As a certified hospice medical director and physician who has worked with patients with HIV/AIDS, Ada Stewart, MD, has broken bad news to patients and their loved ones numerous times.
“It doesn’t get any easier,” said Stewart, who serves on the board of directors for the American Academy of Family Physicians (AAFP). “But I think you get more comfortable.”
Like many doctors, Stewart has worked to find the best way to handle the difficult process of sharing bad news with care and effectiveness.
“The biggest thing is that you have to be compassionate,” she said. “You have to make sure you are truthful with the patient, to the best of your ability. And if you don’t know something, you have to be honest and say, ‘I don’t know.’”
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How should doctors break bad news?
Stewart has refined her approach over time, basing it to some degree on the protocol known as SPIKES. First described by Walter F. Baile, MD, and co-authors in The Oncologist in 2000, the SPIKES protocol employs six steps:
S: Set up the interview
P: Assess the patient’s perception
I: Obtain the patient’s invitation
K: Give knowledge and information to the patient
E: Address the patient’s emotions with empathy
S: Provide a strategy and summary
Even physicians who don’t follow a formal set of guidelines like the SPIKES protocol often use some of the same principles. They know that it’s important to find time to focus on the patient and family members without any distractions and speak calmly, all the while monitoring their reactions, so they can respond with care.
“You have to create a space where they know this is the most important thing,” said Jeremy Topin, MD, a pulmonary and critical care physician at Northwest Pulmonary Associates in Illinois.
Anjali Malik, MD, a fellowship-trained breast imaging radiologist at Washington Radiology in Washington, DC, emphasized the importance of treating each patient individually, including reading their levels of anxiety and understanding, then adjusting your delivery to meet their needs.
“Some patients will want all the information immediately, while others will need time to adjust to the news before moving forward,” she said.
Malik also chooses to give her patients a path forward before concluding the conversation—as the final “S” in the SPIKES protocol suggests.
“I like to give patients a plan, as I find it a positive way to move forward,” said Malik. “For breast cancer patients, that typically involves the appointments they need to make and conversations they should be having with their care team.”
That’s a very important step in the process for Topin, too. He always sets up an appointment with an oncologist for patients to whom he is planning to deliver a cancer diagnosis.
“I want to have that next step planned out for them,” he said. “Because it’s overwhelming. When they hear ‘You have cancer,’ they just don’t hear anything anymore.”
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Tailoring your own approach
At some point, physicians may no longer need to rely stringently on a standardized protocol for delivering a difficult diagnosis or other bad news. For example, radiologist Resham Mendi, MD, used to rely on guided protocols like SPIKES.
“Now that sequence kind of comes more naturally,” said Mendi, the medical director of Bright Light Medical Imaging in Illinois.
“I always make sure that we all have time to talk in a calm environment when the patient has time to absorb what I am telling them,” she said. “I try not to present too much information in the first conversation. It is very difficult for anyone to take so much in at once, especially when they are overwhelmed with fear and emotion.”
Gustavo Ferrer, MD, author of the recent book Graceful Exit: How to Advocate Effectively, Take Care of Yourself, and Be Present for the Death of a Loved One, has changed his approach over time. He remembered how he used to be very pragmatic when approaching a situation in which he had to break bad news to a patient.
“It was not intentional,” he said. “We didn’t get any specific training on delivering bad news. I learned it by trial and error.”
But an experience with a patient’s wife who gently reminded him that her husband wasn’t just a disease—he was a human being—set him on a new path. Today, he focuses specifically on the patients and their families with compassion.
“I work intentionally on keeping people’s emotions, feelings and family dynamics at the center of the conversation,” he said.
Stewart noted that it can be difficult, even emotionally draining, to be the bearer of bad news, especially when it’s a patient with whom she’s had a long-standing relationship.
“That is the hardest thing for us, emotionally,” she said. “But if you don’t feel that emotion, it’s a problem.”
With burnout such a major problem among physicians today, it’s important to recognize the toll that breaking bad news can take on you, Stewart said. Being proactive about self-care can help, whether it’s spending time with your family or your pets or doing something else, she said.
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