Family Members Tend to Pursue Less Aggressive Care Strategies Than the Treating Physician
Delivering Bad or Life-Altering News
Am Fam Doctor. 2018 Jul 15;98(2):99-104.
See related article from FPM: Communicating Bad News to Your Patients
This clinical content conforms to AAFP criteria for standing medical education (CME). See the CME Quiz Questions.
Writer disclosure: No relevant financial affiliations.
Commodity Sections
- Abstract
- Patient Preferences
- Cultural Barriers
- Medico Fears
- Models
- SPIKES Protocol
- Futurity Pedagogy
- References
Delivering serious, bad, or life-altering news to a patient is ane of the nigh difficult tasks physicians encounter. Broadly divers as information that may change a patient's view of his or her future, bad news may include information related to a chronic affliction (e.g., diabetes mellitus), a life-altering affliction (e.g., multiple sclerosis), or an injury leading to meaning change (e.thousand., a season-catastrophe knee injury). Patients prefer to receive such news in person, with the physician'due south total attention, and in clear, like shooting fish in a barrel-to-understand linguistic communication with adequate fourth dimension for questions. Near patients adopt to know their diagnosis, but the corporeality of desired details varies among dissimilar cultures and by education level, age, and sex activity. The physician should respect the patient'due south unique preferences for receiving bad news. Physicians may experience stress related to providing bad news that extends beyond the bodily chat. For instance, physicians are afraid of eliciting an emotional reaction, being blamed for the bad news, and expressing their emotions during the process. Physicians often withhold information or are overly optimistic regarding prognosis, simply this can atomic number 82 to defoliation for patients regarding their condition. At that place are several algorithms available to help guide the physician in the commitment of bad news, including the SPIKES protocol (setting, perception, invitation, cognition, emotion, and strategy and summary). Skillful delivery of bad news can provide comfort for the patient and family.
Family physicians, through building long-term, multigenerational relationships with patients and families, often find themselves the bearer of bad or serious news. Bad news is broadly defined equally information that volition alter a patient'southward view of his or her future and issue in persistent cerebral, behavioral, and emotional responses.1 Some research suggests that culling terms, including serious news or life-altering news, may be more appropriate.2 Ultimately, the determination of what is bad news lies not with the physician, merely with the person receiving the news.3 Although classically related to cancer or a terminal diagnosis, bad or serious news may also include information related to diagnosis of a chronic illness (e.g., diabetes mellitus), a life-altering disease (eastward.one thousand., multiple sclerosis), or an injury leading to a significant alter (e.one thousand., a flavour-ending knee injury). Well-nigh of the research into the delivery of bad news, however, has focused on patients with cancer and subsequently practical to the delivery of bad or serious news in nononcologic settings.
SORT: Cardinal RECOMMENDATIONS FOR Do
| Clinical recommendation | Testify rating | References |
|---|---|---|
| Recognize that the corporeality of information patients desire to receive about their diagnosis varies based on civilization, education level, age, and sex. | B | 6–eight |
| Be aware of the stress physicians may feel before, during, and subsequently delivering bad news. Recognize that it may affect interactions with other patients, colleagues, and family. | C | xi, 12 |
| When delivering bad news, provide a setting that assures privacy, limits interruptions, and involves family, if the patient desires. | C | 20–22 |
| When delivering bad news, apply nontechnical words and avoid medical jargon. Provide empathy; avoid being edgeless and permit fourth dimension for patients to express emotions. | C | twenty–22, 27, 28 |
| When delivering bad news, respond to patients' emotions as they ascend, utilise empathic statements, validate responses, and ask exploratory questions when the emotion is unclear. | C | 28 |
| Use training programs such as communications courses, standardized patient scenarios, and interactive computer courses to ameliorate skills in delivering bad news. | C | thirty–32 |
Patient Preferences
- Abstract
- Patient Preferences
- Cultural Barriers
- Physician Fears
- Models
- SPIKES Protocol
- Future Teaching
- References
In the paternalistic patient-care model, the md acts every bit the patient'due south guardian, providing selected data to steer the patient to what the physician identifies equally the best decision.iv The patient-centered decision-making model became prevalent in the late 20th century, prompting the publication of several skilful consensus guidelines to aid physicians in delivering bad news.v At the same fourth dimension, there has been increased attention to end-of-life care and to instruction advice skills in medical school. There has besides been increased written report of patient preferences in an try to move toward evidence-based guidelines.
