Bad News
- When giving bad news, ensure that the setting is appropriate, and ensure patient’s confidentiality
- Give bad news:
- in an empathic, compassionate manner
- allowing enough time
- providing translation, as necessary
- Obtain patient consent before involving the family.
- After giving bad news, arrange definitive follow-up opportunities to assess impact and understanding.
Approach to breaking bad (or serious) news
Approach to breaking bad (or serious) news
- STEP 1: S—SETTING UP the Interview
- Gather information, test results, treatment options (consider speaking to patient's other doctors).
- Identify if patient has decisional capacity, and if surrogate decision maker has been identified
- Translator if needed.
- Arrange for some privacy.
- Involve significant others (obtain patient consent).
- Sit down, make connection with the patient (eye contact or touch).
- Manage time constraints and interruptions.
- STEP 2: P—Assessing the Patient's PERCEPTION
- What have you been told about your medical situation so far?
- What is your understanding of the reasons we did the TEST?
- STEP 3: I—Obtaining the Patient's INVITATION
- How would you like me to give the information about the test results?
- Would you like me to tell you the details of the diagnosis?
- Would you like me to give you all the information or sketch out the results and spend more time discussing the treatment plan?
- STEP 4: K—Giving KNOWLEDGE and Information to the Patient
- Warning Shot
- I'm afraid I have some bad news
- I wish things were different, I wish I could say that
- I'm sorry to tell you that…
- Give information in small chunks, check understanding, use nontechnical words
- Generally would like to cover Diagnosis, Treatment Plan, Prognosis and Support
- Warning Shot
- STEP 5: E—Addressing the Patient's EMOTIONS with Empathic Responses
- Observe for any emotion on the part of the patient.
- Allow silence, do not argue.
- Identify the emotion experienced by the patient by naming it to oneself.
- If unclear, open questions to query the patient as to what they are thinking or feeling.
- Identify the reason for the emotion if not clear.
- After you have given the patient a brief period of time to express his or her feelings, let the patient know that you have connected the emotion with the reason for the emotion by making a connecting statement.
- I know that this isn't what you wanted to hear. I wish the news were better.
- Observe for any emotion on the part of the patient.
- STEP 6: S—STRATEGY and SUMMARY
- Identify other sources of support for the patient and incorporate them
- Invite questions
- Learn about patient/family goals given new reality
- Knowing that time is short, what's most important to you?
- Tell them what happens next, make recommendation to the patient/family about the most appropriate medical plan
- There's so much more we can do to improve your qality of life
- Suggest it may be in the best interest to have "their last moments of life in dignity and peace - a natural peaceful death", not to prolong the dying experience with procedures that have little benefit
- Arrange definitive follow-up opportunities to assess impact and understanding
References:
- AAFP 2008. https://www.aafp.org/afp/2008/0115/p167.html
- Baile et al. 2000. SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. http://theoncologist.alphamedpress.org/content/5/4/302.full