BREAKING OF BAD NEWS

Methods/protocols of breaking bad news  

1.  SPIKES method 
2. BREAKS method 

Spikes protocol of breaking bad news 

S – Set up the interview: Plan ahead for details such as being sure that you are in a private,  comfortable setting, that significant others are involved (if the patient wants that), and that your  pager is silenced. 

It is worth investing some time and thought in practical issues such as:

•  Where will an interview about bad news take place?
• Who will be present?
• How will you start the discussion?

These simple things can help both you and the patient to feel more at ease, which will aid communication later in the conversation.

Where? If at all possible, use a separate room where you can sit down together in privacy. If this is not possible, and the patient is in hospital, try at least to screen off the area where you will be talking. This does not prevent others from listening, but the patient does not have to cope with the bad news in full view of others. You will probably be more comfortable too; don’t forget to minimize interruptions such as mobile phones.

Who? If the patient has visitors when you arrive, find out who they are. Ask the patient whether she/he is happy to continue the interview with the visitor(s) present. Beware that the patient may find it hard to truthfully answer this question while the visitor(s) is (are) listening. Some patients may wish to have a particular relative present when they are told bad news, and this option should also be given. For example: ‘We now have the results of your tests Benjamin, would you like me to explain them to you now, or would you like a friend or relative to be with you when we go through things?’

How do you start?

Firstly, do not forget to ensure that the patient is covered up and comfortable. Greet the patient by name, and introduce yourself if the patient does not know you well. It is useful to begin by creating a rapport. Next you may ask a question such as ‘How are you feeling today?’ This shows that you are interested in his/her condition, gets the patient talking, and allows you to assess something of the patient’s current symptoms (if the patient is in pain, or feeling nauseated, that should be addressed if at all possible before proceeding to a sensitive conversation).

P – Assess the patient’s perception: As described earlier, before you begin an explanation, ask the  patient open-ended questions to find out how he or she perceives the medical situation. In this way  you can correct any misunderstanding the patient has and tailor the news to the patient’s  understanding and expectations. 

It is vitally important to the rest of the consultation to establish what the patient already knows about their condition, how serious they think it is, and how they expect it to affect the future. Useful starting phrases include:

•  ‘What do you understand about your illness?’
• ‘What have you been told about this illness?’
• ‘Have you been concerned that this may be something serious?’

 Listen to the patient’s reply carefully. As well as telling you about his/her understanding of the medical situation, it will give you information about the patient’s emotional state, educational level, and vocabulary. This will help you later to explain things at a level, which is appropriate.

I – Obtain the patient’s invitation: Find out how much detailed information the patient wants  regarding diagnosis and prognosis. 

In any conversation about bad news, the real issue is not ‘do you want to know’, but ‘at what level do you want to know what is going on’. The majority of patients will know themselves when things are not going well (especially if they have heard no good news). In asking the patient about information sharing, you are simply finding out how much detailed information the patient wishes to know.

 Research studies have demonstrated that most patients do desire full disclosure, although they may not want to know all the details at the start. By establishing how much the patient wants to know we are allowing them to exercise their preference. 

 The following are examples of useful ways to phrase the question:

• ‘Are you the kind of person that likes to know all about their illness?’
• ‘Would you like me to tell you the full details of the diagnosis, even if it is something serious?’
•   ‘Would you prefer me to discuss the situation directly with your family?

In all of these, if the patient does not want to hear about the full details you have not cut off all lines of communication. You are saying clearly that you will maintain contact and communication, but not about the details of the disease.

K – Give knowledge and information to the patient: Communicate in ways that help the patient  process the information. For example, preface your remarks with a phrase such as, “I’m sorry to tell  you that …” or “Unfortunately I have some bad news to tell you.” Use plain language and avoid medical  jargon: use the word “spread” instead of “metastasized,” for instance. Provide information in small  amounts, use short sentences, and check periodically for understanding.

Now the process of sharing information can commence, aimed at bringing the patient’s perception of the situation closer to the medical facts. Information needs to be given in small chunks, and using a warning shot is very valuable, especially if the news is unexpected. 

A useful phrase may be one such as ‘Well, the situation appears more serious….’ followed by a pause then using a narrative approach, possibly describing events leading up to this point.

Understandable language needs to be used, avoiding medical terminology as much as possible. The patient’s understanding of the discussion should be checked frequently and important points can be clarified as necessary. Further clarification may be undertaken by repeating important points and also by using diagrams and writings, if this is appropriate.

E – Address the patient’s emotions with empathic responses: As described earlier, identify the  patient’s primary emotion and express that you recognize that what the patient is feeling is a result  of the information received. This is the place to use continuer statements such as “I can imagine how  scary this must be for you.” 

The success or failure of the interview for breaking bad news ultimately depends on how the patient reacts and how you respond to those reactions and feelings. There are many different ways in which a patient may react.

Some of the more common reactions include: disbelief, shock, denial, fear and anxiety, anger and blame, guilt, hope, relief, despair and depression.

S – Strategy and summary: Present treatment or palliative care options, being sure to align your  information with what you ascertained (during the assessment of the patient’s perceptions) to be the  patient’s knowledge, expectations, and hopes. Providing a clear strategy will lessen the patient’s  anxiety and uncertainty. 

The final stage of this process consists of organising and planning for the future, which will involve putting together what you know of the patient’s wishes, the medical scenario and the plan of management.

Initially an understanding of the patient’s problem list is essential. Through effective listening and reflecting the patient will know that you have an overall appreciation of their immediate problems. Honesty is very important and the Health Professional should not be unrealistically optimistic about the future. This will avoid future lack of trust or disillusionment from the patient.

This is often an appropriate time to formulate and explain a plan or strategy with the patient, which generally includes preparing for the worst and hoping for the best. Throughout this time the coping strategies of the patient should be identified and reinforced, and this will include identifying other sources of support for the patient and incorporating them. These may be other Health Professionals or close family/friends.

Before leaving the patient it is essential that a contract for the future is made, this will include either arranging a time to see the patient again or advising him/her whom they can contact.

(We can either include this or remove since much has been explained above)

In summary, although there are challenges in giving a patient bad news, a nurse can find satisfaction in providing a therapeutic presence during the patient’s greatest time of need. Communication skills play a very big and important role in breaking bad news.