness, a look of sadness, silence, or shock. b. Show the patient that you are sensitive to his/her response and demonstrate that you are paying attention to how the news is affecting him. «. Use some empathic statements: i. can see how upsetting ths is to you Iv, This is very difficult for me also Ti. know this is net good news for you V. Iwas also hoping fora better result Ii Frmsozry to have to tell you thisIf the patient is silent, prompt by asking how they are feeling, and what they are thinking of. However, do not push it too far, and allow time if the patient feels they must cry. Empathetically respond the patient's feelings and justify them - "you have every right to feel this way” or “I understand why you feel this way” or “This would be upsetting for anyone” NOT “I know how you feel”. This validates their feelings or thoughts as normal and to be expected. Whenever he starts crying, empathize with him immediately and ask him if he wants to complete or not, 6- Strategy and summary: Goal: To make sure that the patient has understood his case, and to provide a clear treatment plan. Ask if patients are ready to discuss this. Check the patient understanding Provide a clear plan for the future (if there are any more tests, or if treatment should be conducted immediately). Also, provide treatment options and discuss a management plan. Ask whether they want to clarify something else, Give hope in terms of what is possible to accomplish. Explore patients’ ICE (ideas, concerns and expectations) You need to offer your help by setting a follow up appointment and referral to other supporting specialty like social services and/or psychology. Tell the patient: "You are welcome anytime for further discussions, or for any questions or concerns."