Most patients adopt to know their diagnosis, only the corporeality of information they want varies among demographics. For case, younger patients, female person patients, and patients with higher education levels tend to desire more detailed information.half-dozen,7 The corporeality of information is too dependent on cultural norms and ethnicity. For example, i study found that Korean Americans and Mexican Americans are more likely to favor a family-centered medical decision model; in contrast, African Americans and European Americans prefer a model with more private patient autonomy.viii Given such nuances, information technology is essential that physicians recognize and determine patients' preferences before delivering bad or serious news.
Patients prefer to receive bad news in person with the doctor's full attention, and they want to be confident in the physician'due south skill.nine Patients desire honesty, simple and clear language that they can understand, and adequate time for questions.seven Even amongst patients who want details of the diagnosis and treatment options, many patients are not interested in a specific prognosis.six
Cultural Barriers
- Abstract
- Patient Preferences
- Cultural Barriers
- Medico Fears
- Models
- SPIKES Protocol
- Future Education
- References
Compared with a century ago, when most deaths occurred in the dwelling, nearly deaths now occur in a hospital or facility. Because many persons lack firsthand experience with death, discussing it may be more hard. Patients take unrealistic expectations of health and life, maybe secondary to overplayed media reports of medical advances or unrealistic television portrayals. For case, the fictional survival rate of cardiopulmonary resuscitation portrayed on tv is twice that of real-life statistics.10 In improver, religious diversity makes it increasingly mutual that the physician and patient will take unlike views about an afterlife.
Physician Fears
- Abstruse
- Patient Preferences
- Cultural Barriers
- Physician Fears
- Models
- SPIKES Protocol
- Future Educational activity
- References
Physicians experience stress related to providing bad news, and this stress often extends beyond the actual chat.11 Evidence suggests that this stress does not lessen with a physician's years in practice or experience with delivering bad news.12 In general, physicians fearfulness eliciting an emotional reaction, being blamed for the bad news, and expressing their emotions during the process.
Physicians also fear that delivering truthful news virtually a terminal illness will leave a patient depressed, without promise, and with a shortened life span if hospice is involved.13 In reality, terminate-of-life discussions are associated with less ambitious medical care, before hospice referral, and improved quality of life.xiv Inquiry demonstrates increased survival fourth dimension for hospice patients overall, with the greatest increase observed in patients with congestive heart failure, lung cancer, or pancreatic cancer.xv
Physicians, for a diversity of reasons (e.g., sensitivity to cultural norms, a patient's emotional state, respect for patient and family wishes, fright of destroying promise), oftentimes withhold information or overestimate survival.16,17 The inability to effectively and truthfully evangelize bad news tin lead to patient confusion. For example, one study of patients with incurable lung cancer receiving palliative radiations found that more 60% believed their treatment may pb to a cure.eighteen Although bad news may initially increase psychological stress, full and accurate disclosure may help the patient and family emotionally and practically, making the time the patient has left equally meaningful as possible.19
Models
- Abstract
- Patient Preferences
- Cultural Barriers
- Physician Fears
- Models
- SPIKES Protocol
- Future Teaching
- References
There are several protocols and mnemonics to guide the delivery of bad or serious news, including ABCDE (Tabular array 1xx), BREAKS (Tabular array ii21), and SPIKES (Tabular array 322). The SPIKES protocol, initially adult to guide oncologists in delivering bad news to patients with cancer, may as well be used with children.2 Common themes of the protocols include establishing rapport in an advisable setting, determining the patient'southward previous cognition and want for details, avoiding medical jargon and euphemisms, supporting patient emotions, allowing for questions, summarizing, and determining adjacent steps.
TABLE 1.
