POTD: Breaking Bad News
As we move from med school to intern year, intern year to second year, second year to third year, we start to take on more responsibility in having goals of care discussion and breaking bad news. This was something I struggled with especially at the beginning, and I am no master now by any means. There is no good way to tell a family member that his/her loved one died over the phone, but we can try to mitigate the pain. If this is something that you have trouble with, I just want to provide a basic guide as a starting point from which you can develop your own style. We start today with breaking bad news.
A basic mnemonic for delivering bad news is the SPIKE mnemonic.
S: setting up the interview
P: assessing the patient’s or patient’s family’s perception
I: obtaining the patient’s invitation
K: giving Knowledge and information to the patient
E: addressing the patient’s Emotions with empathic responses
S: strategy and Summary
Setting up
Make sure you know the patient’s info (lab and other results), and know how to explain everything without using Jargon
Find somewhere private. I usually use the waiting area by the entrance of North side. If that is being used, I just try to find a private enclosed area (unused resus bay, etc.)
Give a proper introduction.
I am Dr. X, I’ve been taking care of pt Y.
Assessing the patient’s Perception
Find out how much the patient or family knows, in particular how serious he/she thinks the illness is.
What do you know about your current condition?
What did your doctor tell you about your condition?
Obtaining the patient’s Invitation
Find out how much the patient wants to know. Sometimes, a health care proxy does not want their loved one to know their diagnosis or prognosis.
If this turns out to be something serious, are you the kind of person who wants to know all the details?
Would you like me to tell you the details of the diagnosis?
Giving Knowledge and information to the patient
If possible, start from what the patient already knows. Reinforce those parts which are correct.
Start with a warning shot:
I am sorry, but I have bad news to tell you.
I am sorry to say that your illness is very serious.
Make sure to tell the patients 4 crucial things: Diagnosis, Treatment Plan, Prognosis, and Support
Give the information in small checks without jargon
Check for understanding, repeat, and clarify
Am I making sense?
This is a lot to take in, do you follow what I am saying?
Listen to patient’s agenda
What are some of your concerns? Try to answer to the best of your ability. Be honest about what you don’t know. Most of the times you can tell the patient that specific things will be better answered by a specialist.
Addressing the patient’s emotions with empathic responses
Patient’s response can vary from silence to distress, denial, or anger. Observe the patient and give them time. Acknowledge any shock and ask what they are feeling. Allow silence. Don’t argue.
I can’t imagine how difficult it is for you to hear about this. What are you feeling right now? It is completely understandable that you would feel (distressed, angered, frustrated etc.) by this.
Strategy and Summary
Patients will look to us to help make sense of the confusion and provide plans for the future. Identify sources of support for the patient. Ask for further questions. Tell them the next steps. Prepare for the worst and hope for the best.
Do you have any family or friends you would like to speak to?
The next step is….
Here are two basic sample scripts that come up commonly.
Telling a family member that their loved one has died over the phone.
Hello, I am Dr. X calling from Maimonides Medical Center. I am the physician that took care of patient Y.
Where are you right now? Are you somewhere private? (if driving, advise the person to pull over and park)
I am sorry I have some bad news.
Your family member X has died. (don’t say passed, moved on ect…)
Pause: I can’t imagine how difficult it is for you to hear this.
Give brief description of what happened; the medical details are not important.
(Mr. X came with severe difficulty breathing. So much so that his heart stopped. We tried to resuscitate him but we could not revive him.)
Wait
This must be overwhelming
How are you feeling?
It is completely understandable that you would feel that way.
You do not have to come right away, but would you like to him/her? You can come with another family member or friend if you would like.
We are at Maimonides Medical Center (give address if necessary). We are located in the North Side Emergency Room.
If you have any other questions, you can call me at Spectralink number.
Giving a Diagnosis of Cancer
Your CT results are back. I am sorry I have some bad news.
Your CT shows a mass in your lung as well as your liver concerning for cancer.
I can’t say for sure what it is because you will need a biopsy.
Unfortunately, if the mass has moved to multiple organs, that shows more severe disease.
I can’t imagine how difficult it is for you to hear about this. What are you feeling right now? It is completely understandable that you would feel (distressed, angered, frustrated etc.) by this.
Do you have any family or friends you would like to speak to?
What are some of your concerns? …. I am a general emergency room doctor. I do not know the answer to that question. An oncologist will be able to give you a better answer.
The next step is to speak to an oncologist. I will you follow up with our rapid cancer center.
Do you have any other questions?
I remember in second year; I wrote down a script for giving bad news/goals of care and memorized it. I found this helpful to my delivery when it came up. I make changes to what I say depending on the patient/family (emotion, medical literacy, etc.), but the base is the same.