Module 7: Communicating Through Health Challenges

Healthcare providers can structure difficult conversations using three communication frameworks. These are…

The SPIKES Protocol, the COMFORT model, and the BATHE model.

The SPIKES Protocol

A 6-step structured process for delivering bad news.

SPIKES

S – Setting up the interview: preparing the physical environment, privacy and rapport before beginning.

SPIKES

P – Assessing the patient’s perception: finding out what the patient already knows or suspects about their condition/the situation.

SPIKES

I – Obtaining the patient’s invitation: Asking how much detail or information the patient wants to receive.

SPIKES

K – Giving knowledge and information to the patient: Sharing the diagnosis clearly and directly without overwhelming jargon.

SPIKES

E – Empathic responses: Acknowledging and validating the patient’s emotional reactions.

SPIKES

S – Strategy and summary: Outlining next steps, treatment plans, and summarizing key takeaways.

The COMFORT Model

A set of competencies encouraging providers to adapt consistently to patients' evolving communication needs.

COMFORT

C – Communication: The use of verbal messages to relay the content or information, along with the use of nonverbal messages to connect with the patient and build trust.

COMFORT

O – Orientation and Opportunity: The provider attends to the patient’s culture and identity as well as their health literacy level.

COMFORT

M – Mindfulness: Refers to the ability to be in the moment, and thus following a patient’s cues as well as the provider’s internal cues for how to be authentic.

COMFORT

F – Family: Emphasizes the importance of including the family in any healthcare decisions or experiences.

COMFORT

O – Openings and Oversight: Communication that encourages support beyond the initial disclosure of bad news.

COMFORT

R – Reiterative Communication: Considering that breaking bad news is not necessarily a one-time act, but rather an ongoing conversation that the provider must have with the patient and their family.

COMFORT

T – Team structure and process of care: Making sure that the provider is effectively communicating with the patient and their family, as well as other healthcare team members.

The BATHE Model

Emphasizes the importance of being empathetic when breaking bad news to patients and their family members.

BATHE

B – Background information: Inquiring about what is currently happening in the patient's life.

BATHE

A – Affect: Asking how the patient feels emotionally about the situation.

BATHE

T – Trouble: Inviting the person to identify what aspect of the problem troubles them most.

BATHE

H – Handling: Discuss how the patient is handling the situation or responding emotionally and practically.

BATHE

E – Empathy: Explicitly expressing understanding and emotional validation.

Definition of Empathy

The skill of attending to the emotions of another person, understanding those emotions, and responding to those emotions.

Empathetic opportunity

A point at which it is clear that a patient is feeling a strong emotion.

Example of empathetic opportunity

A patient diagnosed with a chronic illness bursts into tears and says, “I’m terrified I won’t be able to keep my job or provide for my family.”

Empathetic opportunity continuer

A response which invites an explicit expression of emotion with a patient.

Example of empathetic opportunity continuer

Reply with an explicit emotional expression by saying, “I hear how heavy this worry is for you, and it makes complete sense that you're feeling scared right now. Tell me more about what concerns you most about work, and we will work through this together."

Empathetic opportunity terminator

A response that ignores the emotions in the room and steamrolls ahead with a task-oriented agenda.

Example of empathetic opportunity terminator

“Don’t worry about work right now. Let's look at this chart and get your prescriptions sent over to the pharmacy.”

Communication vs. Conformity Orientation

Family communication patterns, guides the way in which we communicate with others. There are two underlying sets of beliefs (communication orientation and conformity orientation).

Communication Orientation

The degree to which members of the family communicate openly with one another about a range of topics after experiencing bereavement of a family member. Families with high conversation orientation communicate regularly with each other. Families with low conversation orientation view communication as something irrelevant and unnecessary for a satisfying successful family life.

Example of Communication Orientation

Following the death of a parent, a family gathers at dinner to share memories, openly talk about their sadness, and discuss individual fears about life without them. No topic is off-limits, family members are encouraged to speak honestly about their feelings.

Conformity Orientation

Describes the degree to which the family maintains shared norms, beliefs, and behaviors while grieving. High conformity families use their interactions to highlight and enforce uniformity of thought. Low conformity families communicate in ways that emphasize diversity in attitudes, beliefs, and values.

Example of Conformity Orientation

Following the death of a parent, the family elders establish an unspoken rule that everyone must stay strong, refrain from crying in front of visitors, and focus solely on carrying on family traditions without expressing doubt or negative emotions. Any family member who tries to voice unconventional feelings or question family decisions is pressured to fall in line.