~Giving Bad News

SPIKES

S: setting

P: perception

I: invitation

K: knowledge

E: emotions

S: summarize and strategize

S: setting

• prepare yourself

  • know the medical facts (e.g., what treatments your patients are going through, what their functional status is, what their prognosis is, etc.)

  • recognize the limitation in your knowledge (i.e., know what you don’t know)

• participants

  • who will be present from the family? (e.g., who are the important people in the family?)

  • who will be present from the medical team (e.g., RN, SW, chaplain, etc.)

  • pre-meeting among the medical team

• check the environment 

  • privacy, sitting, a box of tissues

  • ensure all relevant or requested parties are present

  • turn off beeper/phone 

  • translator if needed (i.e., don’t let family translate)

P: perception

• what does the patient know?

  • ask-tell-ask

• establish what the patient already knows

  • “what do you understand about your condition?”

  • “what have doctors explained to you so far?”

• while you are listening, pay attention to…

  • level of comprehension

  • the vocabulary the patient is using

I: invitation

• how much does the patient want to know?

  • right to know vs right not to know

    • personality, character, preference

    • cultural variation

    • designate someone to communicate on his or her behalf

  • “are you the type of person who wants information in detail…?” (i.e., do they want to know everything about their condition? or would they prefer that information just gets relayed to their caregiver?)

• "is it OK if we talk about how your medical condition is?”

  • always get consent

• giving a warning shot

  • convey the gravity of the situation without harshness in speech

  • “we are very concerned about you” > “you have cancer”

K: knowledge

• speak slowly, clearly, simply

  • 50% rule- don’t be the one speaking for more than 50% of the conversation

  • 2-minute rule- be able to summarize everything you want to say in 2 minutes

• no medical jargon

  • utilize their language

  • consider their health literacy

• allow silence

  • can be good for giving emphasis to your message as well

• do not rush into further discussion

E: emotions

• cognition

  • thinking, reasoning, judging 

  • tells us what patients understand rationally 

• emotion

  • not under conscious control; it is involuntary

  • flash of worry, expression of frustration or shock 

• silence (active listening), empathy, and validation of feelings will help with most emotional reactions 

• when one is emotional, cognition does not work

• NURSE

  • N: Name the emotion 

    • “it sounds like this has been frustrating”

  • U: Understand the emotion

    • “it must be so hard to be in pain like this”

  • R: Respect the patient 

    • “i’m so impressed that you have been able to keep up with your treatment”

  • S: Support the patient

    • “my team will be here to help you and your family”

  • E: Explore the emotion 

• potential pitfalls

  • answering emotions with facts

  • moving onto strategy too quickly

  • check in before moving on

“i’m sorry….” vs “i wish…”

• after you explained everything, “Doctor, is there any other treatment?”

• i wish > i’m sorry 

  • “i wish i could offer chemotherapy…(silence)” > I’m sorry, but I cannot offer chemotherapy any more, because your cancer has progressed, and your kidney function is getting worse, and because your functional status is poor, and…

    • try not to supplement messages with “but” too; it undermines whatever you said before

S: summarize and strategize

• summarize and reassess the understanding 

  • “how will you explain all of this to your family?”

• make a follow-up plan

• pitfalls: thinking about “S” only from your perspective

  • Dispo

  • Getting a DNR

don’t say this…

• do you want us to do everything?

  • who would say no to this? we will do everything anyway

• there is nothing more we can do

  • there are still lots of things we can do; add “for the cancer”

• withdrawal of care

  • care always continues; withdrawal of the life support

• it’s your decision

  • “i’m not responsible; you are”- bad