This document provides guidance on sharing bad news with patients in a structured way. It discusses why open and honest communication is important, even if uncomfortable, and how it can strengthen the patient-physician relationship and allow patients to better plan. A 6-step framework called "SPIKES" is presented for delivering bad news. The steps are to 1) set up the conversation, 2) understand the patient's perspective, 3) obtain their invitation to share information, 4) provide medical knowledge, 5) address emotions empathetically, and 6) summarize and discuss next steps. Maintaining hope is important, and withholding information should only be done after exploring the patient's reasons for preferring that. Overall an honest yet compassion

1. Sharing Bad News
Kristina Newport, MD FAAHPM
Hospice & Palliative Medicine
July 12, 2017

2. Objectives
Establish importance of honest, open communication
Provide framework for sharing information
Provide some scripts that can be personalized for
comfortable use
Share experiences and concerns about sharing bad
news

3. Overall Message
A structured approach facilitates open,
honest communication that helps patients
maintain hope
It’s not really about the words.

4. Why Don’t Providers
Share Bad News?
Uncomfortable for the provider
Fear of affecting relationship
Perception that hope is diminished
Time
Lack of experience, comfort or framework

5. Why Share Bad News?
It’s not about you
Most people want to know* (but won’t ask)
Strengthens physician-patient relationship
Hope is maintained when communication
is honest and open**
Improved illness understanding leads to
more appropriate & guideline-concordant
care***
Permits patients, families to plan, cope
*Advanced cancer patients' prognostic information preferences: a review. Innes S, Payne S. Palliat Med. 2009 Jan;23(1):29-39. Epub 2008 Oct 24. Review.
** Giving honest information to patients with advanced cancer maintains hope. Smith TJ, Dow LA, Virago E, Khatcheressian J, Lyckholm LJ, Matsuyama
R.Oncology (Williston Park). 2010 May;24(6):521-5.
***Freedman RA, Kouri EM, WestDW, et al: Association of breast cancer knowledge with receipt of guideline-recommended breast cancer treatment. J
Oncol Pract 12:e613-e625, 2016

6. Hope
Promoting hope:
 offering the most up to date treatment (90%),
appearing to know all there is to know about the
patient's cancer (87%)
saying that pain will be controlled (87%).
Impairing Hope:
doctor appearing to be nervous or uncomfortable (91%)
giving the prognosis to the family first (87%)
using euphemisms (82%) would not facilitate hope.
Giving honest information to patients with advanced cancer maintains hope. Smith TJ, Dow LA, Virago E, Khatcheressian J, Lyckholm LJ,
Matsuyama R.Oncology (Williston Park). 2010 May;24(6):521-5.

7. 6 Steps “SPIKES”
1. Setting up
2. Establish Perception- Find out what is known
3. Seek Invitation to present information
4. Provide Knowledge
5. Respond to Emotion Empathically- Listen
6. Strategy & Summary- Plan for follow-up
Adapted from: Buckman R. How to Break Bad News: A Guide for Health Care Professionals. Baltimore, MD: The Johns Hopkins University
Press; 1992:65-97.

8. 6 Steps to Communicating Bad News
Step 1: SETTING UP
Gather information: chart, other providers
Determine whom the patient would like present
Ask for invitation: “How much do you want to know?”
Create an physical environment conducive to dialogue
 Sit down
 Turn off pagers, phones
 Allow adequate time

9. Communicating Bad News
Step 2: Assess PERCEPTION
Establish what the patient/family knows
 Ask before you tell
 Assess baseline understanding
 Provides language to use
“Tell me what you know about your condition/situation…”

10. Communicating Bad News
Step 3: Obtain the Patient’s INVITATION
 How much information does the patient want
 Establish to whom information should be given
“Some people want to know every detail about their condition,
others prefer a general idea and yet others don’t want to know
anything. Which best describes you?”
“With whom should I talk about these issues?”

11. Communicating Bad News
Step 4: Give KNOWLEDGE and Information
Fire a warning shot
“As you know, we’ve been waiting for the results of…”
Avoid technical words, euphemisms
 Euphemisms are a source of distrust, loss of hope
Deliver information in simple, unmistakable terms
“Unfortunately, the cancer has grown”
“As we feared, she is paralyzed”
“Unfortunately, your loved one is dying”

12. Then…

13. Communicating Bad News
Stop talking and listen.

14. Communicating Bad News
Step 5: Address EMOTIONS EMPATHICALLY
Observe emotion
Identify the emotion
“You seem surprised sad/scared/angry…”
Normalize/Validate emotions
“It’s normal for you to feel sad/scared/angry…”
“I often see that people feel relieved/ astonished/
hurt when they get news like this…”

15. Communicating Bad News
Step 6: STRATEGY and SUMMARY
Summarize
“It seems that we all agree that Grandma is not going to get
to play bingo again and therefore the best option for her
is…”
“So now that we know that the cancer has returned, our
focus will change to keeping you comfortable by going
xxx….”

16. Communicating Bad News
Step 6: STRATEGY and SUMMARY cont.
Develop and communicate a plan for follow-up
What comes next?
 There is always something we can do
 Empower the patient with a plan
Include support staff, community resources
Ensure non-abandonment
Document/communicate with all providers

17. Communicating Bad News
Withholding Information: “Please don’t tell!”
Explore reasons
Protecting loved ones
Fear of crushing hope
Previous experience
Cultural, religious context

18. Communicating Bad News
Hope & Miracles
Do not refute the possibility:
diminishes trust, invalidates the patient’s beliefs
Possible responses:
“I wish” statements
“I can only speak to what science and experience have
taught us…”
“Hope for the best, prepare for the worst”

19. Communicating Bad News
A structured approach facilitates open,
honest communication that helps patients
maintain hope.

20. Vital Talk:
Tools and Courses
Step What you do
1. Setting
Find a quiet location, private if possible
Invite the important people to be present
Have tissues available
Have enough chairs
Turn off the ringer on your phone/pager
2. Perception – what the patient knows
already
“Tell me what you understand about your
illness.”
“What have the other doctors told you
about your illness?”
Look for knowledge and emotional
information while the patient responds
3. Invitation – information sharing
preferences
“Would it be okay for me to discuss the
results of your tests with you now?”
“How do you prefer to discuss medical
information in your family?”
“Some people prefer a global picture of
what is happening and others like all the
details, what do you prefer?”
4. Knowledge – give the information
Give a warning… “I have something
serious we need to discuss”
Avoid medical jargon.
Say it simply and stop. (e.g.“Your cancer
has spread to your liver. It is getting
worse despite our treatments.”)
5. Empathy – respond to emotion
Wait quietly for the patient.
“I know this is not what you expected to
hear today.” “This is very difficult news.”
6. Summary – discuss next steps and
follow up plan
“We’ve talked about a lot of things today,
can you please tell me what you
understand.”
“Let’s set up a follow-up appointment.”
Copyright VitalTalk 2017
http://
vitaltalk.org/resources/quickguides/

21. Serious Illness
Care:
Ariadne Labs
https://www.ariadnelabs.org/areas-
of-work/serious-illness-care/

22. Discussion &
Questions
knewport@supportivecare.org