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Earn Category I CME credit by reading this article and the article beginning on page 26 and successfully completing the posttest on page 51. Successful completion is defined as a cumulative score of at least 70%   correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CME credit by the AAPA. The term of approval is for 1 year from the publication date of February 2011.

Learning objectives ●● Review the various factors that can create communication problems, and list tools and strategies

that can help providers to improve communication ●● Describe utilization of the Buckman protocol ●● Discuss how these strategies can improve patient care in all areas of practice

Breaking bad news: Communication skills for difficult conversations PAs can develop the basic skills needed to deliver bad news and can learn how to promote consensus and understanding among patients, families, and the health care team.

Lisa Davenport, PA-C, MSHS; Georgeanne Schopp, LMFT, MS


very clinician is eventually faced with having to deliver bad news to a patient. These scenarios are sometimes approached with dread, but the opportunity to enter into a deeper, richer relationship with the patient exists for those who remain open to it. As clinicians, we need to be aware that although medicine may no longer be able to offer a cure, the ability to heal still exists. With our unique scope of practice, PAs can have tremendous impact on a patient’s quality of care. We can ease suffering, provide education and reassurance, vastly improve communication between the care team and the patient and family, and promote understanding between parties dealing with end-of-life (EOL) issues. Many times, PAs work with members of a multidisciplinary team when dealing with complex medical issues. Team members may include multiple specialty clinicians, nurses, physical therapists, occupational therapists, mental health therapists, spiritual leaders, chaplains, social workers, case managers, and others. Introducing and utilizing these team members are important steps in caring for patients with complex medical conditions. While once limited to EOL care, this holistic approach to all patients is recognized as a valuable facet of practice. One emerging and vital concept when approaching a patient with bad news is the awareness of the many dimensions in which the patient will be impacted. Medicine has long concentrated solely on the body. We now recognize that both mental and spiritual suffering must be addressed for both patients and their families. Although addressing such suffer46 JAAPA • february 2011 • 24(2) •

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ing was once confined to end-of-life care, clinicians employ this approach with patients who are not terminally ill as well. To aid in the control of such suffering, a spiritual history should be obtained from patients. A rudimentary spiritual history on all inpatients is required by the Joint Commission on Accreditation of Healthcare Organizations.1 Generally, this information is gathered either from forms filled out by the patient or by nursing interview. Surveys have shown that patients and their families prefer that these conversations begin before the stress and confusion of hospitalization occur.2 Patients also want health care providers, at all levels, to understand their spiritual and religious needs.3 While a spiritual history is not necessary with every patient encountered daily, serious chronic diagnoses and high risk factors for major events do indicate the need for further discussions. Many models exist for taking a spiritual history, among them the FICA (Faith and beliefs; Importance of spirituality in patient’s life; Spiritual Community of support; How spiritual issues should be Addressed) and SPIRIT (Spiritual belief system; Personal spirituality; Integration with a spiritual community; Ritualized practices and restrictions; Implications for medical care; Terminal events planning) models.1 These models should be utilized in the appropriate manner—that is, as a framework for discussion. Obviously, the interview’s effectiveness hinges not only on the clinician’s comfort in asking the questions but also on the patient’s comfort with the clinician. And while a full understanding of spiritual or religious beliefs is not necessary, recognition of the patient’s values creates a deeper level of communication and trust. The medical team should appreciate the patient’s faith practices and be familiar with the support network available through the patient’s religious community. When faced with grave or terminal illness, patients can receive comfort and relief (and, in some instances, redemption) from suffering through their faith. Religious leaders from the patient’s faith practice or hospital chaplains can become key members of the care team. It is, therefore, important to identify and notify them as early as possible. BREAKING BAD NEWS

If the clinician and patient have already established a relationship through a spiritual history, a common language now exists that can facilitate the conveying of bad news. Hopefully,

before hospitalization, some discussion has occurred regarding advance directives (ADs) as well. Still, bad news does have to be delivered. And while it should remain the primary responsibility of the physician to broach the subject, PAs have a vital role in working with the patient during the initial discussion and an increasing responsibility in subsequent encounters. Familiarity with the protocols most commonly used to tell patients bad news is therefore essential. Commonly known as the Buckman or SPIKES protocol, this series of focus points creates a format for difficult discussions (Table 1). The protocol was developed and eventually published by Robert Buckman.4 Variations of it have

