first of all:
provides hope to the patient, support to caregivers, and encourages the healing process
- Be prepared. What do they know and want to know?
- Warn that you have serious news.
- Be simple and clear. Tailor the information to the patient.
- Has the message been understood? If not, check how much more information the patient wishes to know.
- Pause to let it sink in then respond to their reaction and to difficult questions.
- Summarize and establish a plan for how to move on.
meeting these goals is accomplished by completing six tasks or steps, each of which is associated with specific skills. Not every episode of breaking bad news will require all of the steps of SPIKES, but when they do they are meant to follow each other in sequence.
The Six Steps of SPIKES
STEP 1: S—SETTING UP the Interview
Mental rehearsal is a useful way for preparing for stressful tasks. This can be accomplished by reviewing the plan for telling the patient and how one will respond to patients' emotional reactions or difficult questions. As the messenger of bad news, one should expect to have negative feelings and to feel frustration or responsibility [55]. It is helpful to be reminded that, although bad news may be very sad for the patients, the information may be important in allowing them to plan for the future.
Sometimes the physical setting causes interviews about sensitive topics to flounder. Unless there is a semblance of privacy and the setting is conducive to undistracted and focused discussion, the goals of the interview may not be met. Some helpful guidelines:
- Arrange for some privacy. An interview room is ideal, but, if one is not available, draw the curtains around the patient's bed. Have tissues ready in case the patient becomes upset.
- Involve significant others. Most patients want to have someone else with them but this should be the patient's choice. When there are many family members, ask the patient to choose one or two family representatives.
- Sit down. Sitting down relaxes the patient and is also a sign that you will not rush. When you sit, try not to have barriers between you and the patient. If you have recently examined the patient, allow them to dress before the discussion.
- Make connection with the patient. Maintaining eye contact may be uncomfortable but it is an important way of establishing rapport. Touching the patient on the arm or holding a hand (if the patient is comfortable with this) is another way to accomplish this.
- Manage time constraints and interruptions. Inform the patient of any time constraints you may have or interruptions you expect. Set your pager on silent or ask a colleague to respond to your pages.
STEP 2: P—Assessing the Patient's PERCEPTION
Steps 2 and 3 of SPIKES are points in the interview where you implement the axiom “before you tell, ask.” That is, before discussing the medical findings, the clinician uses open-ended questions to create a reasonably accurate picture of how the patient perceives the medical situation—what it is and whether it is serious or not. For example, “What have you been told about your medical situation so far?” or “What is your understanding of the reasons we did the MRI?”. Based on this information you can correct misinformation and tailor the bad news to what the patient understands. It can also accomplish the important task of determining if the patient is engaging in any variation of illness denial: wishful thinking, omission of essential but unfavorable medical details of the illness, or unrealistic expectations of treatment [56].
STEP 3: I—Obtaining the Patient's INVITATION
While a majority of patients express a desire for full information about their diagnosis, prognosis, and details of their illness, some patients do not. When a clinician hears a patient express explicitly a desire for information, it may lessen the anxiety associated with divulging the bad news [57]. However, shunning information is a valid psychological coping mechanism [58, 59] and may be more likely to be manifested as the illness becomes more severe [60]. Discussing information disclosure at the time of ordering tests can cue the physician to plan the next discussion with the patient. Examples of questions asked the patient would be, “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?”. If patients do not want to know details, offer to answer any questions they may have in the future or to talk to a relative or friend.
STEP 4: K—Giving KNOWLEDGE and Information to the Patient
Warning the patient that bad news is coming may lessen the shock that can follow the disclosure of bad news [32] and may facilitate information processing [61]. Examples of phrases that can be used include, “Unfortunately I've got some bad news to tell you” or “I'm sorry to tell you that…”.
Giving medical facts, the one-way part of the physician-patient dialogue, may be improved by a few simple guidelines. First, start at the level of comprehension and vocabulary of the patient. Second, try to use nontechnical words such as “spread” instead of “metastasized” and “sample of tissue” instead of “biopsy.” Third, avoid excessive bluntness (e.g., “You have very bad cancer and unless you get treatment immediately you are going to die.”) as it is likely to leave the patient isolated and later angry, with a tendency to blame the messenger of the bad news [4, 32, 61]. Fourth, give information in small chunks and check periodically as to the patient's understanding. Fifth, when the prognosis is poor, avoid using phrases such as “There is nothing more we can do for you.” This attitude is inconsistent with the fact that patients often have other important therapeutic goals such as good pain control and symptom relief [35, 62].
STEP 5: E—Addressing the Patient's EMOTIONS with Empathic Responses
Responding to the patient's emotions is one of the most difficult challenges of breaking bad news [3, 13]. Patients' emotional reactions may vary from silence to disbelief, crying, denial, or anger.
When patients get bad news their emotional reaction is often an expression of shock, isolation, and grief. In this situation the physician can offer support and solidarity to the patient by making an empathic response. An empathic response consists of four steps [3]:
- First, observe for any emotion on the part of the patient. This may be tearfulness, a look of sadness, silence, or shock.
- Second, identify the emotion experienced by the patient by naming it to oneself. If a patient appears sad but is silent, use open questions to query the patient as to what they are thinking or feeling.
- Third, identify the reason for the emotion. This is usually connected to the bad news. However, if you are not sure, again, ask the patient.
- Fourth, after you have given the patient a brief period of time to express his or her feelings, let the patient know that you have connected the emotion with the reason for the emotion by making a connecting statement. An example:
- Doctor: 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]
- Doctor: [Moves his chair closer, offers the patient a tissue, and pauses.] I know that this isn't what you wanted to hear. I wish the news were better.
