What is bad news? Any news that seriously and adversely

changes the patient’s views of his/her future.

There is a gap between the patients expectations and reality of the patient’s medical condition.

The task is to close this gap. Usually applies to situations where there is ;

o a feeling of no hope.o a threat to an individual’s physical and

mental wellbeing.o a risk of upsetting an established life

style.o a message given which implies a person

has fewer choices.

Examples of medical conditions which could be a bad news

Life threatening illness.eg: Cancer, HIV

Degenerative conditions.eg: Alzheimer dementia

Chronis illnesseg: Rheumatoid arthritis, Systemic lupus erythematosus

Mental retardation in childreneg: Downs syndrome, Cerebral palsy

Breaking bad news Forms part of clinical practice. A skill that can be taught and improved. Patients and relatives appreciate it. The degree to which news is bad depends

on the gap between reality and patient’s perception.

Benefits of learning to break bad news skillfully Better psychological adjustment by patient. Reduces stress in doctors. Facilitates open discussion among patients,

relatives and doctors. Empowers patients by allowing them a

greater say in treatment.

How to deliver sensitive information effectively? By being prepared.o Consider what needs to be told.o Ensure adequate and correct information.o Have answers ready for common

questions. eg: Treatment options and availability. Costs Prognosis How long have I got doctor? Can it be cured?

Follow a protocoleg: SPIKES protocol

SPIKES protocol

S – Setting Where to break news.

eg: A quiet room preferably not during ward round.

By appointment.eg: After ward round, at 3p.m.

Ask whether prefers to have relatives. (or in Sri Lanka perhaps first speak to relatives)

Physical context of interview.eg: Sitting down, body language, eye contact

Introduce your self and ascertain how others are related to the patient.

Listening skills – open questions to start, do not interrupt.

P – Perception of condition/seriousness Ask what he already knows about the

medical condition or what he suspects. Listen to level of comprehensions. Accept denial but do not confront at this

stage.

I – Invitation from the patient to give information Ask patient if s/he wishes to know the

details of the medical condition and/or treatment.

Accept patient’s right not to know. Offer to answer questions later if s/he

wishes.

Spikes protocol for breaking bad newsDr. P. Galappaththy

K – Knowledge: giving medical facts Use language intelligible to patient. Give to patient’s level – Consider

educational level, socio-cultural background, current emotional state

In small chunks Check whether patient understood what

you said. Respond to patients reactions as they

occur. Give any positive aspects first.

eg: Cancer has not spread to lymph nodes, highly responsive to therapy, treatment available locally etc.

Give facts accurately about treatment options, prognosis, costs etc.

E - Explore emotions and sympathize Empathetic response1. Identify emotion.2. Identify cause/source of emotion.3. Respond in a way that you have recognized

connection between 1 and 2.4. In empathetic response not necessary for

you to feel same emotion or agree to patient’s view point.

S – Strategy and summary Close the interview. Ask whether they want to clarify something

else. Offer agenda for the next meeting.

eg: I will speak to you again when we have the opinion of cancer specialist.

Response to reaction1. If patient begins to cry

Allow sometime to cry. Could say, “I can see you are very upset” Could touch the patient appropriately. After a few moments you should continue

talking even if patient continue to cry.

2. If patient becomes angry Defensive or irritation with patient are

unhelpful. Acknowledge patient’s position and avoid

talking about it.

3. If the patient refuses to accept the diagnosis Explore reasons for patient’s denial. Do not be combative. Appreciate that there is an information gap

and try to educate the patient. Check that patient has a clear

understanding of the problem. Empathize with patient. Get family members involved if

appropriate. Give time to adjust to new information.

Discussing prognosis Identify patient’s concerns. Be realistic Avoid giving specific times of survival – can

say years, months. Provide examples for what patient can

reasonably hope. Eg :- Pain free, Symptom control

Common pitfalls Inadequate time / information. Failure to elicit patient’s understanding of

situation. Giving news at doctor’s speed. Not allowing time for responses. False reassurances about the future. Allowing denial to remain. Removing all hope.

Sri Lankan context Does breaking bad news happening

appropriately in Sri Lanka? If it is not happening what are the reasons? Is it needed? What modifications would be needed to

suit our socio- cultural background? Can we do it? Would you do it?