Learning to Deliver Bad News

How do you tell a 45-year-old mother of 2 that not only has her breast cancer returned but it is now incurable? Or how do you explain to a 22-year-old student that despite intensive chemotherapy and a 6-week hospitalization, he still has acute leukemia and is not eligible for a bone marrow transplant? Even for an experienced oncologist, walking into a room and initiating a conversation that will change the life of someone who sought your help can be a daunting challenge.

Early in your oncology training, learning the biology and treatment of a dozen malignancies was a task that seemed overwhelming. For many oncologists, knowing how to compassionately deliver bad news—something that is often learned through trial and error—is less important than absorbing and understanding an avalanche of cancer-related information. But just as you need to know how to discuss the efficacy and side effects of a chemotherapeutic agent whose name at first you could barely pronounce, you must learn to disclose the truth with sensitivity for patients’ concerns. This is a vital skill that all oncologists must hone.

The Importance of Compassionate Communication

Difficult conversations between oncologists and patients about prognosis, disease progression, and death are a crucial part of the treatment process. Whereas physicians may not recall all the difficult conversations they have had, despite how painful they seemed at the time, patients and their families will remember them word for word. They will remember whether you approached this juncture with truth and compassion, or whether it was awkward, rushed, and filled with medical terms they could not understand. They will remember if they left this life-changing visit with a sense of clarity and understanding or with fear and hopelessness.

Good communication can help clarify patients’ understanding of their disease, ease adjustment, and lessen physical and emotional pain. It can also leave them more satisfied with their care.

Learning Communication Skills

Many people believe that effective communication skills are not something that can be taught or learned and that some physicians are just better or more natural at it. Though it may be true that some may have an innate facility for conversation, you can develop the necessary tools to communicate clearly, effectively, and compassionately.

Fellowship is an excellent time to begin developing your skills. Just as you study the algorithms of the National Comprehensive Cancer Network to treat lung cancer, you can learn a framework for how to approach a difficult conversation that will make the task less daunting while offering deeper value to your patients.

The literature has proposed a number of models for effective communication, but the most widely accepted is “SPIKES,” a 6-step protocol developed by Dr Walter Baile and colleagues at The University of Texas MD Anderson Cancer Center.¹ The individual letters represent the following: (1) setting up the interview, (2) addressing the patient’s perception, (3) obtaining the patient’s invitation, (4) giving knowledge and information to the patient, (5) addressing the patient’s emotion with empathic responses, and (6) strategy and summary.

According to Baile and his team, the goal of SPIKES is to allow you to fulfill the following 4 important objectives of the interview in which you deliver bad news¹:

1. Gather information from the patient.
2. Provide intelligible information in accordance with the patient’s needs and desires.
3. Support the patient by employing skills to reduce the emotional impact and isolation experienced by the recipient of bad news.
4. With the patient’s input and cooperation, develop a strategy in the form of a treatment plan.

The SPIKES Protocol

Meeting these 4 goals can be accomplished by completing the steps of the SPIKES protocol. Although all 6 steps are not always needed, when they are it is important that you follow them in order:

"You will ultimately develop your own style of delivering bad news to patients."

Step 1: Setting up the interview. You should be sensitive to the patient’s surroundings as she receives life-changing news. Be sure that you are in a private room and that she is accompanied by a family member, if desired. One of the most challenging aspects of having difficult conversations is the time involved. But even if you feel rushed, you should sit down and maintain eye contact with the patient to help her relax and show her that she is your priority. You should tell her in advance of any time constraints or expected interruptions.

Step 2: Addressing the patient’s perception. Before launching into a detailed conversation, ask open-ended questions to get an accurate picture of how the patient perceives her medical situation. Th is not only gives you a glimpse into whether she is experiencing denial, wishful thinking, or unrealistic expectations, but it allows you to tailor your discussion based on what she already knows.

Step 3: Obtaining the patient’s invitation. To you as an oncologist, it may seem obvious that the patient is in your office and therefore is prepared to hear full information about her diagnosis, prognosis, and treatment. But some patients do not want all this information. Asking a patient, “Would it be okay to go over the details of your test results?” or “Shall we spend more time discussing the treatment plan?” will let you know how she wants to receive the information.

Step 4: Giving knowledge and information to the patient. Th is is the part of the conversation we tend to focus on and likely have the most experience with. When giving medical facts, start at the level of comprehension and vocabulary of the patient. If necessary, use words such as “spread” instead of “metastasized” and “sample of tissue” instead of “biopsy.” Do not forget to repeatedly check in with the patient to ensure that she understands what you are saying.

Step 5: Addressing the patient’s emotion with empathic responses. Responding to strong emotions is one of the most difficult challenges in breaking bad news. Patients’ emotions may vary from silence to disbelief, crying, anger, or denial. Physicians often feel uncomfortable addressing these strong emotions and may compensate by providing more information about the disease or treatment. An empathic response is one in which you not only recognize the emotion that the patient is experiencing (such as anger, sadness, or denial) but directly name it back to her. For example, after hearing that her metastatic colon cancer has progressed, the patient is surprised and angry. An empathic comment would be, “I can tell that this news is not the news you expected and that it makes you very angry. I also wish that the news were better.” A comment like this lets the patient know that you understand how she feels and validates that such thoughts are normal and expected.

Step 6: Strategy and summary. Before discussing the treatment plan, it is important to determine whether the patient is ready. If she is still experiencing strong emotion, it is unlikely that she will be able to move on to discuss a treatment plan or prognosis. Isolation, fear, and uncertainty are common feelings that patients may have, and letting them know that you will be with them on this journey is reassuring. Once you determine that the patient is ready to discuss the treatment plan, you must understand her treatment goals, such as symptom control. You can then frame hope in terms of what is possible to accomplish.

Final Thoughts

You will ultimately develop your own style of delivering bad news to patients, and this model is just 1 tool that can be used as a beginning framework for enhancing your communication abilities. The patient benefits, plus you are rewarded by learning skills that transform the dreaded task of delivering bad news into a skill that can be mastered with practice. Also, you will probably find that your self-confidence increases over time. Armed with this knowledge, you will soon find that the words will flow easier, your connections to your patients will become stronger and more meaningful, and you will become better able to understand their disappointments, fears, and hopes for the future.

This edition of Oncology Fellows is supported by Genentech, a member of the Roche Group.

Reference

Sheetal M. Kircher, MD, is a second-year oncology fellow at Northwestern University’s Feinberg School of Medicine in Chicago, Illinois. 1. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—A six-step protocol for delivering bad news: application to the patient with cancer. The Oncologist. 2000;5:302-311.