CCFP Topic: Bad News

In this episode we will go through the “SPIKES” 6 step protocol for delivering bad news to illustrate the four main objectives for this CCFP / CFPC topic. The objectives are:

1. When giving bad news, ensure that the setting is appropriate, and ensure patient’s confidentiality. (S in spikes)
2. Give bad news: in an empathic, compassionate way, allowing enough time, providing translation as necessary. (I,K,E in spikes)
3. Obtaining patient consent before involving family. (S in spikes)
4. After giving bad news, arrange definitive follow-up opportunities to assess impact and understanding. (Last S in spikes)

The SPIKES approach to delivering bad news was developed by Baile et al. at the University of Texas and Toronto-Sunnybrook Regional Cancer Centre, and the article, published in The Oncologist in 2000 is a short but great read to familiarize yourself with the background of this topic. They outline four goals of of the delivering bad new interview:

1. Gathering information from the patient: their knowledge, expectations, and willingness or capacity to receive information.
2. Providing information that is compatible with the patients needs and desires.
3. Support the patient by reducing emotional impact and isolating experience of receiving this bad news.
4. Develop a strategy in the form of a treatment plan or main goals with collaboration from the patient.

This includes physical as well as mental/emotional set-up. Arrange for a private place, with some kind of comfortable seating and arrangement so you can face the patient and anyone they bring with them. 

If you have examined them previously, allow them to get dressed first. 

Something that is really important but often overlooked is having tissues already in the room! Nothing stalls your train of thought like running around the ward trying to find a tissue box half-way through the interview.

Involving a significant other or close friend can also be very helpful in providing support to the patient and also helping them remember what was discussed. As the CCFP objectives appropriately set out, the patient must consent before family is involved. Ask the patient if there is someone they would like there, or to have on the phone. 

Turn your phone on silent or choose a time preferably when you’re not on-call. The BC Cancer Serious Illness Conversation guide has a great resource for patient-tested language. And the phrase they recommend for set-up is:

• “I’d like to talk about what is ahead with your illness and do some thinking in advance about what is important to you so I can make sure we provide you with the care you want – is this okay?” 

This phrase encompasses so many things – plan for the conversation and reasoning for it, establishing support for the patient and inviting them into the conversation.

This is part of the first goal – gathering info from the patient on their knowledge about the medical condition which you are to discuss so you can both be on the same page. As with any interview, open-ended questions are best to allow the patient to illustrate this. A few ways to word this are, 

• “what have you been told about your medical condition and what lies ahead”,
  or 
• “what do you think has been going on thus far”. 

Based on this information, you can address various misconceptions or recognize the advanced or minimal understanding the patient has and adjust accordingly.

The CCFP objectives outline the importance of recognizing when translation services are needed, which can not only apply to language translation but translation of medical information into easy-to-understand language. 

Use an official translation service if available, watch your patient for clues of misunderstanding, and check-in frequently.

We understand that most patients want to know the full and honest truth about their diagnoses, but a select few may only want to know certain details. The question 

• “how much information do you want to know about your condition and what lies ahead?” 

can be a good starting point. Some may want you to share information with a family member or friend, but just ensure that this is consented by the patient and documented accordingly.\
This step can become difficult from an ethical perspective if patients don’t want all the information but informed consent is required for treatment plans. Call your friendly hospital or regional medical ethics team if difficult situations arise where you need guidance.

This is where we try and accomplish goal 2, sharing information with the patient in a way that is compatible with their understanding and wishes.

•  “I want to share with you my understanding of where things are with your illness” 

is a good reciprocal phrase to use after exploring the patient’s own understanding. 

Start with the level of comprehension and vocabulary of the patient and limit technical medical terms where possible. 

Allow for periods of silence and leave space for contemplation throughout.

As primary care providers we may not know exactly what is to be expected for a specific condition until the patient sees a specialist. For these situations of prognostic uncertainty, a phrase such as

•  “it can be difficult to predict what will happen with your illness. I hope you will continue to live well but I’m worried that you could get more sick and want to ensure we are prepared if that happens”, 

can be helpful to frame the conversation.

Patient emotions and reactions will vary greatly, and it’s important to be flexible with your approach to mirror the needs of the patient. Observe emotion they may exhibit, offer tissue, silence, a hand on the arm, or what you sense is appropriate given the situation and your relationship with the patient. It can be helpful to name emotions you see, such as 

• “I see this is upsetting to you and not what you wanted to hear, tell me what you’re thinking”. 

In order to have an appropriate plan forward, we must explore key topics with the patient about their goals of care. This looks different for each patient and disease process of course, but key topics remain similar. BC Cancer again has a great list of topics and ways to word these, including goals, fears and worries, sources of strength, critical abilities, trade-offs and family.

We want to know what the patient’s most important goals are if their health condition worsens. What are their biggest fears and worries about the future of their health? What gives them strength going forward? What are their most important abilities that are critical to their life?

If they are to get sicker, how much are they willing to go through for the possibility of gaining more time? How much does their family know about their priorities and wishes? These questions are super important in directing the patient’s goals of care and treatment plans, but can also change over time so are good to revisit. 

Finally, summarizing the conversation by reiterating what you heard from the patient about what is important to them is helpful to establish a plan going forward. Re-affirming support for the patient by saying something like, 

• “We will be here for you every step of the way”, 

will strengthen the knowledge that there is a team behind them. 

Patients who have a clear plan, clear communication of this and appropriate follow-up are less likely to feel anxious and uncertain.

Baile et al. at the University of Texas and Toronto-Sunnybrook Regional Cancer Centre, and the article, published in The Oncologist in 2000 is a short but great read to familiarize yourself with the background of this topic.

Serious Illness Conversation guide https://www.fraserhealth.ca/-/media/Project/FraserHealth/FraserHealth/Health-Professionals/Clinical-resources/Advance-Care-Planning—Serious-Illness/Serious-Illness_Mini-Reference_COVID19-Guide.pdf