COMMUNICATION SKILLS WORKSHOP– COMMUNICATING BAD NEWS
Before getting started, a note to the facilitators of this session:
- Use this faculty guide as a resource to help facilitate; feel free to focus on aspects you think are necessary for your audience.
- Text in small print and italics is for your information and direction.
- Encourage comments and interaction from participants, and not just focusing on the faculty guide for generating discussion.
- Ensure a confidential and safe environment for practice
- Allow “time-outs” if participant wants to think through in the middle of role-play.
- Take notes as the participants are role-playing, to be able to give them specific and useful feedback at the end of the role-play
- Request specific feedback (both verbal and written on post-test) from participants
- Please remember to get post-test questionnaire completed by the trainees after the session
- Have fun teaching!
Session Outline
communicatiNG BAD NEWS
Developed by: Alicia Williams, MD and Ravishankar Ramaswamy, MD
TOTAL TIME: 75 min
- Objectives (2 min)
- Introduction (3 min)
- Didactic (15 min)
- Role-Play (50 min)
- Conclusion (5 min)
- Objectives
At the end of the session, the participants should be able to:
- Understand the SPIKES mnemonic
- Use the SPIKES mnemonic to communicate bad news
- Introduction
What is bad news?
Elicit trainees’ responses before saying the following:
•Any news that is bad to the PATIENT.
•Usually something that adversely affects his or her future.
Why is communicating bad news so difficult?
Elicit trainees’ responses before saying the following:
•Worry that you won’t be able to do it well
•Uncertainty about how patients or families will react
•Worry that it will be difficult to handle the reaction of patient or family
•Challenge of individualizing the approach
- SPIKES mnemonic
SPIKES was developed by an oncologist in Canada as a six-step model to communicate bad news with oncology patients. It is now extrapolated to other scenarios.
SPIKES model
•S-Setting
•P-Perception
•I-Invitation
•K-Knowledge
•E-Empathy
•S-Strategy and Summary
Setting
•Be prepared (discussed with medical team)
•Private setting
•Avoid interruptions (cover pager)
•Involve significant others
•Sit down (if possible)
•Look attentive and calm
•Listening mode (active listening, as in Session I)
Be prepared- ensure that you have discussed the diagnosis and plan with all caregivers for the patient, including specialists etc.
Be in a safe, quiet, setting whenever possible.
Avoid interruptions. Some examples include- scheduling meetings/appointments as the last one in the day; having a colleague cover pager or urgent telephone calls.
Ask patient prior to meeting who he/she would like to be involved in the meeting/discussion.
Be at patient’s eye level whenever possible.
Use active listening skills learned in Session I.
Perception
•Ask-Tell-Ask
•“What have you been told so far?”
•“Are you worried that this is something serious?”
•Do not confront denial (coping mechanism)
Perception- what does the patient (and significant others) know?
Some examples of some phrases that can be used to determine this.
Use the skills from Session I, such as Ask-Tell-Ask.
Do not confront denial. This has been shown to be a coping mechanism, and confrontation can sometimes lead to anger and deterioration in communication.
Clarify if the patient has denial or ignorance- some examples to trying to determine if patient is in denial
“What concerns you most about having cancer?”
Invitation
•Don’t assume that patients want to know everything
•“How much information would you like me to tell you about your diagnosis and treatment?”
•You must be invited by the patient or caregiver to discuss more regarding the diagnosis or prognosis.
•Also clarify in which setting patients would like to be told, and with whom.
Knowledge
•A few seconds to prepare psychologically
•“I have some bad news to tell you.”
•Avoid jargon
•Allow silence
•Small chunks of information (“Is this making sense?”)
Give patients the factual knowledge related to the diagnosis and prognosis.
Avoid medical jargon.
Be confident in delivery of information.
Become comfortable with silence, in order to allow patient to process information and come to terms with his or her emotions.
Do not bombard patients with too much information at once.
Give small amounts at a time, allow time for processing the information. Continue to review with the patient- Is this making sense?
Empathy
•Identify emotions
•If unclear- “How does this make you feel?”
•Validate emotions
•Can you think of some phrases?
•“I understand…”
•“I see that you are angry…”
•“This must be very frustrating…”
•Non-verbal support
Empathy- The ability to co-experience and relate to the thoughts, emotions, or experience of another without them being communicated directly by the individual
Sympathy- The ability to understand and to support the emotional situation or experience of another being with compassion and sensitivity.
First, start with trying to identify the patient’s emotions.
If it does not seem clear, ask the patient.
Strategize and Summarize
•Summarize discussion
•Plan the next steps
•Be available for follow-up.
Strategy and Summary involves preparation
Summarize the discussion/ meeting
Does the patient know what is going to happen next?
Who is he/she going to call and what is he/she going to say?
Let the patient know that you will be available for further follow-up/discussions.
