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L 21 Challenging Patient Encounters and SPIKES Protocol — Study Notes

Learning Objectives

  • Recognize various patient, provider, and situational factors that may contribute to challenging patient encounters.
  • Describe communication strategies that can be used during a challenging patient encounter to improve the outcome.
  • Understand the components of the SPIKES protocol and describe how the protocol is used to deliver bad news to a patient.

Prevalence and Forms of Challenging Encounters

  • Difficult encounters are estimated to represent 15\% \text{ to } 30\% of family physician visits.
  • They take on many different forms and arise from multiple factors contributing to why an encounter is perceived as difficult or challenging.

Key Concepts in Challenging Encounters

  • Challenging patient encounters involve: identification of the encounter as difficult, development of feelings of angst or helplessness generated during the conversation, and emotional responses such as frustration affecting the interaction.

Contributing Factors

  • Factors are categorized as Health, Patient, Situational, and Provider.

Health, Patient, and Situational, Provider factors

  • Factors can be interrelated and may influence the quality of interaction.

Health/Provider Factors

  • Attitudes
  • Emotional burnout
  • Intolerance of diagnostic uncertainty
  • Negative bias towards specific health conditions

Health/Provider Factors (Additional Aspects)

  • Conditions
  • Anxiety/depression
  • Personal health issues
  • Sleep deprivation

Provider Knowledge and Skills

  • Knowledge: Inadequate training in psychosocial medicine; Limited knowledge of the patient’s health condition
  • Skills: Difficulty expressing empathy; Easily frustrated; Poor communication skills

Patient Factors (Behavioral and Conditional)

  • Behavioral: Angry/argumentative/rude; Demanding/entitled; Drug-seeking; Highly anxious; Hypervigilance to body sensations; Manipulative; Non-adherent; Not in control of negative emotions; Reluctant to take responsibility for health/self-saboteur
  • Conditional: Addictions to alcohol or drugs; Belief systems foreign to provider; Chronic pain syndrome; Conflict between patient’s and provider’s goals for the visit; Financial constraints affecting adherence; Functional somatic disorders; Low health literacy; Multiple (more than four) medical issues per visit; Physical, emotional, or sexual abuse

Patient Factors (Psychiatric Diagnoses)

  • Borderline personality disorder; Dependent personality disorder; Mood disorders (anxiety, depression)

Situational Factors

  • External factors influencing the visit: Time pressures; patient/staff conflicts; complicated social issues
  • Conflict between addressing pathophysiological issues and patient’s psychological needs

General Principles for Success

  • Active listening to show messages are heard; think before reacting; engage in a fair and conscientious manner; keep the focus on the problem, not personal issues; seek mutual gains in resolution (Ballweg’s Chapter 14).
  • Be empathetic, caring, and non-judgmental.
  • Foster a team relationship.
  • Redirect an encounter when appropriate using effective communication strategies.

Redirecting an Emotionally Charged Encounter: Effective Communication Strategies

  • Active listening
  • Validate the emotion and empathize
  • Explore alternative solutions
  • Provide closure

Active Listening (Provider Actions and Examples)

  • Understand the patient’s priorities; let the patient talk without interruption; recognize that anger is usually a secondary emotion.
  • Examples:
    • "Please explain to me the issues that are important to you right now."
    • "Help me to understand why this upsets you so much."

Validate the Emotion and Empathize (Provider Actions and Examples)

  • Name the emotion (you can be corrected if wrong)
  • Disarm intense emotion by agreement when appropriate
  • Understand the emotion and do not share it
  • Examples:
    • "I can see that you are angry."
    • "You are right – it’s annoying to sit and wait in a cold room."
    • "It sounds like you are telling me that you are scared."

Explore Alternative Solutions (Provider Actions and Examples)

  • Engage the patient to find specific ways to handle the situation differently in the future
  • Examples:
    • "If we had told you that appointments were running late, would you have liked a choice to wait or reschedule?"
    • "What else can I do to help meet your expectations for this visit?"
    • "Is there something else you need to tell me so that I can help you?"

Provide Closure (Provider Action and Examples)

  • Mutually agree on a plan for subsequent visits to avoid future difficulties
  • Examples:
    • "Would you like to call us before your next appointment and we can tell you if we’re behind?"
    • "Would you prefer to be referred to a specialist, or to follow up with me to continue to work on this problem?"

Challenging Encounters: Variation by Patient Characteristics and Approaches

  • The type of challenges varies by patient, and different approaches may work better depending on the situation.

Insecure, Desperate for Assurance, Worried About Abandonment

  • Approach: Patient may seek sympathy; provider should maintain professional demeanor and establish boundaries; offer assurance of non-abandonment; schedule regular follow-ups.

Often Angry, Does Not Want Unnecessary Steps, May Be Reacting to Fear and Loss

  • Approach: Patient may be aggressive and see provider/health system as barriers; provider may feel anger, guilt, doubt, or frustration.
  • Strategy: Suspend judgment; examine your own feelings; address evident emotion directly without reacting defensively; reinforce the right to good care but manage anger directed toward systems.

Wants Attention, Has Difficulty Trusting; Recurrent Help-Seeking/Non-Improvement

  • Approach: Patient manipulates to engage; engage by sharing frustrations over poor outcomes; work with the patient to set limits on expectations; reformulate health plan to focus on symptom relief rather than cure.

Feels Hopeless About Changing the Situation; Possible Untreated Anxiety/Depression; Self-Destructive Habits Persist

  • Approach: Provider may feel ineffective; recognize complete resolution may be limited; set realistic expectations; redirect to identify non-adherence causes (money, time, access); celebrate small successes; offer psychological support or arrange it.

