How to break a bad news to the patient

1. BREAKING BAD NEWS
Dr.Imdadul Magfur
MD,Phase-A Resident
Department of Psychiatry, SOMC

20. Practical approaches
SPIKES ABCDE BREAKS
Setting and Listening Skills
Patient Perception
Invitation to Give Information
Knowledge
Explore Emotions & Empathize
Strategy and Summarize
A- Advance Preparation
B- Build environment/
relationship
C- Communicate well
D- Deal with reactions
E- Encourage & validate emotions
B – Background
R – Rapport
E – Explore
A – Announce
K – Kindling
S – Summarize

21. Setting up and Listening Skills
• Check information & introduction
• Privacy
• Body language and eye contact
• Positioning friends and relatives
• Significant others

22. SPIKES Approach (2)
Assessing perception
• Check how much is already known
• Gauge level of understanding
• Assess emotions , display of anxiety / denial
• Take note of language used

23. SPIKES Approach (3)
 Obtaining Invitation
• Respect relative /patients/ career's wishes
• “Would you like to tell me the details of what happened?”

24. Giving knowledge & Information
• Warning shot
• Give information in small chunks
• Offer clarification
• Respect important points
• Listen to concerns

25. SPIKES Approach (3)
Explore Emotions and Empathize
• Identify the emotion
• Identify the cause or source of the emotion
• Respond to show you have made the connection

26. Strategy and Summarize
• Propose a strategy
• Assess response
• Agree to a plan
• Give a summary
• Invite questions
• Make contract for next visit

27. BREAKS approach
• B –Background: in-depth knowledge of the patient’s problem,
“googling”, Cultural and ethnic background
• R- Rapport: establish a good rapport with the patient
• unconditional positive regard,
• Avoid patronizing attitude
• Avoid hostile attitude and hurried manner

28. • provide ample space for the windows of self-disclosure to open up.
• comfortable position.
• physical set up is very important (e.g. physical barriers must be removed to
maintain eye contact, switch mobile off, pagers?)
• E – Explore:
• start from what the patient knows about his/her illness confirming bad
news rather than breaking it.
• Avoid premature reassurance,
• Avoid Absolute certainties about longevity
• Discuss the prognosis in detail

29. • A –Announce:
• A warning shot is desirable
• Avoid lengthy monolog, elaborate explanations, and stories of
patients who had similar plight.
• Information should be given in short, easily comprehensible
sentences.
• Do not give more than three pieces of information at a time

30. • K- Kindling:
• People listen to their diagnosis differently (anger, denial, tears,
silence, humor?). Be ready.
• Ask the patient to recount what s/he has understood.
• Do not to utter any unrealistic treatment options
• Beware of the “differential listening,” (patient will listen to only those
information he/she wants to hear.)

31. • S –Summarize:
• Summarize the session and the concerns expressed by the patient
• Treatment/care plans for the future has to be put in nutshell.
• Offering availability round the clock and encouraging the patient to
call
• The review date also has to be fixed before concluding the session.
• Secure the patient’s safety (e.g. driving back home all alone
suicide?!

32. Do Not’s
• Do not start giving information until it is required
• Do not hit and run
• Do not leave the job for someone else (your patient, your responsibility),
unless necessary (examples?)
• Do not share information (e.g. to relatives), unless appropriate and after
consent
• Do not lie
• Do not give false hopes (science cannot always do miracles)
• Do not use terms such as “there is nothing more we can do for you”
• Do not abandon patients after session