ABCDE Protocol for Delivering Bad News
| Advanced preparation Review the patient'south history, mentally rehearse, and emotionally gear up. Arrange for a support person if the patient desires. Decide what the patient knows about his or her illness. |
| Build a therapeutic environment/relationship Ensure adequate time and privacy. Provide seating for everyone. Maintain middle contact and sit shut enough to touch the patient, if appropriate. |
| Communicate well Avoid medical jargon, and use plain language. Permit for silence, and movement at the patient's pace. |
| Deal with patient and family reactions Address emotions every bit they arise. Actively listen, explore feelings, and express empathy. |
| Encourage and validate emotions Correct misinformation. Explore what the bad news means to the patient. Exist cognizant of your emotions and those of your staff. |
Tabular array two.
BREAKS Protocol for Delivering Bad News
| Groundwork Know the patient'due south background, clinical history, and family unit or support person. |
| Rapport Build rapport, and permit time and space to understand the patient's concerns. |
| Explore Determine the patient's understanding, and showtime from what the patient knows almost the disease. |
| Announce Preface the bad news with a warning; use nonmedical language. Avoid long explanations or stories of other patients. Give no more than 3 pieces of data at a time. |
| Kindle Accost emotions as they ascend. Ask the patient to recount what you said. Be aware of deprival. |
| Summarize Summarize the bad news and the patient'south concerns. Provide a written summary for the patient. Ensure patient safety (e.g., suicidality, power to safely drive dwelling house) and provide follow-upwards options (eastward.g., on-call physician, help line, office appointment). |
TABLE three.
SPIKES Protocol for Delivering Bad News
| Step | Fundamental points | Example phrases |
|---|---|---|
| Setting | Arrange for a private room or surface area. Have tissues available. Limit interruptions and silence electronics. Allow the patient to dress (if later on examination). Maintain eye contact (defer charting). Include family or friends equally patient desires. | "Earlier nosotros review the results, is in that location anyone else you would like to be here?" "Would it be okay if I sat on the edge of your bed?" |
| Perception | Utilise open-ended questions to decide the patient's agreement. Correct misinformation and misunderstandings. Identify wishful thinking, unrealistic expectations, and denial. | "When yous felt the lump in your breast, what was your first thought?" "What is your understanding of your test results thus far?" |
| Invitation | Determine how much information and detail a patient desires. Inquire permission to give results and so that the patient can control the conversation. If the patient declines, offer to meet him or her again in the future when he or she is fix (or when family is available) | "Would it exist okay if I give you lot those exam results now?" "Are yous someone who likes to know all of the details, or would you prefer that I focus on the nearly important effect?" |
| Knowledge | Briefly summarize events leading upward to this bespeak. Provide a warning statement to help lessen the daze and facilitate understanding, although some studies suggest that not all patients prefer to receive a alert. Utilize nonmedical terms and avoid jargon. Stop oftentimes to confirm understanding. | "Before I go to the results, I'd like to summarize so that nosotros are all on the same page." "Unfortunately, the test results are worse than we initially hoped." "I know this is a lot of data; what questions do you have and so far?" |
| Emotions | Stop and address emotions every bit they arise. Use empathic statements to recognize the patient's emotion. Validate responses to aid the patient realize his or her feelings are important. Ask exploratory questions to help understand when the emotions are not clear. | "I tin see this is not the news you were expecting." "Yes, I can understand why you felt that fashion." "Could you tell me more about what concerns you?" |
| Strategy and summary | Summarize the news to facilitate understanding. Set a plan for follow-upward (referrals, further tests, treatment options). Offer a means of contact if additional questions ascend. Avoid maxim, "There is nothing more than we can do for you." Even if the prognosis is poor, determine and support the patient's goals (east.chiliad., symptom command, social support). | "I know this is all very frightening news, and I'm sure you will retrieve of many more questions. When you practice, write them down and we can review them when we meet over again." "Even though nosotros cannot cure your cancer, we can provide medications to control your pain and lessen your discomfort." |
SPIKES Protocol
- Abstract
- Patient Preferences
- Cultural Barriers
- Physician Fears
- Models
- SPIKES Protocol
- Future Didactics
- References
SETTING
Reviewing the patient'south history and situation are critical components of the first stride. Mental rehearsal may increase physician confidence. A proper setting also assures privacy, limits interruptions, and involves family unit if the patient desires. Tissues should be available. Sitting at the bedside increases the perceived time spent in discussion,23 and although one study constitute that women with cancer consider a seated physician more compassionate,24 sitting does not necessarily influence patient perception of the physician's bedside manner.25 For this reason, to enhance advice, the medico should ask the patient's preference.26
PERCEPTION
The second footstep is to make up one's mind the patient's understanding of his or her status. The physician should utilise wide, open-ended questions, such as, "What is your understanding of what has occurred and so far?" The physician may also identify misunderstanding, denial, and unrealistic expectations.