Do’s and Don’ts in Challenging Encounters

Some Do’s

  • Understand patients can have “bad days" too.
  • Realize people aren’t usually at their best when sick, afraid, in pain, newly diagnosed, dying, or dealing with death.
  • Use self-reflection to identify personal biases; discuss challenges with trusted colleagues; seek experienced input.
  • Serve as a good representative of your medical group and the PA profession.

Some Don’ts

  • Don’t expect perfection from self or patients; don’t argue with patients; don’t belittle or humiliate; don’t allow things to escalate; consider rescheduling if needed.

And Some More Don’ts

  • Don’t dismiss concerns without adequate time, work-up (history, exam, labs/tests as needed), and explanation.
  • Don’t let another provider’s label prevent you from doing your own assessment.
  • Don’t give up on your patients.

Breaking Bad News (Overview)

  • Bad news in medicine: any news that drastically and negatively alters the patient’s view of their future.
  • It is unfortunate but a frequent part of medicine.

SPIKES Protocol: Overview

  • Six-step protocol for delivering bad news; not every episode requires all steps, but when used, steps follow in sequence.

SPIKES Protocol: The Steps

  • Setting
  • Perception
  • Invitation or Information
  • Knowledge
  • Emotions
  • Strategy and Summary

SPIKES: Setting

  • Arrange for privacy
  • Involve significant others if the patient wishes
  • Sit down and make connection with the patient
  • Manage time constraints and interruptions

SPIKES: Perception (Assessing the Patient’s Perception)

  • Determine what the patient already knows and what their perceptions are about the medical situation
  • Gather understanding using open-ended questions
    • Examples:
    • "What have you been told so far?"
    • "What is your understanding of the reasons we did the MRI?"
  • This step helps assess misunderstandings and illness denial
  • Ask how much and what kind of information the patient wants
  • Sample questions:
    • "How would you like me to give the information about the test results?"
    • "Would you like me to give you all the information or sketch out the results and spend more time discussing the treatment plan?"
  • Some patients may not want all details; offer to answer future questions

SPIKES: Giving Knowledge and Information

  • Warn the patient that bad news is coming to lessen shock and aid processing
  • Example phrase: "I’m sorry to tell you that…"
  • Guidelines for explaining medical facts:
    1) Start at the patient’s level of understanding and vocabulary
    2) Use plain language (e.g., "spread" instead of "metastasized", "tissue sample" instead of "biopsy")
    3) Avoid excessive bluntness (e.g., avoid saying the patient will die without immediate treatment)
    4) Provide information in small chunks and check understanding
    5) For poor prognosis, avoid phrases like "There is nothing else we can do for you"

SPIKES: Address the Patient’s Emotions

  • Patients’ emotional reactions vary; shock and grief are common; be ready to provide empathy

Four Steps to an Empathetic Response

  • Observe for any emotion
  • Identify the emotion by naming it to oneself
  • Identify the reason for the emotion
  • After giving time to feel, acknowledge connection between emotion and reason with a connecting statement

Examples of Expressing Empathy

  • PA: "I’m sorry to say that the x-ray shows that the chemotherapy doesn’t seem to be working [pause]. Unfortunately, the tumor has grown somewhat."
  • Patient: "I’ve been afraid of this!" [cries]
  • PA: [moves chair closer, offers tissue, pauses] "I know that this isn’t what you wanted to hear. I wish the news were better."

Examples of Empathetic Responses

  • "I can see how upsetting this is to you"
  • "I can tell you weren’t expecting to hear this"
  • "I know this is not good news for you"
  • "I’m sorry to have to tell you this"

Expressing Empathy: Validating Responses

  • "I was also hoping for a better result"
  • "I also wish the news were better"
  • Empathetic responses validate and acknowledge clinician emotion while supporting patient feelings
  • Examples of validating responses:
    • "I can understand how you felt that way"
    • "You were perfectly correct to think that way"
    • "Many other patients have had similar experiences"

SPIKES: Strategy and Summary

  • Summarize information using patient-understandable language
  • Discuss and present a strategic plan

SPIKES: Readiness, Shared Decision-Making, and Misunderstandings

  • Before discussing a treatment plan, ensure the patient is ready for that discussion
  • Maintain shared responsibility for decision-making with the patient
  • Check for misunderstandings

Practical Takeaways and Additional Resources

  • Coffee with Bailey: When facing challenging encounters, consider that the problem may reflect the caregiver’s feelings toward the patient; thorough social history can illuminate patient problems.
  • Additional resources and videos for breaking bad news and serious illness discussions are recommended (MD Anderson course materials and Pearls and Pitfalls videos).

References and Further Reading

  • An PG, Rabatin JS, Manwell LB, et al. Burden of difficult encounters in primary care: data from the minimizing error, maximizing outcomes study. Arch Intern Med. 2009;169(4):410-414.
  • Haas LJ, Leiser JP, Magill MK, Sanyer ON. Management of the difficult patient. Am Fam Physician. 2005;72(10):2063-2068.
  • Cannarella Lorenzetti R, Jacques CH, Donovan C, Cottrell S, Buck J. Managing difficult encounters: understanding physician, patient, and situational factors. Am Fam Physician. 2013;87(6):419-425.
  • Buckman R, Kason Y. How to break bad news: a guide for health care professionals. Baltimore: Johns Hopkins University Press; 1992.
  • Fallowfield L, Jenkins V. Effective communication skills are the key to good cancer care. Eur J Cancer. 1999;35(11):1592-1597.
  • Baile WF, Buckman R, Lenzi R, et al. SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-311.
  • Kaplan M. SPIKES: a framework for breaking bad news to patients with cancer. Clin J Oncol Nurs. 2010;14(4):514-516.
  • Ritsema et al. Ballweg’s Physician Assistant: A Guide to Clinical Practice, 7th Edition, 2022