For some medical schools, they want to see how you communicate in difficult situations. One such situation is delivering bad news, a perfect test for empathy, listening and communication skills, as well as how you handle uncertainty and discomfort. Nonetheless, if you ask most doctors, they still find the breaking of bad news to be extremely stressful, so the question is – how should one approach such a scenario?
Let’s suppose that you need to break the news to your patient that he/she has advanced cancer (poor prognosis).
SPIKES is an approach which you could use – practical, simple and easy to remember.
Ensure the patient is seated comfortably in a room with privacy. If possible, arrange a meeting involving their significant other or family member, and make sure you as a doctor won’t be interrupted either by your colleagues or your busy pager during the process.
It is appropriate to first ask the patient what they know about their condition. A question like “What do you know about your medical condition so far?” would be a good start, so that you can steer the subsequent discussion based on your patient’s understanding and also clear up any misconceptions.
Similar to the concept of “consent,” a doctor should overtly ask for the patient’s permission as to whether they want to receive their full diagnosis and prognosis. To avoid the awkward interjection of asking permission, it has been recommended to ask at the time of ordering tests. Note that it is possible for patients to refuse, since it has been shown psychologically that shunning information is a coping mechanism adopted by cancer patients. If that is the case, do make sure to offer that you will answer any questions that may pop up in the future.
Upon obtaining the patient’s permission, warn them what is coming by saying something like “I’m sorry to tell you that…” in order to lessen the impact of the bad news. Make sure you break it to them in small chunks, in simple language (i.e. no medical jargon), and with pauses (long enough for them to understand the information given to them). Furthermore, avoid being too negative. For instance, when talking about treatment options for a bleak prognosis, mention treatment options that are still available for the patient, such as palliative care.
Emotions + Empathy
Observe and identify the emotions of the patient, and it is often desirable to name the reason behind their emotions to show that you understand. A friendly touch on the arm and an offer of tissue paper may help the patient.
Strategy + Summary
Similar to the “invitation” step, it is wise to ask for permission to talk about treatment plans before launching into it, since patients may not be ready after a shocking revelation of their condition. Although there are many models for doctor-patient relationships, it may seem that a deliberative model is most suitable: the doctor may help the patient explore their values and goals, and choose the treatment that befits them.
Lastly, end with a brief summary of what was covered and ask the patient again if there are issues that have not been discussed.
Handbook of Advanced Cancer Care by Michael J. Fisch, Eduardo Bruera