Breaking bad news to patients is not always a skill that comes naturally to healthcare professionals. The SPIKES protocol provides a framework for doctors and nurses to follow in order to get the most out of meetings with patients, allowing them to communicate the seriousness of the news and agree treatment plans.
In this article, we’ll talk about the importance of delivering bad news in a structured and empathetic manner, and look at the various stages of the SPIKES protocol in more detail.
Let’s get started…
3.6. Strategy and Summary
In terms of healthcare, “bad news” can be defined as a diagnosis or prognosis which will negatively affect a patient’s quality of life in the present or future.
One obvious example of this comes in palliative care when a clinician has to break the news that treatment has been unsuccessful and that death is imminent. This is a difficult situation for any doctor to navigate and is one that requires care, tact, empathy and sensitivity from the practitioner.
Although the most extreme, an end-of-life prognosis is not the only example of “bad news” in the field of healthcare, and clinicians are not the only professionals that need to be adept in this skill.
Informing patients of new chronic illnesses, the treatment of which will drastically change how the patient lives their life, can also be considered “bad news”. Likewise, the worsening of a chronic condition and the subsequent changes to treatment plans can also have a severe, negative impact on a patient’s quality of life.
And it’s not only clinicians who deliver this type of news, GPs, nurses and specialists may also need good communication skills to effectively convey the message, ensuring that the patient understands the treatment and that they face the future, not only with realism, but with a feeling of hopefulness.
Breaking bad news is not an easy process for healthcare professionals. They may be faced with grief, denial and despair from the patient. This is a skill that requires a great deal of patience and energy from the practitioner in order to get the message across to the patient.
The goal when meeting with patients and / or their family is:
Obviously, juggling so many aspects of a conversation is not an easy task, especially in a busy medical environment where time is not usually at a premium. Doctors and nurses need training in the delivery of bad news, and it takes a lot of practice to become adept at it.
But there are some accepted methods of breaking bad news, and the SPIKES protocol is one of the most common standardised approaches. The protocol gives healthcare professionals a solid structure for delivering bad news and is an extremely useful tool for ensuring a patient’s understanding.
SPIKES was developed in 2000 by Walter F. Baile et al at the University of Texas, Houston. Initially perceived as a way of breaking news to cancer patients, it soon spread to other areas of the healthcare industry.
SPIKES is an acronym which stands for Setting, Perception, Invitation, Knowledge, Emotions, and Strategy.
When using this protocol, the person who is delivering the news needs to consider their responses. They should be empathetic, acknowledge the patient’s feelings and validate them, provide information about treatment plans, and ensure the patient understands what they are being told.
Now, let’s take a closer look at each part of the protocol.
In this stage of the protocol, the practitioner must think carefully about where they break the bad news.
Some aspects which should be considered include:
This stage is all about gauging the patient’s state of mind and finding out how much they already know about their illness and how it will affect them in the future. This stage is extremely important as it will allow the person breaking the news to judge the patient’s understanding and how much information they are going to take in and retain for the remainder of the conversation.
In order to do this, the healthcare professional must pay attention to what the patient says, how they say it, and their body language. Perhaps the patient is in denial, perhaps they are extremely agitated or over emotional, or it could be that they have absolute awareness of what they are about to go through.
Whatever the case, the practitioner must tailor the conversation around the patient’s understanding, and do so in a non-judgmental manner. Bad news affects everyone differently and there are any responses from the patient that may hinder their understanding. Doctors and nurses must tread carefully and check understanding at regular intervals.
In this stage, the medical practitioner must determine how much information the patient actually wants to hear. Obviously, the bad news must be delivered, but there are different levels of information about a diagnosis or prognosis that can be shared. This can differ from patient to patient.
Not everyone wants to know every single detail about their illness, preferring instead to concentrate on the treatment plan. This must be respected. As long as the patient understands the seriousness of their illness, they don’t need to know everything that’s happening to their body.
On the other hand, the patient might get a certain degree of comfort from knowing all the little details. Again, the doctor cannot be judgemental and reply with “you don’t really need to know that”. If the patient wants to know everything about their diagnosis, they have every right to be told about it.
