Discussing Disease Progression and End-of-Life Decisions

Breaking Bad News Well: Yes, But How?

Few of us enjoy performing a task if we feel that we are not very good at it. Furthermore, the simpler the task appears to be, the more embarrassed we feel about our perceived lack of ability. As a result, we tend to avoid the whole situation and the discomfort associated with it.

This is the central problem that has bedeviled communication skills in medical practice for the last few decades. We all know what we are supposed to be doing—because experts have been reminding us about it for years—but there has been remarkably little practical guidance about how we should do it. All of this makes the article by Dr. Walter Baile and colleagues on the most difficult communication task—breaking bad news—extremely welcome.

No Universal Script Available

In difficult clinical interviews, there is no such thing as a universal fix-all script. This is because the main objective of breaking bad news well is to deal sensitively with this individual patient facing this particular piece of news and responding with these particular emotions.

Over the last few years, there have been many excellent suggestions regarding the principles that should guide us—and almost all of them are of undisputed benefit. We clearly understand from research studies and from patients that we have to show support for the patient, use empathy, appreciate the individual patient’s particular concerns, and understand and respond to those concerns honestly and with the appropriate amount of information. These principles, among others, are beyond dispute.

There has been no real controversy in recent times about what to do—the real question has become, how do we do it? Fortunately, there exist some useful guidelines and tips that we can all employ in clinical practice—and Dr. Baile’s group outlines the main steps with some valuable illustrations.

A Step-by-Step Strategy

This article details a step-by-step strategy for the process of breaking bad news that, as research now shows, meets the objectives of carrying out this task well. To some extent, a protocol for use in a communication task can be legitimately compared to a protocol for any medical intervention. Protocols used in cardiopulmonary arrest, diabetic coma, or septic shock, for example, are actually strategies for coping with medical events. Like all protocols, these present a sequence of steps for use in a clinical situation as it evolves and changes.

When you analyze their structure, protocols such as these consist of two elements: (1) sequential steps based on fundamental principles, and (2) a set of ways in which the clinician responds to what happens next (in other words, an algorithm). Thus, for example, we are trained to carry out the first steps of cardiopulmonary resuscitation (CPR) in an unvarying sequence (ie, establishing a patent airway, starting chest compressions, getting an intravenous line started) and then to base the next steps on the patient’s cardiac rhythm, restoration of circulation, and so on.

The comparison between a CPR protocol and one for breaking bad news is not too great a stretch. The fundamental components are the same: The clinician has to (1) assess what is happening as the situation unfolds, and (2) have ready a set of techniques that are helpful in each of those outcomes.

The SPIKES six-step protocol (an inelegant acronym, but not inappropriate!) presents the main stages for breaking bad news, and the authors’ sample dialogue illustrates the communication tasks and the techniques involved at various stages. In the sample dialogue—and in the discussion that follows—Dr. Baile’s group provides examples of: assessing the patient’s knowledge, describing recent treatment and tests, introducing bad news (using a warning shot and such words as “unfortunately”), employing silence and pauses, repeating a key word that has been used by the patient, and responding with empathy to an identified emotion. They also provide many other practical tips and guidelines that can be assimilated quite easily into oncology practice.

Taking the Mystery and Mystique Out of Communication

The techniques illustrated in the article are not highly specialized. They are accessible to all of us in medicine, and it’s helpful to see them described in detail. It’s always reassuring to know that this is what other practitioners do, and therefore that we have “permission” to do it ourselves. That is one of the major advantages of examples of dialogue—they provide a clear illustration of the “how” of breaking bad news. (For those who would like to see more examples in videotaped form, it may be worth looking at the CD-ROM set referred to in the article.)

Examples of techniques and practical details take the mystery and mystique out of communication skills—and that’s what exactly we need in oncology at the moment. The techniques are becoming less mysterious, and our ability to communicate is gradually becoming a learnable—and crucial—part of our daily job.