Methods/Protocols for Breaking Bad News

Healthcare professionals utilize structured communication protocols to effectively and sensitively deliver difficult news. Two widely recognized and helpful protocols are:

1. SPIKES Protocol

2. BREAKS Protocol

SPIKES Protocol for Breaking Bad News

SPIKES is a six-step protocol designed to guide healthcare providers in breaking bad news in a structured and empathetic manner. The acronym SPIKES stands for:

S – Setting up the Interview:

• Plan and Prepare: Prioritize careful planning and preparation before the conversation. Key considerations include:

  • Privacy: Ensure a private and comfortable setting for the discussion, free from interruptions.

  • Support Persons: Ascertain if the patient wishes to have significant others (family, friends) present and accommodate their preference.

  • Minimize Interruptions: Silence pagers and mobile phones to minimize distractions and demonstrate focus on the patient.

• Practical Considerations: Invest time in addressing practical aspects to create a more conducive environment:

  • Location: Choose a separate, private room if possible. If privacy is limited (e.g., in a hospital ward), use screens to create a more shielded area, offering a degree of visual privacy.

  • Attendees: Upon arrival, identify any visitors present with the patient. Respectfully ask the patient if they are comfortable having visitors present during the discussion, while being mindful that the patient may feel pressured to agree even if they prefer privacy. Offer the option to have a specific relative present if desired. For example: “Benjamin, we now have your test results. Would you prefer to discuss them now, or would you like a family member or friend to be here for support?”

  • Initiating the Discussion: Begin the conversation thoughtfully:

    • Ensure the patient is physically covered and comfortable.

    • Greet the patient by name and introduce yourself if you are not well-known to them.

    • Establish rapport by initiating with general, open-ended questions, such as “How are you feeling today?”. This shows concern, encourages patient engagement, and allows for a quick assessment of their current physical state before proceeding to sensitive topics. Address any immediate patient discomfort (e.g., pain, nausea) if possible before moving to the main discussion.

P – Assessing the Patient’s Perception:

• Explore Existing Understanding: Before delivering any explanations or bad news, use open-ended questions to understand the patient’s current perception of their medical situation. This step is vital for:

  • Correcting any misunderstandings or inaccurate information the patient may have.

  • Tailoring the delivery of news to the patient’s existing level of understanding and expectations.

• Establish Baseline Knowledge: It is crucial to ascertain what the patient already knows about their condition, their perceived level of seriousness, and their expectations for the future. Utilize starting phrases such as:

  • “What is your understanding of your illness at this point?”

  • “What have doctors or nurses previously told you about your condition?”

  • “Have you had any concerns that this illness might be serious?”

• Active Listening is Key: Carefully listen to the patient’s responses. Their answers provide valuable insights into:

  • Their understanding of the medical situation.

  • Their emotional state and current level of anxiety or concern.

  • Their educational level and ability to comprehend medical terminology.

  • Their vocabulary and preferred communication style.
    This information will guide you in tailoring subsequent explanations and communication to be appropriately targeted and sensitive.

I – Obtaining the Patient’s Invitation:

• Information Preferences: Determine the patient’s preferred level of detail and how much information they want to receive regarding their diagnosis and prognosis.

• Level of Information Desired: Recognize that the key question is not simply “Do you want to know?” but rather “At what level of detail do you want to know what is happening?”. Most patients have an inherent sense when things are not progressing well, particularly if they have not received positive updates.

• Empowering Patient Choice: By directly asking about their information preferences, you are empowering the patient to exercise control over how and how much information they receive.

• Research-Backed Approach: Studies indicate that the majority of patients prefer full disclosure, although they may not want all details upfront. Establishing their information preference at the outset respects patient autonomy and allows for individualized communication.

• Phrasing the Invitation: Use open and respectful phrasing to inquire about their information preferences:

  • “Are you the type of person who prefers to know all the details about your illness?”

  • “Would you like me to explain the diagnosis to you in detail, even if it involves serious findings?”

  • “Or would you prefer that I discuss the situation more directly with your family or a designated family member?”
    By offering these options, even if the patient initially expresses a desire not to hear full details, you are:

    • Not completely cutting off communication.

    • Clearly communicating your willingness to maintain ongoing contact and support, even if the initial conversation focuses on broader aspects rather than intricate medical details.

K – Giving Knowledge and Information:

• Facilitate Information Processing: Communicate information in a way that aids patient comprehension and emotional processing.

• Use a Warning Shot: If the bad news is unexpected or particularly difficult, preface your remarks with a gentle warning to prepare the patient emotionally. Examples include:

  • “I’m very sorry to have to tell you that…”

  • “Unfortunately, I have some difficult news to share with you today…”

• Plain Language and Avoiding Jargon: Use clear, plain language that is easily understandable to the patient. Avoid medical jargon and technical terminology. For instance, use everyday words like “spread” instead of medical terms like “metastasized”.