The person breaking the news must be prepared for both extremes and anywhere in between, but they must first must receive the patient’s permission to pass on the information they want.
How is this established? By asking direct, non-leading questions.
It should also be made clear to the patient that any questions can be answered at a later date if they don’t want the information at that particular moment.
This is the stage where the medical practitioner breaks the bad news and passes on their knowledge of the illness. This must be done in a sympathetic way which takes into account the needs of the patient on an intellectual and cultural level, while avoiding excessive bluntness on the part of the person conveying the news.
Somethings to consider include:
This stage of the protocol is concerned with exploring the emotions of the patient and providing a sympathetic response. This is also one of the most difficult parts for practitioners to get right.
In general, doctors and nurses should give the patient the freedom to explore their feelings and express themselves accordingly after the news has been delivered. There may be a lot of shocked silence, disbelief, or even anger.
It’s easy to believe that the emotional response is connected to bad news that has just been given, but this may not always be the case. It’s possible that the patient is thinking more about their family than themselves, for example. Identify the cause of the emotion by asking the patient directly.
The bearer of bad news must allow for all these emotions and avoid arguments or confrontations with the patient. They should allow silence and not try to fill it with platitudes, but, at the same time, they should also be honest, display empathy, and always monitor the patient’s understanding of the situation.
Body language is also important at this stage. Practitioners should sit openly, not with crossed arms and legs, inviting the patient to express themselves openly. Physical contact, a touch on the arm, for example, may also be appropriate at this stage.
Allowing the stage to get through the initial emotional response will make it easier to discuss subsequent treatment plans later.
This is the final stage in the SPIKES protocol. This is where the patient and doctor plan the next step and summarise the meeting.
Before discussing the next step, it’s important to double check the patient’s understanding of the situation and to ask whether they are capable of making this decision at the moment. It may be necessary to schedule a meeting further down the line if the patient is emotionally overwhelmed.
Things that should be discussed include:
As the meeting comes to a close, the practitioner should summarise everything that has been discussed, check the emotional state of the patient, and offer any additional support that might be needed, such as contacting family members on behalf of the patient.
Even with the SPIKES protocol in place, breaking bad news can be extremely emotionally draining on the practitioner. After the meeting, the doctor or nurse should check their own feelings and ensure they are emotionally fit to move on to the next patient. This is especially true if the next patient has similar issues.
A period of self-reflection should follow. Some questions that can be asked include:
When it comes to self-reflection, having a video record of interactions can be helpful, and analysis software can help you improve your communication skills.
Codimg is a software tool specifically designed for monitoring performance in the workplace. It has been used successfully for many years for analysing student doctors and nurses in medical simulation scenarios, and other healthcare situations.
The basic premise is that a simulated or real event is filmed. The trainer or observer has a premade interactive template which can be used to mark moments of interest during the event. This can either be done live, or retrospectively through video. If done live, the collected information will be synched with the video at a later time. When these moments are marked, an interactive database of video clips is created. These clips can then be accessed quickly and easily at any time.
Example of SPIKES protocol digital checklist template. To get this template free, contact us.
At the same time, the collected data can be used to create a dashboard with insightful statistics about the event. The dashboard is also interactive and linked to video clips.
Example of SPIKES protocol dashboard. To get this dashboard free, contact us.
Analysis of this type has been proven to give valuable insights into working practice which allows professionals to improve in all aspects of their post.
So, there you have an overview of the SPIKES protocol. If you have any questions about anything you have read in this article, please don’t hesitate to get in contact with us and we’ll be happy to point you in the right direction.
In addition, we’d be happy to offer you a completely free, no-obligation trial of the Codimg software. The best way to get an idea of how Codimg can help you improve your practice is to try it for yourself. Again, get in contact with us and we’ll talk through your needs, and we’ll set you up with a trial.
Until then, thanks for reading.
Holistic nursing can’t really be described as a new trend. Afterall, the founder of modern nur...
Telerehabilitation - also known as telephysiotherapy - allows healthcare professionals to treat pati...
And the healthcare sector is no different. For a few years now, the concept of Lean Healthcare has g...