P R E S E N T E D B YK E N M E E K E R , L M S W

P A L L I A T I V E C A R E S O C I A L W O R K E RM O N T E F I O R E M E D I C A L C E N T E R

M A R C H 1 3 , 2 0 1 8

Is There a Good Way to Break Bad News? Utilization of the SPIKES Protocol

In Family Meetings

Objectives

� To define “bad news” in a medical setting� To understand the barriers to physicians delivering

bad news effectively� To introduce and break down the six components of

the SPIKES Protocol� To position the palliative care social worker as an

advocate and teacher for junior medical staff

Definition of Bad News

“…any information which adversely and seriously affects an individual’s view of his or her future.”

� Recipient’s expectations and level of understanding have an important bearing on the impact of bad news.

What Constitutes Bad News in a Medical Setting?

� New diagnosis of a potentially life-threatening illness

� Patient’s condition suddenly changes or is rapidly declining

� Curative treatments are no longer effective or not an option

� Devastating/disappointing test results � Limited or poor prognosis� Shift toward comfort care and hospice

What Do Patients Want?

� Most patients want the truth¡ Survey results (1982):

÷96% wished to be told their cancer diagnosis÷85% wanted realistic estimate of life expectancy

¢Assists patients with quality-of-life decision making

How We Deliver Bad News Matters

� Because it can affect the patient’s:¡ Understanding of information shared by MDs¡ Satisfaction with medical care¡ Level of hopefulness¡ Psychological/emotional adjustment

� In a qualitative study, surviving family members judged the most important features of delivering bad news to be: ¡ Attitude/manner of the person who gave the news ¡ Clarity of the message ¡ Privacy ¡ Having their questions answered

Barriers to Breaking Bad News

� Why it can be hard for MDs to deliver bad news:¡ Lack of training; inexperience¡ Anxiety¡ Burden of responsibility/inadequacy

÷ Going back on your word; sense of failure¡ Fear of negative responses and strong emotional

reactions¡ Uncertainty about patient’s and family’s expectations¡ Fear of destroying patient’s sense of hope

The Six Steps of S-P-I-K-E-S Protocol

Step 1: S - Setting Up the InterviewStep 2: P - Assessing the Patient’s PerceptionStep 3: I - Obtaining the Patient’s InvitationStep 4: K - Giving Knowledge and Information to

the PatientStep 5: E - Addressing the Patient’s Emotions with

Empathic ResponsesStep 6: S - Strategy and Summary

S – Setting/Set-up

� Privacy¡ Interview room (close door)¡ Patient’s room (draw curtain)

� Involve significant others¡ Ask patient who she’d like to have present

÷ Important: Who will take on role of spokesperson?÷ “Family” = Blood relatives, friends, neighbors, co-workers, clergy

� Book interpreter, if needed� Have tissues available! � Pre-meeting, check in with participating health care

providers (IDT) to identify roles and discuss objectives

S – Setting/Set-up (con’d)

� Manage time constraints¡ Allow adequate time for meeting

÷ Establish boundaries!

� Avoid interruptions¡ Silence/turn off beepers and cell phones

� Sit down (close to patient, if possible)¡ Avoid barriers between patient and you

� Make connection, look attentive ¡ Maintain eye contact¡ Use “active listening” skills

÷ Allow for silence ÷ Show respect by not interrupting or overlapping÷ “Moscow technique” – slight delay in responding÷ Repetition – reflecting and restating patient’s words

S – Setting/Set-up (con’d)

� Introductions = good icebreaker¡ Names ¡ Relationship to patient

� Explain what palliative care is¡ “Most people don’t know what palliative care is. May I explain

that to you?” � Check in with patient and family

¡ “How is everyone doing”¡ “How are you all holding up?”

P – Perception

“Before you tell, ask”� Explore how patient (and family) perceives his/her

medical condition, and how serious it is, with open-ended questions:¡ “What’s your understanding of your current medical condition?” ¡ “What have the doctors told you so far?”

� Reflect patient’s language and vocabulary in your responses¡ Creates alignment with patient

� Gauge patient’s (and family’s) level of medical literacy to tailor your presentation of bad news

P – Perception (con’d)

� Opportunity to correct misinformation� Identify/note signs of denial in patient

¡ Denial is a coping mechanism that may present as:÷Wishful thinking÷Omission of unfavorable medical details÷Unrealistic expectations of treatment

¡ May increase in direct proportion to the severity of the illness

I - Invitation

How much does the patient want to know?� Obtaining permission from the patient to report medical

information respects his/her right to know or to choose NOT to know. Explore with Qs:¡ “How much information would you like me to give you about your

diagnosis and treatment?”¡ “Would you prefer I speak with your family alone and then come

back to share with you what we discussed?”÷ Patients may need loved ones to filter the info for them

� Consider issues of race, ethnicity, culture, religion, and socioeconomic status

K - Knowledge

� “Warning shot” can be helpful to prepare patient/family members for bad news¡ “I’m so sorry to have to tell you this…”¡ “I’m afraid I have some bad news to share…”¡ “Some of the news we have to share today may be difficult

to hear.” (pause, allow silence) ¡ “I wish the news was better.”

