Delivering Bad News
No one likes giving bad news, even those with practice like doctors
I read an interesting article in the Omaha World-Herald last week titled “Future doctors trained to show some heart when giving bad news.” In it the author spoke of the way doctors and medical students are trained to deliver bad news. In a byline a short list of helpful hints were listed that are frequently taught in medical school to educate young trainees on how to best break regrettable news (in the form of the poorly-conceived mnemonic “SPIKE”):
S is for Setting
The setting should be a private place with the door closed or curtains drawn around the hospital bed.
P is for Perception
Perceive the patient’s view of the situation by asking something like “What have you been told so far?” or “Are you worried this might be serious?”
I is for Invitation
Invite a discussion. Don’t assume the patient wants details. “How much information would you like me to give you about your diagnosis and treatment?”
K is for Knowledge
Before imparting knowledge, warn the patient that bad news is coming. This gives the patient or relative a few seconds to prepare. Say “Mrs. Smith, I’m so sorry to have to tell you . . .” or “Unfortunately, I’ve got some bad news to tell you, Mr. Andrews.”
E is for Empathy
Empathize. Listen for and observe the patient’s emotion. Show your patient that you have identified the emotion. Say: “Hearing the result of the bone scan is clearly a major shock to you” or “Clearly, this is very distressing.”
S is for Strategize and Summarize
Summarize the information and give your patient a chance to voice concerns or questions. Work out a plan for the next steps that should be taken.
Reading this article reminded me of the absolute worst interaction I’ve ever seen between a doctor and the family of a recently deceased patient. It was several years ago while I was a fellow in cardiovascular medicine. The senior physician I was assisting had just unsuccessfully attempted to open a blocked vessel in a relatively young woman with a heart attack. We pulled the family members into a room and he proceeded to give them the news. It went something like this:
Doctor: I’m afraid I have some bad news. Please sit down.
Husband: What is it? What happened? Is she going to be okay?
Doctor: The coronary lesion was complex and ulcerated and we couldn’t get the wire to pass through the lumen. She developed a dissection flap and occluded flow to a large part of her myocardium.
Husband: Is she all right?
Doctor: We tried to place a balloon pump to support her perfusion but her pressure kept dropping. We had her on several pressors and I think that may have contributed to her arrhythmia.
Husband: What do you mean by arrhythmia? Is she okay? Can we see her?
Doctor: We—the whole staff—did everything we could but I’m afraid we couldn’t resuscitate her.
Husband: Resuscitate her? What does that mean?
Doctor: Well, we lost her.
Husband: Lost her? What are you saying? Are you saying she died?
Doctor: You have to understand that she had already suffered a lot of damage even before she got to the emergency room.
Husband: Did she die?
Doctor: Well, . . . yes.
I don’t think I need to point out all the ways in which the doctor messed up this delicate encounter. It’s pretty clear to me that my esteemed mentor must have missed the day in doctor school when they taught this lesson. I don’t think he could have done a worse job.
Honesty and clarity are key
When delivering news about a death, the only advice I could add to that give in the World-Herald article is this: Deliver the news in plain, simple, direct language (“I’m sorry to say that your mother has died”). Don’t use euphemisms (“we lost her,” “she has passed,” “she’s not with us anymore”) or technical language. Just come out with it. I also don’t think it’s helpful to go into much detail about the events leading up to the death since most families won’t hear another word you say after you’ve told them the news. There will be time later for this.
I can still remember the way I felt as I sat in the room listening to the senior cardiologist deliver his obtuse report. I was sick to my stomach and wanted to either slink out of the room or strangle him. I did neither, but I did apologize later to the family and I think it helped. And I did it in plain English.
Great article Eric. Too often, we physicians hide our discomfort with poor outcomes by speaking in complex technical terms. We must always remember that patients and their families deserve clear communication delivered with compassion.