"A moment please," my mother says to the nurse, pressing a tissue to my face, and I understand that she is the perfect person for this moment, that she is the perfect person to tell someone news so bad that no one else can even form the words. I wonder if she was always this way, or if she learned to be this way when someone told her terrible things.
- "Every Last One" by Anna Quindlen 2010
As a neurologist who specializes in rehabilitation there have been countless times in my career when I have had to deliver terrible news to a patient or family. There was the young man with the incurable brain tumor and the family of the teenager who could not believe that their daughter would never awaken from her coma. I try to think back to the first time that I had to figure out how to phrase the words, comfort the family and "act professional." I really can't remember a specific first encounter, but even worse is the fact that I cannot remember ever being shown or told how to deliver bad news. Imagine that you are the first person to tell a woman that she has breast cancer or a man that he has Parkinson's disease that will change his life forever. But, it isn't just health care providers. Like Mary Beth's mother in the novel, "Every Last One," you may be pulled into this role.
What Is Bad News?
Early in my career I remember being told that, "Life is full of bad news." The person's point was not to win the "cynic of the year award", but to make me aware that it is all about the perspective of the particular individual. While your initial thought might be that we are talking about cancer, bad news comes in many different forms.
- A chronic illness like diabetes or multiple sclerosis
- Disabling arthritis that limits a person's activities
- The need for surgery that forces someone to cancel a much anticipated vacation
- An abnormal fetal sonogram that will change a family's life forever
We have to understand the other person's perception of the event and how this news will impact them. Stress is very much about dealing with unmet expectations, so first we must understand the other person's expectations. We must anticipate how they will receive the news we are about to deliver.
It is surprising how little attention is paid to this important issue during our medical training. It wasn't that long ago that it was acceptable to conceal the whole truth from a patient and many family members didn't want to "burden" their mother with the truth about her terminal illness. Today, full disclosure is mandatory and the vast majority of people want to know everything. Most of us deal much more effectively with the details of what is known as opposed to the uncertainty of the unknown.
We must learn to avoid the scene that is played out nightly on our television screens. The doctor in green scrubs approaches a family, shakes his head slightly and the family begins to cry and mourn as the young handsome physician retreats behind the swinging doors.
The 6 Step SPIKES Strategy
For the last 20 years, Dr. Robert Buckman, an oncologist at the University of Toronto, has been at the forefront of teaching health care professional how to communicate bad news. His 1992 book, "How to Break Bad News" introduced a 6 Step Protocol for delivering bad news. In 1998 he introduced the S-P-I-K-E-S strategy that supplied an easy way to remember the 6 steps, while a subsequent article in Community Oncology clearly outlined the six steps and strategies. These six steps are useful, not only in a health care setting but, also in such "bad news" situations as having to tell someone they are losing their job, telling a child about an impending divorce or a spouse about the loss of their loved one.
• Setting (S) - I am always amazed and appalled by how many people impersonally convey bad news over the telephone. Always deliver bad news in person and have the individual bring another person with them as an extra set of ears. The setting is important and should be private and as distraction free as possible. Turn off your phone! Don't just jump into the "facts," but start a dialogue with the person. A simple inquiry of, "how are you feeling right now?" can help start the conversation. Listen and don't interrupt, as it sends a clear message that you care about the person's feelings and what is about to take place.
• Perception (P) - It is important to find out how much the person knows and why do they think they are meeting with you? Exploratory questions like, "What have you been told so far?" or "What is your understanding of the situation?" are helpful in determining where to start your explanation.
• Invitation (I) - Although most people want the whole truth and nothing but the truth, it is best to establish this as a fact. Educational levels, along with medical sophistication vary greatly and different people will want different amounts of detail. Gauge how much detail this patient or family wants to know.
• Knowledge (K) - Give people a warning of what is to come with opening statements like, "I wish I had better news" or "I am sorry to have to tell you this." It gives the person a chance to prepare themselves. Deliver the information in small digestible bites, as people will shut down and not remember much else after the initial statement of bad news. Make sure they are ready to move on to the next bit of information, for the more information you give out, the less they will recall. If the person starts to cry, take a break and be sure that they are once again ready to move forward. You don't need to race for a box of tissues, but be prepared to react calmly to what may be a very emotional response.
• Empathy (E) - Let the person know that you understand that this is a difficult time and situation for them. It is demeaning to say, "I know how you feel," unless you really do. I often say, "I have never had to walk in your shoes and I hope that I never will, but I can help you through this." It is helpful to ask someone, "What are you feeling?" and to empathize with them by saying, "This must be very distressing to you."
• Strategy and Summarize (S) - Briefly summarize the conversation that just took place and articulate a plan for the future. Make sure that they know that you are available and how to get hold of you. It can be particularly helpful to have the person tell you in their own words what you just told them, explaining that, "I want to make sure I did a good job explaining this to you."
You may not get it right every time, but hopefully you will get it wrong less often. Chances are that most people have been in this situation, so this is a good opportunity for you to tell us your personal experiences in either receiving or having to deliver bad news.
Follow Richard C. Senelick, M.D. on Twitter: www.twitter.com/RichardSenelick