“Sitting close to and at eye level with the patient conveys your openness as well as your patience with the coming discussion.” gradually been adopted throughout the medical community and provide a loose framework that clinicians can use to discuss difficult news with patients. The first step in delivering bad news is to arrange the setting. Clinicians should be aware of the time this discussion requires and manage their schedules accordingly. A minimum of 40 minutes, with minimal interruption, is appropriate for the initial conversation. Privacy should be ensured, and the patient’s physical comfort and ability to have an extended discussion must also be assessed. Informing the patient a day or two in advance of the meeting and requesting that family members and/or significant others be present gives everyone time to arrange their schedules. Limiting the number of family members to two or three is useful, and sometimes requesting others to leave may be necessary. Sitting close to and at eye level with the patient conveys openness as well as patience with the coming discussion. This simple positioning creates intimacy, a sense of partnership and caring. It also allows for better assessment of the patient’s receptiveness and fatigue as the discussion progresses. Continued on page 48

Key Points ■■ While clinicians often approach the need to deliver bad news to a patient with dread, they should remember that even when medicine

cannot offer a cure, the ability to heal still exists. ■■ The medical team should take a spiritual history from the patient and should appreciate the patient’s faith practices and be familiar

with the support network available through the patient’s religious community. ■■ The SPIKES protocol offers an effective format for having difficult discussions with patients. ■■ Other important strategies include using the Four Cs (Caring, Curious, Concerned, and Confused), which can help the patient explore

and express emotion, defuse anger, and avoid such common pitfalls as failing to recognize that people from different cultures hear and process bad news differently. • february 2011 • 24(2) • JAAPA 47

CME Communication Understanding the patient’s knowledge of his or her disease process helps in determining how to approach the discussion. The clinician should already know the patient’s educational level and vocabulary. Hearing the patient’s story of the immediate disease process will give important clues to the patient’s level of understanding and even some early indicators of distress. Transitioning into the next step involves determining what the patient wants to know about the disease. Describing tests that have been or will be ordered and asking how the patient would like to learn of the results is one strategy to determine how much the patient wants to know. Confirming the patient’s wishes regarding who should know and what they should be told must be clarified. Frequent checks allow the patient to reiterate what has been said and can avoid confusion, stimulate questions, and maintain understanding. It is the clinician’s responsibility to be aware of both overt and subtle signs that the patient or a family member is confused, distressed, or unable to process additional information. If the tolerance limit has been reached, an offer to return later in the day should be made. Sharing knowledge involves outlining the diagnosis, treatment plans/options, prognosis and support and then describing these in detail. During this process, both the patient and clinician educate each other and collaborate to forge a partnership of understanding on how best to manTABLE 1. SPIKES protocol for delivering bad news1,13 Setting: Privacy, time, positioning and family presence Patient knowledge: What does the patient know about his or her situation? Invitation: What does the patient want to know about the disease? Knowledge: Sharing the diagnosis, treatment plan, prognosis, support, and options Empathy: Responding to the patient’s feelings and concerns Strategy and summary: Creating a plan together; summarizing and creating a follow-through plan TABLE 2. Additional training and resources

A Time for Listening and Caring, by Christina Puchalski (2006) Education in Palliative and End-of-life Care: The EPEC Project, available at Five Wishes, available from Aging with Dignity Web site:

How to Break Bad News, by Robert Buckman (1992) Peace, Love and Healing, by Bernie Siegel (1990) Respecting Choices, available at

When Professionals Weep, Katz and Johnson, eds (2006)