INVITATION
There is variability among patients' want for detailed data. It is important to obtain the patient's permission before delivering the bad news. A phrase such as, "Would it be okay to give you the results of the tests right at present?" engages the patient in shared decision making. If the patient declines the invitation, it is of import to decide the reason (e.g., waiting for a spouse, partner, or other family member to provide support).
KNOWLEDGE
Physicians should utilize uncomplicated, nontechnical words and avoid medical jargon when delivering bad news. They should provide empathy past fugitive being edgeless and by allowing time for patients to limited emotions. Information should be provided in small amounts, followed by a confirmation of understanding. The SPIKES method advocates delivering a warning statement before the bad news (e.m., "I'm afraid the exam results were worse than we initially hoped."), but some research indicates that this is not a universal preference.27
EMOTIONS
Before providing additional information or even firsthand reassurance, the doc should acknowledge and accept the patient'south response. Empathic statements (e.one thousand., "Information technology seems like you are feeling…") are useful during expressions of sadness and acrimony. Validating responses (e.chiliad., "This has been a difficult time for you.") helps patients realize their feelings are important. Supportive statements (e.grand., "I am here to help you.") guard against the feeling of abandonment, and exploratory questions (e.g., "You said y'all were worried about your children. Can you lot tell me more nigh that?") are helpful when the emotion is non clear. NURSE (naming, understanding, respecting, supporting, exploring) is a useful acronym of the key steps in expressing empathy (Tabular array four).28 A physician tin can take a patient's response (e.g., the desire to be cured of cancer), without agreeing with it (e.g., cure is not probable).
TABLE 4.
NURSE Mnemonic for Expressing Empathy
| Technique | Example phrases |
|---|---|
| Naming | "It sounds similar you lot are worried about…" "I wonder if you are feeling angry." |
| Agreement | "If I understand what you are saying, you are worried how your treatments volition affect your work." "This has been extremely hard for y'all." |
| Respecting | "This must be a tremendous amount to bargain with." "I am impressed with how well you have handled the treatments." |
| Supporting | "I will exist with you during the treatments." "Delight let me know what I can practice to help you lot." |
| Exploring | "Tell me more about your concern about the handling side effects." "You lot mentioned you are afraid nearly how your children will accept the news. Can you tell me more about this?" |
STRATEGY AND SUMMARY
Physicians should provide a summary, explore options, and decide patient-specific goals. Even with the worst prognosis, most patients prefer to know what is coming next.29 Follow-upward should include the patient's adjacent appointment and a manner for the patient or family to contact the doctor with questions. A second engagement in the next few days may exist useful to review the bad news and to answer questions. A give-and-take of treatment options may exist appropriate at that time, or it may be delayed, depending on patient preference. Physicians should avoid the phrase "I'm afraid there is aught more we can do for you." This leaves the patient feeling helpless and abased. Instead, in the absenteeism of cure, the focus should be on defining and supporting the patient'south redefined hopes (due east.k., less pain, more time with family). Patients should be assured that the dr. volition be with them and support them.
Hereafter Education
- Abstract
- Patient Preferences
- Cultural Barriers
- Physician Fears
- Models
- SPIKES Protocol
- Future Educational activity
- References
Despite marked advancements in medicine, not all patients can be cured. Skilful commitment of bad news can provide comfort for the patient and family. Communications courses,thirty standardized patient scenarios,31 and interactive computer courses32 have all demonstrated improvement in md communication skills. Education tin can ameliorate a physician's skill in delivering bad news, but research has yet to certificate improved patient outcomes. Current algorithms and guidelines are not considered prove-based,33 but increased research in the field continues to improve physician guidance with this hard chore.
This article updates a previous article on this topic by VandeKieft.29
Data Sources: A PubMed search was completed in Clinical Queries using the central terms bad news and communicating bad news. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. We also searched Essential Evidence Plus. Search date: March 22, 2017.
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