K – Knowledge (con’d)

Five Helpful Guidelines for Delivering Bad News:1) Use language that matches (“aligns”) with patient’s

level of education, comprehension, and vocabulary2) Avoid technical, scientific jargon and acronyms –

keep it simple (Use “spread” rather than “metastasized”)3) Deliver the information in a sensitive, but direct

manner4) Give information in small chunks and then stay quiet for a

few seconds (pause frequently)5) If prognosis is poor, avoid statements that express futility

(e.g., “There is nothing more we can do for you.”)

E – Empathy/Emotions

� Emotional responses can include:¡ Crying (tearfulness to sobbing); anger/rage; sadness; anxiety;

relief; denial; shock; disbelief; grief; isolation/withdrawal; fear; blame; guilt; shame; silence; numbness; the need to flee the room

¡ Some may intellectualize as a form of denial� Patient’s reaction may be impacted by his/her

psychosocial context¡ Financial/relational/practical problems¡ Timing of life events (e.g., weddings; births; graduations)

E – Empathy/Emotions (con’d)

“The Empathic Response” – 4 Steps:1) Observe the emotion by listening quietly and attentively (use

active listening skills)¡ “Bearing witness” – a powerful therapeutic tool

2) Identify and acknowledge the emotion¡ “I can see this news is very upsetting to you. Can you tell me about

what you’re feeling?” 3) Identify the cause/source of the emotion

¡ Usually connected to the bad news, but it may center on other concerns (e.g., “What will happen to my children?”)

¡ If not sure, explore with open-ended questions (e.g., “What worries you most about what I’ve told you?”)

4) Show the patient that you have made the connection between the emotion and the reason behind it

¡ Move closer to patient; use touch if it feels right

E – Empathy/Emotions (con’d)

� Validate and Normalize patient’s emotions� Combining empathic, exploratory, and validating

responses allows you to “join” with the patient and expresses solidarity and support

� Resist the temptation to make things better¡ Often a physician's reaction to his/her sense of

helplessness or feelings of failure ¡ Avoid platitudes

� Don’t ignore your own feelings

S – Strategy and Summary

� Summarize the clinical information and ask if the patient understands it¡ Ask questions to uncover discrepancies in comprehension and clarify

them if there are� Ask patient if he/she is ready to discuss treatment options

(revisit “Invitation”)� If so, make the patient a partner in the decision-making

process¡ Honors right of self-autonomy and patient’s “voice”¡ Inquiring what the patient’s goals/wishes are can engender hope in

the patient

S – Strategy and Summary (con’d)

� Don’t pressure the patient to make a decision on the spot, but encourage him to take some time

� Identify goals of care with open-ended Qs:¡ “What is most important to you right now?”¡ “What are your greatest concerns/fears/hopes?”

� Reframe goals using “wish” statements� Identify patient’s support system; sources of

emotional/practical support� Ask if a follow-up meeting would be helpful� Establish a plan for “next steps”

¡ What treatment plan will focus on:÷ Pain/symptom control ÷ Relief of emotional distress÷ Concrete services for family÷ Discharge (e.g., hospice/palliative care services)

Questions?

Thank you

Contact:Ken Meeker, LMSW

Palliative Care Social WorkerMontefiore Medical Centerkmeeker@montefiore.org

References

Baile, W. F., Buckman, R., Lenzi, R., Glober, G., Beale, E. A., & Kudelka, A. P. (2000). SPIKES – A six-step protocol for delivering bad news: Application to the patient with cancer. The Oncologist, 5(4), 302-311. doi: 10.1634/theoncologist.5-4-302

Buckman, R. A. (2005). Breaking bad news: The S-P-I-K-E-S strategy. Community Oncology, 2, 138-142.

Emanuel, L. L., von Gunton, C. F., & Ferris, F. D. (1999). The education for physicians on end-of-life care (EPEC) curriculum. EPEC handbook module 2: Communicating bad news. Institute for Ethics at the American Medical Association EPEC Project, M2-1-M2-10.

Halifax, J. (2008). Being with Dying: Cultivating Compassion and Fearlessness in the Presence of Death. Boston: Shambhala Publications.

Jurkovich, G. J., Pierce, B., Pananen, L., & Rivara, F. P. (2000). Giving badnews: The family perspective. Journal of Trauma, 48, 865-70.

References (con’d)

Meier, D. (2016). Transforming the care of serious illness. In Ellison, K. P. &Weingast, M. (Eds.), Awake at the Bedside: Contemplative Teachings onPalliative and End-of-life Care (pp. 5-19). Somerville, MA: WisdomPublications.

Shin, J. & Casarett, D. (2011). Facilitating hospice discussions: A six-steproadmap. Journal of Supportive Oncology, 9(3), 97-102. doi:10.1016j.suponc.2011.03.004

(2002) Giving bad news. Medical Oncology Communications Skills Training, Learning Module 2, 7-9. http://depts.washington.edu/oncotalk/learn/modules/Modules_02.pdf

(2008) Communication: What do patients want and need? Journal of Oncology Practice, 4(5), 249-253.

Search SPIKES demonstration videos on by Robert Buckman, MD, PhD, on YouTube.