• Small Chunks of Information: Break down complex information into smaller, manageable segments. Use short sentences and deliver information in digestible portions.

• Periodic Checking for Understanding: Regularly check for patient understanding throughout the information-sharing process. Pause frequently and ask clarifying questions to ensure they are following and comprehending the information being provided.

• Narrative Approach: When sharing information, consider using a narrative approach, particularly if the news is unexpected. This may involve:

  • Starting with a “warning shot” phrase to prepare the patient.

  • Pausing briefly to allow for initial emotional processing.

  • Describing events leading up to the current situation in a step-by-step manner, providing context and a clearer picture of the progression of their condition.

• Multimodal Communication: Enhance understanding and retention by using various communication methods:

  • Verbal Explanation: Provide clear and concise verbal explanations.

  • Repetition: Repeat important points and key information as needed to reinforce understanding.

  • Visual Aids: Utilize diagrams, written notes, or visual aids if appropriate to illustrate medical concepts or treatment plans, catering to different learning styles.

E – Addressing the Patient’s Emotions with Empathic Responses:

• Emotional Recognition: Actively identify and acknowledge the patient’s primary emotional response to the bad news. Recognize that a wide range of emotions are normal and valid reactions to difficult news.

• Empathic Statements: Express empathy and validation by using continuer statements that reflect your understanding of their emotional experience. Examples include:

  • “I can only imagine how upsetting and scary this news must be for you.”

  • “It’s understandable to feel shocked and overwhelmed right now.”

  • “This is a lot to take in, and it’s okay to feel whatever you are feeling.”

• Common Patient Reactions: Be prepared for a variety of emotional reactions from patients and families. Common responses to bad news include:

  • Disbelief and shock

  • Denial and resistance to accepting the news

  • Fear and anxiety about the future and implications of the diagnosis

  • Anger and blame directed at oneself, healthcare providers, or others

  • Guilt and self-reproach

  • Hope, sometimes unrealistic hope for a cure or positive outcome

  • Relief, in some cases, if the diagnosis explains previously unexplained symptoms or suffering

  • Despair and profound sadness

  • Depression and feelings of hopelessness

• Responding to Emotions: The ultimate success of breaking bad news depends on how the patient reacts emotionally and, crucially, how you, as the healthcare provider, respond to those reactions. Your empathetic and supportive response is critical in helping the patient begin to cope with difficult news.

S – Strategy and Summary:

• Present Options and Plan of Action: In the final stage, shift the focus towards planning and strategizing for the future. Present a clear and actionable plan, outlining:

  • Treatment options available, even if curative treatment is not possible.

  • Palliative care options to manage symptoms, improve comfort, and enhance quality of life.

  • Ensure that the information presented about treatment or palliative care options is directly aligned with:

    • The patient’s knowledge of their condition.

    • Their expectations for treatment and care.

    • Their hopes and values.

• Reduce Anxiety and Uncertainty: Providing a clear strategy and plan of action, even when facing a difficult prognosis, can significantly lessen the patient’s anxiety and reduce feelings of uncertainty and helplessness.

• Organize and Plan for the Future: Focus on organizing and planning for the patient’s future care, which involves:

  • Synthesizing your understanding of the patient’s wishes, values, and preferences.

  • Integrating the medical reality of their condition and prognosis.

  • Collaboratively developing a comprehensive plan of management that addresses both medical and psychosocial needs.

• Address Problem List and Reinforce Coping:

  • Acknowledge Patient Problems: Begin by demonstrating an understanding of the patient’s immediate concerns and “problem list” through active listening and reflecting back their stated concerns. This shows you have grasped their individual situation.

  • Honest and Realistic Outlook: Maintain honesty and transparency while avoiding being unrealistically optimistic about the future. Present a balanced and realistic perspective to build trust and avoid future disillusionment.

• Formulate and Explain a Strategy: Collaboratively formulate and explain a clear plan or strategy with the patient, which should encompass:

  • “Preparing for the worst”: Addressing potential challenges and planning for contingencies.

  • “Hoping for the best”: Maintaining a sense of hope and focusing on achievable goals, such as symptom control and quality of life.

• Identify and Reinforce Coping Strategies: Throughout the planning process, actively identify and reinforce the patient’s existing coping strategies and strengths. Acknowledge their resilience and past coping mechanisms.

• Incorporate Support Systems: Actively identify and incorporate other sources of support for the patient into the plan. This may include:

  • Referral to other healthcare professionals, such as specialists or palliative care teams.

  • Involving close family members and friends in the care plan and support network.