In the above dialogue, the physician observed the patient crying and realized that the patient was tearful because of the bad news. He moved closer to the patient. At this point he might have also touched the patient's arm or hand if they were both comfortable and paused a moment to allow her to get her composure. He let the patient know that he understood why she was upset by making a statement that reflected his understanding. Other examples of empathic responses can be seen in Table 2⇓.
View this table:
Table 2.
Examples of empathic, exploratory, and validating responses
Until an emotion is cleared, it will be difficult to go on to discuss other issues. If the emotion does not diminish shortly, it is helpful to continue to make empathic responses until the patient becomes calm. Clinicians can also use empathic responses to acknowledge their own sadness or other emotions (“I also wish the news were better”). It can be a show of support to follow the empathic response with a validating statement, which lets the patient know that their feelings are legitimate (Table 3⇓).
View this table:
Table 3.
Changes in confidence levels among participants in workshops on communicating bad news
Again, when emotions are not clearly expressed, such as when the patient is silent, the physician should ask an exploratory question before he makes an empathic response. When emotions are subtle or indirectly expressed or disguised as in thinly veiled disappointment or anger (“I guess this means I'll have to suffer through chemotherapy again”) you can still use an empathic response (“I can see that this is upsetting news for you”). Patients regard their oncologist as one of their most important sources of psychological support [63], and combining empathic, exploratory, and validating statements is one of the most powerful ways of providing that support [64-66] (Table 2⇑). It reduces the patient's isolation, expresses solidarity, and validates the patient's feelings or thoughts as normal and to be expected [67].
STEP 6: S—STRATEGY and SUMMARY
Patients who have a clear plan for the future are less likely to feel anxious and uncertain. Before discussing a treatment plan, it is important to ask patients if they are ready at that time for such a discussion. Presenting treatment options to patients when they are available is not only a legal mandate in some cases [68], but it will establish the perception that the physician regards their wishes as important. Sharing responsibility for decision-making with the patient may also reduce any sense of failure on the part of the physician when treatment is not successful. Checking the patient's misunderstanding of the discussion can prevent the documented tendency of patients to overestimate the efficacy or misunderstand the purpose of treatment [7-9, 57].
Clinicians are often very uncomfortable when they must discuss prognosis and treatment options with the patient, if the information is unfavorable. Based on our own observations and those of others [1, 5, 6, 10, 44-46], we believe that the discomfort is based on a number of concerns that physicians experience. These include uncertainty about the patient's expectations, fear of destroying the patient's hope, fear of their own inadequacy in the face of uncontrollable disease, not feeling prepared to manage the patient's anticipated emotional reactions, and sometimes embarrassment at having previously painted too optimistic a picture for the patient.
These difficult discussions can be greatly facilitated by using several strategies. First, many patients already have some idea of the seriousness of their illness and of the limitations of treatment but are afraid to bring it up or ask about outcomes. Exploring the patient's knowledge, expectations, and hopes (step 2 of SPIKES) will allow the physician to understand where the patient is and to start the discussion from that point. When patients have unrealistic expectations (e.g., “They told me that you work miracles.”), asking the patient to describe the history of the illness will usually reveal fears, concerns, and emotions that lie behind the expectation. Patients may see cure as a global solution to several different problems that are significant for them. These may include loss of a job, inability to care for the family, pain and suffering, hardship on others, or impaired mobility. Expressing these fears and concerns will often allow the patient to acknowledge the seriousness of their condition. If patients become emotionally upset in discussing their concerns, it would be appropriate to use the strategies outlined in step 5 of SPIKES. Second, understanding the important specific goals that many patients have, such as symptom control, and making sure that they receive the best possible treatment and continuity of care will allow the physician to frame hope in terms of what it is possible to accomplish. This can be very reassuring to patients.
Experience with the SPIKES Protocol
Oncologists' Assessment of SPIKES
In the ASCO survey mentioned previously, we asked participants if they felt the SPIKES protocol would be useful in their practice. Ninety-nine percent of those responding found that the SPIKES protocol was practical and easy to understand. They reported, however, that using empathic, validating, and exploring statements to respond to patient emotions would be the greatest challenge of the protocol (52% of respondents).
In teaching, the SPIKES protocol has been incorporated into filmed scenarios, which appear as part of a CD-ROM on physician-patient communication [67]. These scenarios have proven useful in teaching the protocol and in initiating discussion of the various aspects of breaking bad news.
Does the SPIKES Protocol Reflect the Consensus of Experts?
Very few studies have sampled patient opinion as to their preferences for disclosure of unfavorable medical information [69]. However, of the scarce information available, the content of the SPIKES protocol closely reflects the consensus of cancer patients and professionals as to the essential elements in breaking bad news [3, 13, 50-54]. In particular, SPIKES emphasizes the techniques useful in responding to the patient's emotional reactions and supporting the patient during this time.
Can Students and Clinicians Learn to Use the Protocol?
Most medical undergraduate and postgraduate programs do not usually offer specific training in breaking bad news [70] and most oncologists learn to break bad news by observing more experienced colleagues in clinical situations [39]. At the University of Texas M.D. Anderson Cancer Center we used the SPIKES protocol in interactive workshops for oncologists and oncology fellows. As an outcome, before and after the workshop we used a paper and pencil test to measure physician confidence in carrying out the various skills associated with SPIKES. We found that the SPIKES protocol in combination with experiential techniques such as role play can increase the confidence of faculty and fellows in applying the SPIKES protocol [47] (Table 3⇑). Undergraduate teaching experience also showed that the protocol increased medical students' confidence in formulating a plan for breaking bad news [
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