Breaking Bad News

Abdulmalik Binkhunayfir & Thamir Aldahmashi

 Breaking Bad News
(Approved by Dr.Reem Al Sudairy)

What is the definition of bad news?

-Any information, which adversely and seriously affects an
individual's view of his or her future
-It might be a medical-threatening case such as malignancy, HIV
infection or chronic illness such as diabetes or hypertension.
Keep in mind that "bad" news is different from one person to
another, yet the common dominator is that bad news is a message,
which has the potential to shatter hopes and dreams leading to very
different lifestyles & futures.
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.
In delivering any bad news, we usually use a method called
SPIKES protocol:

SPIKES Model for Breaking Bad News

1. S: Setting-up interview.
a. Introducing yourself.
b. Gather full information about patient. (Be prepared for any kind of
questions, especially regarding the choices of management.)
c. When you sit down:
-Keep eye contact.
-Keep the level of your chair relative to his/her. i.e. sit down face to face,
without any barriers between you (too close may feel intrusive to the
patient, but too far away may seem unconnected)
- Make sure tissues are there.
d. Ask if the patient wants someone else to be with him/her. (prior to the
interview)
- "Do you want your brother (or spouse, family member etc) to be with
you?"
2. P: Perception: Assessing patient's 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.

a. Determine what the patient knows about the medical condition or what
he suspects:
-What have you been told about your condition so far? OR I want to
make sure were on the same page; what have other doctors told you?
-What is your understanding of why we did the MRI? OR When you
first had (symptom), what did you think it might be?

3. I: Invitation: Obtaining the patients invitation.

Goal: Obtain the patients 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 the permission:

- would you like detailed information about your condition? Or do you
prefer me to give a general idea about it? OR 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?
b. If the 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. K: Knowledge: Giving knowledge and information to

patient.
Goal: To tell the patient the diagnosis in an appropriate way.
a. Give a warning shot:
- Unfortunately I've got some bad news to tell you OR Im afraid the
test results shows that the problem is fairly serious OR Im sorry to tell
you.
b. Avoid all medical jargon.
- Use non-technical words such as spread instead of metastases.
- Remember: patients may not understand the word malignancy. So use
the word cancer instead.
c. Provide information simply and honestly, avoiding excessive
bluntness.
- DO NOT SAY: you have cancer", as it is likely to leave the patient
isolated and angry with a tendency to blame the messenger (you).
- Use: It looks like. NOT You have.
And there are tumors in the liver NOT you have tumors in your
liver
d. Give the information in small chunks and stop periodically to check the
patients understanding.
- ask, encourage questions and allow time: Do you understand so far?
Do you have any questions?" *
* The idea here is give the patient time to digest the information & to
make sure that he understands what you are saying.

5. E: Empathy: Explore emotions and sympathize.

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.
c. Use some empathic statements:
I can see how upsetting this is to you
I know this is not good news for you
Im sorry to have to tell you this
This is very difficult for me also
I was also hoping for a better result
d. 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.
e. Empathetically respond the patients 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.
F. Whenever he starts crying, empathize with him immediately and ask
him if he wants to complete or not.

6. S: Summary and Strategy.

Goal: To make sure that the patient has understood his case, and to
provide a clear treatment plan.
a. Ask if patients are ready to discuss this.
b. 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.
c. Ask whether they want to clarify something else.
d. Give hope in terms of what is possible to accomplish.
e. Explore patients' ICE (ideas, concerns and expectations)
F. Close the interview.
- Check for the patient's understanding of what you have told him.
- You need to offer your help by setting a follow up appointment and
referral to other supporting specialty like social services and/or
psychology.
- You need also to refer the patient to patient's educator for more
information and support.
- Tell the patient: "You are welcome anytime for further discussions, or
for any questions or concerns."