Volume 8 Issue 2 February, 2018
Doctors need astute clinical skills; they also need good communication skills. Doctors face the unique challenge of having to break bad news to patients and their families thousands of times over span of their professional lives.
Disclosing unfavourable information is an act which evokes distress in both the physician and the patient. It is complex communication task, when done skilfully renders benefits to both. As all medical procedures, it can be broken down to steps and protocols. It can impact the following.
- Patient’s comprehension of medical information
- Prevention of unhelpful emotional responses and promote positive psychological adjustment to diagnosis, treatment and prognosis
- Patient’s active participation in therapeutic decisions
- May avoid unhelpful use of ‘curative’ treatment, and focus on improving quality of life.
- Gives opportunity to patient and family to set financial and other family affairs in order, use available time fruitfully.
Number of factors aside from deficient knowledge can affect the doctor’s ability to impart bad news sensitively, like burnout and fatigue, personal difficulties, personal beliefs on disease and death.
SPIKES PROTOCOL for breaking bad news is discussed below.
Step 1: Setting up the interview
Be thorough with patient’s medical history and current medical condition. Familiarise yourself with information on patient’s education, occupation, cultural and ethnic background, family tree, important and close family members. Physical setting of interview room is important.
Step 2: Assessing patient’s Perception
Follow the adage,’ before you tell, ask’
Step 3: Obtaining patient’s Invitation
While majority of patients desire full information, some patients don’t. Shunning information is a normal psychological defense mechanism. If the patient is not yet ready to receive the news, respect patient’s decision and postpone the interview until patient is ready.
Step 4: Giving Knowledge and information to the patient
A warning shot to prepare them may be helpful, such as, “I’m afraid the news is not good”. Such words can lessen the emotional impact, and partially prepare the patient to receive bad news by anticipating it.
Chunk and check: Give information in chunks, and check whether the patient is listening and comprehending the information. Use empathy and supportive gestures.
Step 5: Addressing patient’s emotions with Empathic response
Observe for patient’s emotions like fearfulness, sadness, silence, shock. Identify and address them.
Step 6: Strategy and Summary – Finish with a summary and agree a plan for the next steps, including a further appointment. Do not expect to deal with everything in one appointment. If there has been lot of information, it may need repetition and reclarification in another session. Inform other colleagues in care giving team about how the interview went.
Dr. Vasudha Rao, Consultant psychiatrist, Kannur dist. Kerala
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