- Skills Practice
Have the participants break into groups of 2 for role-play, one person acting as the physician, and the other as the patient.
They can use any of their own clinical scenarios or ones mentioned in the guide.
Assess participants for the skill they choose to practice, like one or more of aspects within the SPIKES
After the role-play session, elicit participants’ feedback on what they did well and what they could improve
Give specific feedback on aspects done well, and aspects that could be improved.
Allow for an opportunity to practice again, if time permits.
Then, have the participants change roles, so as to give the other person a chance to be the physician.
- Use of role-play to improve skills learned today
- Use any of your own challenging situations or practice cases given here
- Conclusion
Revisit the objectives, positives and challenges faced by the trainees during the session
- SPIKES is a systematic approach that can be used to communicate bad news in a clinical setting.
- Using this approach has been shown to improve patient satisfaction and hence the doctor-patient relationship.
References:
- Emanuel LL, von Gunten CF, Ferris FF, Hauser JM eds. “Module 2: Communicating Bad News” the Education in Palliative and End-of-Life Care (EPEC) Curriculum.
- Breaking bad news: the S-P-I-K-E-S strategy. Buckman, RA. Commun Oncol 2005; 2:138–142.
Additional Reading Resources:
- Discussing treatment preferences with patients who want “everything”. Quill TE, Arnold R, Back AL. Ann Intern Med. 2009; 151:345-349.
- “I wish things were different”: Expressing wishes in response to loss, futility and unrealistic hopes. Quill TE, Arnold RM, Platt F. Ann Intern Med. 2001; 135:551-555.
Cases for SPIKES Practice:
Case 1:
The Patient
You are a Grace Michaels, 67 year-old divorced female.
Until 5 years ago, you were happily married mother of 3 boys. You worked as a librarian and were involved in the community. After more than 30 years of marriage, you found out that your husband was having an affair with his secretary. You have since divorced, and found new happiness as a yoga instructor and with your boyfriend of 2 years, George.
You were fit and well until you were admitted to the hospital 3 weeks ago with shingles.
You were not concerned until a junior doctor asked you if you wanted to be tested for HIV. But you are confident of a negative diagnosis.
The Physician
Ms. Michaels is a 67 year-old female who was recently admitted to the hospital with shingles. She was also leukopenic, and HIV was checked. The result was positive. You checked the social history in the computer, and it states that she is a yoga instructor, divorced, adult children, sexually active with one male partner.
Your goal is to provide patient with HIV results- positive diagnosis. You do not know how to approach this.
Case 2:
The Patient
You are a Mr. Jones, aged 74.
You were recently admitted to the hospital with a severe case of pneumonia. There was some “fluid on the lungs” that was removed and sent for some tests. The doctor wants to discuss this with you.
You do not have any major medical illnesses and you do not see a primary care physician regularly. You and your wife live together in an apartment in the Bronx. You have 5 grown children, who live in Bronx, Long Island, Queens, North Carolina and Texas. Your daughter Susan, who lives in the Bronx, is in frequent contact, but you and your wife manage to take care of yourselves without any outside help
The Physician
You are the intern taking care of Mr. Jones.
Mr. Jones is a 74 year-old African-American male who was admitted to the hospital 5 days ago via the emergency room with shortness of breath. He had a dense infiltrate on X-ray and he is being treated with intravenous antibiotics and IV fluids. He had a large pleural effusion that was drained. Earlier today, you received the cytology report which states that pleural fluid contains adenocarcinoma cells. Repeat CXR also shows a mass in the right lower lobe and resolving infiltrate. Mr. Jones has been very lethargic since admission, but his mental status is improving.
You have asked to meet with Mr. Jones to discuss the results.
Case 3:
The Patient
You are the daughter of Mr. Smith.
Mr. Smith is an 89 year-old Caucasian male who was in a nursing home until 8 days ago. He became confused at the nursing home. His vital signs were checked, he had a high fever and he was sent to the ER. He was diagnosed with a severe urinary infection and sent to the ICU.
He is now on a breathing machine and has a lot of medications through his veins. You and your siblings, who live in California and Connecticut, have already made plans to take him on a boat cruise for his 90thbirthday. He was in the Navy and he is really looking forward to it.
You have a meeting with one of the ICU doctors who has been taking care of him. Three days ago, the doctors told you that he was not doing well; buthe has had many urinary tract infections before, and you don’t understand why the antibiotics are not working, and why he needs the breathing machine.
The Physician
Mr. Smith is an 89 year-old male with multiple medical problems, including COPD, prostate cancer, type II diabetes mellitus, hypertension and CKD. He was admitted 8 days ago with a high fever and had to be intubated and ventilated in the ER. He grew ESBL E. coli from his urine and is now in multi-organ failure on vasopressors. He cannot receive hemodialysis due to his blood pressure.
You are meeting with one of his daughters, Janet Smith, to discuss his prognosis.
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