On July 3, 2015, at approximately 2:00 a.m., I was awakened by my mobile phone ringing. I looked at the number the call was originating from and was fearful this was the call I was dreading to receive. My mother’s long-term care facility was calling, and the news was not good. My mother was found without a pulse and was rushed to a local hospital.
I called the emergency department of the local hospital and spoke to a physician. He proceeded to tell me all the medical procedures done to my mother. He said nothing worked and mother did not make it. He was friendly, yet business-like in his tone. He said he would be available for any questions. He never made any type of sympathetic statement.
My brother and I rushed to the emergency department, and a nurse took us to a private room. Based on her body language and voice, she seemed visibly uncomfortable sharing the news. She stumbled on her words. I could understand that giving bad news is challenging. She reiterated what was done and asked if we wanted to see my mother’s body. She never made any type of sympathetic statement, but she did say, “Our bodies were not meant to last forever.”
The nurse took us to see my mother’s body. My brother and I said our emotional goodbyes. During this time, a young lady walked in the room. She was smiling and upbeat. In most cases, that type of behavior is welcome, but not in this case. My brother and I are standing next to our mother’s body, and she stated in a perky manner, “Hi. I need you to sign some forms.” She never made any type of sympathetic statement.
A new nurse came into the room and stated he previously took care of my mother and remembered her sweetness. He said, “You have my condolences.” Finally, the fourth person we spoke to offered sympathy for our loss.
Everyone we encountered during that fateful night was certainly pleasant. However, everyone could have handled the situation in a much more appropriate and caring manner. No one effectively handled the situation. This article will focus on three steps to delivering bad news.
The three steps provide a general framework, however there is a vast array of situations in which bad news must be delivered, from notifying a family member of a loved one’s death to discussing the diagnosis of a life-threatening illness. Within each situation, there are multiple variables. Also, this is not meant to be a comprehensive review of the process; rather these are the general guidelines.
I have been studying the process of delivering bad news for over a decade. I have read the academic literature, interviewed experts in the field and spoke to thousands of patients and family members about their experiences receiving difficult news.
Working in health care all my life, I know we don’t have the luxury of time. With high patient volumes and massive amounts of documentation, we have little time. These steps are designed to help you quickly assess the situation and provide the appropriate clinical information in a caring manner.
One of the pioneers in the field is the late Dr. Robert Buckman, who was an oncologist at the University of Toronto, and author of the ground-breaking book, How to Break Bad News. He developed the SPIKES approach, which is an acronym containing the following items: Setting (S), Perception (P), Invitation (I), Knowledge (K), Empathy (E) and Strategy and Summarize (S). Dr. Buckman passed away in 2011 at the age of 63; however his legacy lives on through his amazing body of work. I feel honored to have known Rob (he always insisted on having me call him by his first name). I tend to think in chronological order, so I have taken all the elements of his SPIKES tool and put them into this three-step sequential process.
Before giving the news (patient not present)
- Plan the agenda. Think about the 2 to 3 key points the patient or family members must know.
- For each point, use everyday language; no jargon.
- Arrange the physical setting in an appropriate manner. It is ideal that both the professional and patient or family members are sitting. When professionals sit, this sends a message, “I have time for you.” Be sure tissues are readily available!
- Schedule a time to speak. Also, think of who needs to be present, such as a spouse or adult child.
Giving the news
- Assess the patient’s current level of knowledge. This assessment will help you understand where to begin the discussion. For example, you can say, “How much do you know about the situation?”
- Determine the amount of information the patient or family wants to know. Some people only want the “big picture” while others want every detail.
- Utilize a buffer statement, also known as a “Warning Shot.” These statements help people psychologically prepare for the news. For example, you can say, “I’m afraid I have some difficult news …” or “I’m afraid the test results were not what we hoped for …”
- Deliver the news.
After giving the news
- Immediately use an empathic response. For example, you can state, “I know this is hard to hear …” (Add a sympathetic response in cases where the patient died. For example, you can state, “I’m sorry for your loss.” or “You have my deepest condolences.”)
- You have provided empathy (and sympathy, if appropriate); now allow time for the response. Take your cues from the person and, if present, the family members. People need time to process.
- Share the action plan. Review the plan and highlight key points. If you have delivered a difficult diagnosis, discuss what happens next. Do not give a long continuous review of the plan. Use the “chunk and check” strategy; provide a “chunk” of information, then “check” into determine understanding. Repeat the chunk and check process. You are breaking down the material into manageable units of information. Please keep in mind, people feel overwhelmed and may not remember a lot of what was said so be sure to include written information. Many patients have told me, for example, “As soon as she said the word, ‘cancer,’ I didn’t hear anything else after that …”
- Supply resources. The information can include helpful websites and referrals to community organizations.
- Close with partnership language. For example, you can state, “We will be with you every step of the way.”
Delivering the news in person vs. on the phone. Throughout the past decade, in my many interviews with patients about their experiences with bad news, I was surprised about the responses to this topic. Most people said immediacy was the most important factor for them. They did not want to wait for an appointment; they wanted the news ASAP, and if that meant calling, then that is fine. Intuitively, I would have thought just the opposite, that people would prefer an in-person meeting. When you must deliver the news via a phone call, the same steps apply.
Not a “physician only” subject. People often think that this topic applies only to physicians; however every healthcare professional needs to understand the basic process. It is vital because sometimes, a healthcare professional may unexpectedly be giving the news and not even know it. An example will clarify this statement. A physician told me of a case where a hospitalized patient was diagnosed with sarcoma. The physician carefully planned his words and was preparing for intense emotions. However, he found the patient took the news much better than he expected. A few days later, a nurse was reviewing the discharge plans with this patient and mentioned an appointment with an oncologist. The patient then stated, “An oncologist? Why? I don’t have cancer.” No one told the patient that sarcoma is a type of cancer. The nurse unexpectedly delivered the news, and it was a very emotional scene.
Unexpected reactions. In these cases you are expecting a significant emotional response; however that is not what occurred. One urologist mentioned he always carefully plans his words when he has to deliver the difficult news to a man that has just been diagnosed with prostate cancer. He did all the right things (e.g., quiet room, employed empathy, etc.) with one older patient and after breaking the news, the gentleman calmly stated, “Most of my buddies have it, so no big deal.” A medical social worker mentioned an experience when she told a patient that his HIV test was positive. He nonchalantly responded by saying, “Yeah, thought so. I haven’t been careful.” A big word of caution in these cases! Simply because they appear to be OK initially, doesn’t mean they are OK in the long term. Careful follow through is vital with all patients, even those that appear to be initially fine with the news.
By incorporating the steps outlined in this article, you will be able to compassionately help patients facing these difficult life experiences.
Edward Leigh is founder and director, Center for Healthcare Communication.
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