  • Connecting the patient with community resources, support groups, or spiritual advisors.

• Contract for Future Contact: Before concluding the consultation, establish a clear “contract for the future” to ensure ongoing communication and support. This includes:

  • Scheduling a follow-up appointment for continued discussion, monitoring, and support.

  • Providing clear instructions on whom the patient can contact and how to reach you or other members of the healthcare team if questions or concerns arise before the next scheduled appointment.

BREAKS Protocol for Breaking Bad News

BREAKS is another helpful mnemonic protocol designed to simplify and structure the process of breaking bad news, emphasizing empathy and patient-centered communication. BREAKS stands for:

1. Background (B):

   • Thorough Assessment: Before initiating the conversation, thoroughly assess crucial aspects of the patient’s situation, including:

     • Current disease status and prognosis.

     • Patient’s emotional well-being and psychological state.

     • Existing coping mechanisms and resilience factors.

     • Educational level and health literacy to tailor communication appropriately.

     • Social support system and family dynamics.

     • Cultural and ethnic considerations that may influence their understanding and response to bad news.

   • Create Conducive Environment: Prepare the physical and emotional space for the conversation:

     • Turn off or silence mobile phones to minimize interruptions and show respect for the patient’s time and emotions.

     • Maintain consistent eye contact to build rapport and demonstrate attentiveness.

     • If helpful, arrange for a coworker to be present to assist with note-taking or transcribing key points of the conversation, freeing you to focus fully on the patient.

2. Rapport (R):

   • Establish Positive Connection: Focus on establishing a positive and empathetic rapport with the patient.

   • Avoid Patronizing Tone: Ensure your communication is respectful and avoids any hint of condescension or patronizing language.

   • Build Trust: Foster trust through genuine empathy, active listening, and a caring demeanor.

   • Open-Ended Questions: Initiate the conversation with open-ended questions about the patient’s current condition and how they are feeling. This shows you are interested in their perspective and well-being beyond just delivering information.

   • Assess Readiness: If you sense the patient may be unprepared or resistant to receiving bad news immediately, allow them to initially discuss their general well-being and comfort level before transitioning to more sensitive topics.

3. Explore (E):

   • Patient’s Pre-existing Knowledge: Begin by exploring what the patient already knows and understands about their illness. This is a less abrupt and more patient-centered approach than directly breaking bad news.

   • Confirm, Don’t Abruptly Break: Frame this step as confirming their existing understanding, rather than suddenly dropping unexpected bad news.

   • Discuss Understanding: Engage the patient in a discussion about:

     • Their understanding of their illness and its progression.

     • Their comprehension of the diagnosis and its implications.

     • Any potential conflicts or discrepancies between their beliefs or expectations and the medical diagnosis.

   • Family Involvement (with Consent): If the patient consents, involve significant others (family members, caregivers) in the decision-making process, respecting patient autonomy while including their support network.

4. Announce (A):

   • Warning Shot: Provide a “warning shot” or gentle preface to soften the initial impact of the bad news. This prepares the patient emotionally for difficult information.

   • Clear and Direct Language: When delivering the news, use clear, straightforward language that is easily understood, avoiding complex medical jargon or technical terms.

   • Seek Consent: Before explicitly announcing the diagnosis or prognosis, verbally seek the patient’s consent to proceed with sharing the information, reinforcing their control in the conversation.

   • Mirror Emotions: Pay attention to the patient’s emotional cues and “mirror” or reflect back their emotions to establish a deeper connection and demonstrate empathy. Acknowledge and validate their feelings, reflecting back emotions like:

     • Embarrassment

     • Agony

     • Fear

5. Kindling (K):

   • Acknowledge Varied Reactions: Recognize and understand that patients will react to bad news in diverse ways. Be prepared for a range of emotional responses, such as:

     • Tears and intense sadness.

     • Silence and withdrawal.

     • Denial and disbelief.

   • Allow Emotional Space: Provide ample space and time for the patient to express their emotions without interruption or judgment.

   • Active Listening: Ensure active listening throughout the patient’s emotional response. Engage them with open-ended questions to encourage them to verbalize their feelings and recount their understanding of the situation.

   • Avoid Unrealistic Hope: Refrain from offering unrealistic or false treatment options or overly optimistic reassurances that are not medically sound.

   • Tailored Responses: Tailor your responses and support to the individual patient’s specific emotional reactions, questions, and concerns.

6. Summarize (S):

   • Session Conclusion: Conclude the session by providing a clear and concise summary of the key points discussed during the conversation.

   • Address Patient Concerns: Reiterate and directly address the patient’s specific concerns and questions that have arisen during the discussion.

   • Emphasize Future Plans: Shift the focus towards the future by emphasizing:

     • Next steps in treatment and care.

