YOUNG PHYSICIANS SECTION
Breaking Bad News: Practical Applications in the Emergency Department Reed Wise, MS and Danielle Goodrich, MD FAAEM FACEP
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reaking bad news is one of the most difficult tasks physicians are asked to do. An emotional minefield awaits even the most experienced communicators given that each patient has their own unique set of goals, expectations, and desires that must be considered. Approaching emotionally taxing conversations without a plan can decrease the efficacy of the conversation and may lead to miscommunication and adverse patient reactions. In this article, we present a model, SPIKES, originally developed to deliver cancer diagnoses, for adaptation to the emergency room setting. The SPIKES model focuses on six critical facets: (1) Setting Up the Interview, (2) Perception, (3) Invitation to the Encounter, (4) Knowledge, (5) Empathy and Emotion, and (6) Summary and Strategy.1 Within this framework, the authors lay out the four primary goals for an interview in which bad news is discussed which include information gathering, collaborating with the patient on treatment strategies, transmitting medical information, and providing support. Given the nuances and stakes at play, entering the conversation prepared is necessary to create an environment for successful communication with your patients and their families.
S When “Setting Up the Interview,” the physician should take space both physically as well as mentally to privately acknowledge their own feelings and create a plan. Location as well as the involvement of those that the patient wishes to accompany them while they receive their diagnosis are important considerations. Moreover, this may be a life-changing moment for the patient and they will appreciate your full support, so ensuring adequate time is also necessary. Additional considerations also include sitting at the level of the patient and making eye contact to express support through body language.
Our patients need to know their diagnoses so that we can adequately treat and care for them, but that does not mean that sharing poor prognoses is easy for either the patient or the physician.”
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P Perception. Every patient’s level of understanding of their condition differs so “before you tell, ask” about your patient’s knowledge to assess their basis of knowledge. Politely correct any misinformation once they are done sharing to tailor the conversation to the patient’s needs. Useful open ended questions include: “What do you know about your condition?” or “What are your goals for treatment?” Assess for illness denial, such as omission of difficult details, unrealistic expectations, and wishful thinking. I In the “Invitation to the Encounter” the physician allows the patient to discuss the topic on their own terms. Every patient receives bad news differently so it can be beneficial to engage the patient on their terms. For example, would the patient prefer to get the news now? Would they prefer someone else to be present? Do they prefer to have someone else receive their news?
K When sharing Knowledge with a patient, the physician should alert the patient before delivering the bad news. Consider beginning with a statement like, “I have some heavy news for you, are you ready for me to share it?” or similar prompts to ensure that the patient is indeed ready for the conversation. Employing empathy, eliminating medical jargon, and avoiding extreme bluntness can go a long way toward helping patients digest difficult information. If there is a lot of information to be shared, such as a complex diagnosis or treatment plan, it can be helpful to break up the news with periodic assessments of patient comprehension and goals. Statements such as “Does that make sense?” or “Would you like to discuss some alternatives to my suggested treatment plan?” can be helpful to break up the interview and recenter it on the patient’s goals and level of >> understanding.