This article is written in collaboration with Mind The Bleep – a free education platform designed to help medical students as they prepare for FY1.
Facing difficult situations
As a junior doctor, you will face situations where you have to deliver potentially distressing information – from explaining a diagnosis to giving bad news to the relatives of your patients.
Breaking bad news in an appropriate way is an essential communication skill that can strengthen the patient-doctor relationship and create an environment where the patient and their families feel respected and supported.
How to prepare as an FY1
As an FY1, you shouldn’t be breaking news about a terminal diagnosis unless you feel comfortable to do so. This is because you’re unlikely to have expertise on further steps, management and prognosis.
That said, FY1s spend the most time on the ward and probably build the best rapport with patients and family members, which may mean you’re better able to deliver bad news.
Before even approaching the patient or applying the SPIKES model below, you should have complete and up-to-date knowledge on what has occurred and what is likely to occur next.
You should be able to respond to the dreaded “How long do they have left?” or “Are they going to die?” questions that may be asked.
The SPIKES protocol
The SPIKES protocol, developed by Baile et al. in 2000, is a six-step framework designed to help doctors to deliver bad news. The steps of the framework are:
S – Setting up the conversation
- When you’re delivering bad news, it’s important to find a private place on the ward to do so – whether that’s the family room on the ward or a side room that’s free. If you aren’t sure where these places are on the ward, ask a staff nurse for the best place for you to have a private, sensitive discussion. Avoid breaking bad news in a corridor.
- Minimise interruptions. If possible, give your bleep to a colleague to hold on to and let the nurses know what you are doing.
- It can be useful to have a nurse or healthcare worker in the room with you to offer support to the patient and/or their family.
- Introduce yourself to the patient, as well as any other colleagues who are present. When speaking to a patient, you can ask if they would like to have this discussion with a family member or friend present. If any relatives or friends join, clarify their relationship with the patient.
P – Perception
- It’s important to elicit the patients’ perceptions and understanding of what is going on and how much they are aware of.
- Good questions to ask are: “What have you been told so far?” and “Can you tell me what has been happening?” This is a good opportunity to ascertain their concerns and expectations.
- From this discussion, it may be possible to identify which patients are in denial or need additional support in receiving a difficult diagnosis.
- What you might consider to be bad news might not be what the patient considers to be bad news. It’s best to err on the side of caution, but the best way to appreciate a patient’s perceptions is simply to ask.
I – Invitation
- Invite the patient and their relatives to ask questions and be sure to check how much they want to know about the news you’re delivering.
K – Knowledge
- It’s a good idea to let the patient or relative know that you are going to deliver some difficult news.
- This news needs to be handled carefully. For example, you could say: “The results of the scan/blood tests/biopsy are back and unfortunately, they are not as we had hoped for. I’m sorry to tell you that the results/ tests show…”
- Explain the diagnosis and results in clear, simple language, and avoid medical jargon. Deliver the information in sizeable chunks with long pauses in between. This gives patients the chance to take in the information and ask any questions they may have.
- Give time after delivering the initial diagnosis or test results and wait for the patient or relative to initiate the conversation.
- Repeat important points as it can be difficult to take on further information after receiving distressing news.
E – Emotions/Empathy
- Be open and honest with patients. It’s important not to give false hope.
- Acknowledge their emotional reactions (which can vary from silence, grief and anger) with empathy and respect, as well as recognising how difficult the situation is for them.
- Address the fact that you have given them a lot of information to take on board and offer them the opportunity to ask questions or to re-visit this discussion at a later date if needed.
S – Strategy/Summary
- It’s often easier for patients and family members to deal with upsetting news if there is a clear plan of action ahead that both parties (the clinical team and the patient) can agree to. This plan might involve treatment options, further discussions about prognosis or, if appropriate, the management of end-of-life care.
- Do not rush patients into making decisions about management and give them time to think it over. Finally, summarise information and offer written materials if appropriate.
Remember that breaking bad news can be exhausting, so it’s always a good idea to debrief with your colleagues afterwards.