According to bioethical practice, dependent on the age and level of competence, the patient has the right to informed consent, informed decision, and informed choice. These rights of patients essentially culminate to a right to full disclosure regarding findings about their health. Doctors are fully aware of these principles and are morally obliged to comply with them. However, the main issue faced is the dilemma on how exactly to deliver bad news to patients.

Keeping it Simple

Figuring out the best way to deliver bad news to patients has always been a thorn in the side for doctors. Factors such as age, gender, religion, culture, socio-economic status, chronicity of disease, availability of a support system etc. are considered when delivering the news to the patient. Given the numerous things to take into consideration, there is no single foolproof way that can be adopted across all cases.

It is very important to keep things simple. Doctors tend to overuse medical jargon or technical language when speaking to patients. This type of language is appropriate when communicating with colleagues or other health professionals but is unsuitable when communicating with a patient. Using such language often brings about misunderstandings which should be avoided as much as possible when giving negative news to a patient. Due to the overwhelming levels of stress the news could bring, the last thing patients need is to be faced with terms that they do not understand; this might end up frightening them even more than necessary. When explaining the pathophysiology, prognosis and survival rate as well as treatment options, they need to be simplified into layman’s terms.

Contrary to what people may think, it is very stressful for doctors to deliver bad news to their patients and their respective families. Being the harbinger of bad news is never easy, and even the best doctors struggle to suppress their personal feelings in order to deliver the news in the most sympathetic manner. Surgeons, and specialists like oncologists, frequently have to go through this process due to the high risk of morbidity and mortality rates within their practice.

SPIKES: The 6-Step Protocol

As there is no sure win way to do get about this, Baile et. al. (2000) have provided a six-step protocol for delivering bad news for patients with cancer. Although aimed towards oncology patients, it can be easily adopted to suit other medical situations as well.

1. Setting up the meeting

The first step involves setting up the meeting. Not only does the doctor have to mentally prepare the patient for the bad news, but he or she has to be prepared to deliver the news as well. The room needs to be free from distractions and interruptions, so that a focused and conducive environment would be available to talk to the patient. Sitting is encouraged, as it helps to relax the individual. There should be no physical barriers between the doctor and the patient. If loved ones are available, with the permission of the patient, it would be good for them to be present to provide emotional support.

2. Assessing perception of the patient

The second step involves assessing the perception of the patient. This is done by employing open-ended questions in order to be aware of what the patient knows and has understood thus far. This also allows for the chance to correct any misinformation and misdirected expectations the patient might have.

3. Level of disclosure

The third step involves the level of disclosure. Although a doctor is obliged to divulge all related medical information, there might be some patients who may not want to know everything. In these situations, it is important to determine their competence and understanding of the situation. If the patient refuses to know more, it might be necessary to assess the willingness of the patient to involve their loved ones, so that the information might be relayed to them instead.

4. Knowledge and Information provision

The fourth step involves the actual provision of knowledge and information on their current situation. It is best to give some amount of warning before delving further so as to help mentally and emotionally prepare the patient, and lessen the shock. It will allow time for the patient to process the information given. Information that is relayed should be free of technical language, provided at the appropriate level of competency, given empathically and slowly, with pauses to check on patient’s understanding, and avoiding the use of disheartening phrases.

5. Addressing the emotions of the patient

The fifth step involves addressing the emotions of the patient in an empathetic manner. A doctor should appear supportive at all times, and remain calm despite any outbursts that patient may have. A doctor should be intuitive of the patient and anticipate their needs (i.e. for a patient who cries, provide them with tissues). Open-ended questions can be used with patients who remain silent in order to gain a clearer understanding of their feelings towards the news delivered.

6. Strategy and Summary

The sixth and last step involves the strategy and summary of the encounter. The steps to be taken following the news should be a collaborative effort. A doctor needs to establish on what the patient wants by thoroughly discussing with them their options. False hope should not be given. If the prognosis is bad, the patient has the right to know this. All approved medical treatment plans should be given by explaining the pros and cons of each procedure.

The principle of autonomy needs to be remembered. As long as the patient is competent and rational, upon providing all the necessary information, he or she should be able to make an informed decision. MIMS

Reference:
- Baile et. al., "SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer.”, Oncologist. 2000;5(4):302-11, http://theoncologist.alphamedpress.org/content/5/4/302.full