     • Practical aspects of managing their condition.

     • Emotional support resources available.

   • Written Summary (Optional): Offer to provide a written summary of the key points discussed, particularly for anxious patients who may have difficulty retaining verbal information.

   • 24/7 Availability: Reassure the patient of your ongoing availability and encourage them to call at any time, for any reason, if they have further questions or concerns.

   • Maintain Optimistic Outlook: Maintain a realistically optimistic outlook, focusing on achievable goals like symptom management and quality of life, while acknowledging the seriousness of the situation.

   • Family Communication (If Requested): Offer assistance in sharing the information with other family members if the patient requests or consents to this.

   • Schedule Review Date: Set a specific date for a follow-up review appointment to ensure ongoing care and support.

   • Safety Check: Before the patient leaves the room, ensure their immediate safety and well-being, addressing any immediate emotional distress or safety concerns.

Checklist for Breaking Bad News (Illness-Related)

A checklist format can be a helpful aide-memoire for healthcare professionals when breaking bad news:

Patient Reactions to Receiving Bad News

Patient reactions to bad news are diverse and can encompass a wide spectrum of emotional and behavioral responses. Common reactions often align with stages of grief and bereavement and may include:

• Emotional Responses:

  • Crying and tearfulness

  • Denial and disbelief, refusing to accept the reality of the news

  • Shock and numbness, feeling emotionally detached or overwhelmed

  • Anger and blame, directed at oneself, healthcare providers, or external factors

  • Guilt and self-reproach

  • Sadness and profound grief

  • Anxiety and worry about the future, treatment, or implications of the news

  • Bargaining, attempting to negotiate for a different outcome

  • A sense of profound loss and emptiness

  • Paradoxically, in some situations, relief, particularly if the bad news provides an explanation for previously unexplained symptoms or suffering.

  • Fear, apprehension about the future, pain, or unknown aspects of their condition.

Handling Difficult Questions from Patients and Families

Effectively addressing difficult questions requires specific communication strategies. Some helpful hints (Faulkner, 1998) include:

1. Explore Question Rationale: Before directly answering a difficult question, first check the underlying reason or motivation behind the question. Ask: “What makes you ask that question right now?” or “What are you hoping to understand by asking that?”. This helps uncover the patient’s real concerns and allows for a more targeted and relevant response.

2. Seek Patient’s Perspective: Show genuine interest in the patient’s own ideas and understanding of the situation. Ask: “How does it appear to you?” or “What are your thoughts on this?”. This encourages patient participation and provides insights into their current perspective.

3. Confirm and Elaborate: When appropriate, confirm aspects of the patient’s understanding and elaborate further to provide additional information or clarification. For example, “You are probably right in that…” or “That’s a very insightful observation because…”.

4. Acknowledge Uncertainty: Be prepared and comfortable to admit when you genuinely do not know the answer to a question. Honesty builds trust. It is okay to say, “I don’t know the answer to that right now, but I can try to find out for you” or “That’s a question we can explore further together as we move forward.”

5. Express Empathy: Acknowledge and validate the patient’s emotional experience, particularly when questions reflect feelings of unfairness, injustice, or distress. Use empathic statements like: “Yes, I can understand why this must seem incredibly unfair to you” or “It’s natural to feel this way given the circumstances.”

Handling Your Own Emotions as a Healthcare Professional

Breaking bad news is emotionally demanding for healthcare professionals as well. It is important to develop strategies for managing your own emotional well-being in these situations. Helpful approaches include:

1. Self-Awareness: Cultivate self-awareness of your own emotional responses, personal limitations, and coping mechanisms when dealing with emotionally challenging situations. Recognize your own emotional boundaries and triggers.

2. Team Support: Utilize team support systems within your workplace. Debrief with colleagues, seek peer support, and engage in team discussions to process emotional burdens and share experiences related to breaking bad news.

3. Clinical Supervision: Seek clinical supervision or mentorship from experienced colleagues or supervisors. Supervision provides a structured space for reflection, guidance, and emotional processing of challenging patient interactions, including breaking bad news.

4. Reflective Practice: Engage in reflective practice regularly to process your experiences, emotions, and communication techniques related to breaking bad news. Journaling, self-reflection exercises, or mindfulness practices can aid in emotional processing and skill development.

5. Continuous Skill Development: Commit to ongoing development of your communication skills, specifically focusing on techniques for breaking bad news, empathy, and emotional support. Attend workshops, training sessions, and seek resources to enhance your communication competence in these sensitive areas.

6. Remember Professional Boundaries: While empathy is essential, remember to maintain professional boundaries. Acknowledge and validate the patient’s pain, but also remember that it is not your bad news to carry personally. Maintain a healthy emotional distance while providing compassionate care