Giving Bad News Sucks. This Can Help
As a hospitalist, communication skills are very important to have when conveying information to patients, families and other healthcare providers. In addition, patients and families span across the spectrum of healthcare literacy and exposure, adding to the complexity of this task. Even when equipped with as many soft-skill-tipped arrows as can fit within your quiver, every archer of medicine grapples with one problem; giving bad news is a very tough task. It is a very complex process encompassing involving the patient and family/support system in decision making while managing emotions and and expectations in unfavorable situations. Thankfully, it can be done systematically improving provider strain and reinforcing the patient centered approach to care.
To achieve this, a six step strategy was created by Walter Baile. I have summarized the six steps below.
Spikes is an acronym for:
Set up
When arranging a meeting, always remember to hold it in a private location to give the patients the dignity and decency they deserve. In addition, be sure to include the support group of the patients choosing such as family, friends, power of attorney, etc. This may require some flexibility and forethought when planning your workday, but it will lead to improved satisfaction and lessen interruptions. Lastly, create an inviting and comfortable environment to combat the stress and anxiety surrounding the patient's condition. The privacy as mentioned above will contribute a lot to the comfortability of the patient and support group. A few other considerations are, find a room where everyone can be comfortably seated, be a good listener and be empathetic, especially when the interview takes an emotional turn.
Perception
Use open ended questions when assessing patients understanding. For example, a physician may ask, "what were you told of your medical condition so far?" to get a grasp of their understanding, assess for unrealistic expectations or other red flags suggesting illness denial. Identifying these potential roadblocks can prevent conflicts when discussing prognosis and treatment options.
Invitation
A provider may ask, "I do have some unfortunate news. How would you like for me to give you the results?" Forewarning the patient that bad news is coming can sometimes help them prepare for whats next. It also frames the conversation in a way that empowers them to drive discussion and decision making. As the example above, this message should be concise and focused, free from drama and cliffhangers.
Knowledge
Conversations during these stressful moments will be complicated by emotions such as fear, anxiety, anger and sadness. Deliver the message clearly by refraining from jargon, and acronyms. Most importantly, NEVER say there is nothing more you can do. There is always symptom control.
Emotions and Empathetic Responses
Pause during emotional moments such as crying, provide a hand to hold and communicate in a way that reflects your acknowledgement of what your patient is going through. A little empathy goes a long way.
Strategy
When discussing a treatment plan, give the patient an opportunity to take any time they may need to shift gears. Consider their level of understanding and tailor the treatment plan to align with their goals of care.
According to Baile et al, creating a plan for consistently delivering bad news to patients in a way that considers their values, wishes for participation and incorporates a strategy to manage distress when the news is shared will:
- Give physicians more confidence and comfortability during these encounters
- Empower patients to participate in difficult decisions regarding their treatment
- Decrease physician stress and burnout
I hope this helps you and your patients traverse the path ahead.