Breaking Bad News

Situations where it needs

• Disclosing the diagnosis of cancer
• Any failure of treatment where serious
consequences
• Disclosing metastatic disease
• Discussing serious treatment toxicity
• Announcing death to close personnel
• Disclosing positive results of genetic disease
• Withdrawn of support system
• The aim for any health-professional is to use
their skills to deliver bad news
– clearly
– honestly
– sensitively

in order that patients can both understand and

feel supported.
 SPIKES –
The Six-Step Protocol for Delivering Bad News

• STEP 1: SETTING UP the Interview

• STEP 2: Assessing the Patient’s PERCEPTION
• STEP 3: Obtaining the Patient’s INVITATION
• STEP 4: Giving KNOWLEDGE and Information
to the Patient
• STEP 5: Addressing the Patient’s EMOTIONS
with empathic responses
• STEP 6: Strategy and Summary
 Setting
• Greet the person appropriately
• Introduce yourself

• Establish reason for Visit

• Who else the patient wants to be present
• Sit down

• Maintain privacy
• Look attentive and calm with Listening mode
• Make sure you have checked all the available information and have test
results
• Decide general terminology to be used
 Perception
• What patients knows
• What has happened to patient
• What was informed to patient
• What changes he aware of from last visit
• Is the patient is in denial?
 Invitation

• Indicate you have the results

• Encouraged to ask questions

• Ask whether patient would like to know again

• Assess how much the patient would like to know

• If patients do not want details, offer to answer any

questions they may have later or talk to a relative or
friend
 Knowledge
• Give a warning to help the patient prepare
• At this point WAIT: allow the patient to think and only
continue when the patient gives some lead to follow.
The pause may be a long one, commonly a matter of
minutes
• Give the information without fudging in small chunks.
Avoid technical terms. Check understanding frequently.
Watch the signs the patient can take no more
• A broad time frame (whatever) can be given
• Be prepared for question. “What is my prospect?”
• Warm: Provide some positive information
 Empathy
• Be prepared for the patient to have disorderly
emotional responses of some kind
• Crying can be a release for some patients. Allow
time
• Learn to judge which patients wish to be
touched and which do not.
• Always watch out for shutdown
• Keep pausing to allow patients to think
• Stop the interview
 Strategy and summary
• The patient has understand what has been
discussed because thought processes are
disorganized at times of emotion and
misconceptions can take root
• The patient writes down crucial information to
take away
• The patient knows how to contact the appropriate
team member and thus has a safety net in place
• Family members are invited to meet the clinicians
as the patient wishes
• Everyone is bid goodbye, starting with the patient
SEGUE Model
 Set the stage
• Greet patient/person appropriately
• Establish reason for Visit
• Outline agenda for visit
• Make a personal connection during visit
• Maintain patient’s privacy
 Elicit Information
• Elicit patient’s view of health problem and/or progress
• Explore physical/physiological factors
• Explore …./emotional factors
• Disease accident treatment
• Disease lifestyle issues/prevention strategies
• Avoid leading questions
• Give patient opportunity / time to talk
• Listen give undivided attention
• Check clarify information
 Give Information
• Explain rationale for diagnosis procedures
• Teach patient about his/her own body &
situation
• Encourage patient to ask questions
• Adapt patient’s level of understanding
 Understand the patient’s perspective

• Acknowledge the patient accomplishments

• Acknowledge waiting time
• Express caring concern, empathy
• Maintain a respectful tone
 End the counter
• Ask if there is anything else patient would like
to discuss
• Review next steps with patient’s
 Don’t in the counseling relationship

2. Don’t use
1. Don’t ask ‘why’
‘should’ and
questions ‘ought’
3. Don’t blame
the patient
4. Don’t compare 5. Don’t invalidate
the patient’s
experience
feeling
 Four habit model
• Invest at the beginning
• Elicit the patient’s perspective
• Demonstrate empathy
• Invest at the end