48 JAAPA • february 2011 • 24(2) •

age the disease process. Again, frequent checks of understanding are critical as the partnership reaches a consensus on a treatment plan. If appropriate, a palliative care consult can be discussed. Many patients are initially resistant, fearing palliative or hospice care to be a euphemism for abandonment. Reassurances regarding the increased level of care devoted to symptom relief and level of services can generally alleviate most fears. Stressing that the patient has control over whether to accept proffered care and whether to change the mode of treatment, and being willing to return to the subject at a later date, are also important ways to maintain communication and trust. The invitation stage is a time for the clinician to explore the patient’s wishes. In allowing the patient to express his or her understanding and feelings about the disease process, the clinician is able to open conversation and delineate how much the patient wishes to know. Open questions regarding the patient’s concerns can provide additional insight into the patient’s understanding and fears about treatment and future decisions. The next stage is often the most difficult for clinicians. Responding empathetically, after allowing the patient to express feelings, can be uncomfortable; and clinicians often feel unprepared or ill-trained for this exchange. Nevertheless, acknowledging the patient’s feelings is important for the patient-clinician relationship. Touching the patient (holding a hand, touching a shoulder) is not only acceptable but therapeutic. Gently asking what a patient is feeling or thinking can establish an opening for the patient to talk. Respecting the silence as the patient processes what has been said is also important. It may mean listening in a nonjudgmental way— simply being present to the patient. Summary and strategy involve a restatement of the plan. In the preceding conversation, both the patient’s and clinician’s concerns have been identified and a plan has been formulated, with the patient understanding what can be fixed and what cannot. This difficult subject causes distress for families, who generally are overly optimistic about their loved one’s prognosis.5 Reiterating the basic facts as a prelude to outlining the plan—for example, “You have lung cancer that has spread to the bone, and you have decided to …”—can help to avoid confusion. The patient should be reassured often that he or she is not being abandoned and remains in control of treatment options. Scheduling a time for reevaluation and another discussion of the plan before leaving gives patients greater sense of control. It also helps to offer patients an expedited form of contact for additional questions or concerns that avoids the normal office gate keepers. If advance directives are not already in place, obtaining these is a critical step at this juncture. Both patient and family need to be aware of the gravity of the situation, and clinicians need a clear understanding of what the patient wants. Some facilities have formalized AD forms, which may be cumbersome and intimidating. Many patients need help going through even the simplest format, and many facilities

delegate the duty to either social workers or nursing personnel. One form available online, Five Wishes,6 has been found to be an effective tool and comes in many languages and in a children’s version. Written in simple language and with minimal legal terminology, it is user-friendly and is accepted as a legal document by most institutions. Code status and changes to it need to be disseminated to all members of the team and to the patient’s surrogate. The medical durable power of attorney (DPOA), the surrogate decision maker for the patient, should be identified and this person’s designation verified and recorded. The surrogate must understand his or her responsibility for medical decision making on behalf of the patient. Although DPOAs are now usually included in advance

“Patients need to be reminded that care will continue, even if curative treatments have already been abandoned.” directives, many families are unsure of what the responsibility involves. The situation can become even more difficult when there is no clear DPOA during high-stress moments when rapid medical decisions must be made. Instructing the patient and family on what being a DPOA means and the responsibilities involved, designating and recording the DPOA, and keeping this person informed of the clinical situation can avoid conflict and confusion. While this protocol is presented as an initial strategy for conveying bad news, clinicians should employ it frequently in subsequent conversations. While using the protocol in follow-up encounters should not require as much time as during the first discussion, PAs are instrumental in ensuring that communication remains open and understanding remains high among the members of the team, patient, and family members. COMMUNICATION TOOLS

All team members must remain aware of the complex factors that can impact communication. Physical symptoms, fear, economic pressures, family dynamics, and uncertainty create a powerful mix of feelings that can be expressed in innumerable ways. Frequent, open-ended questions to assess the patient’s physical, mental, and spiritual status allow the clinician to address problems as they arise. Patients also need to be reminded that care will continue, even if curative treatments have been abandoned. Allowing the patient to express feelings regarding the illness can not only improve overall well-being but also alert the clinician to potential misunderstandings or problems with therapy plans. Communication strategies can also help to defuse emotional situations that threaten to get out of hand. Anger is

common when dealing with EOL issues, and the clinician should remain alert to early warning signs. Encouraging the patient to explore these feelings in an open, nonjudgmental way not only helps processing but can also reveal issues that had been submerged and are causing subconscious distress. One successful strategy is using the Four Cs: Caring, Curious, Concerned, and Confused. “You seem very distressed today. I care about you and want to help. What’s going on right now?” “I’m curious why you said that just now—want to tell me what you were feeling when you said it?” “I’m confused why you want to change your treatment plan— can you tell me more about that?” When utilized within nonjudgmental, open dialogue, the Four Cs can help the patient explore and express the emotion and defuse anger. Significant issues, especially between the patient and family, may need additional exploration and even therapy for expedited resolution. Additional training and reading exists for clinicians willing to increase their skill level in this area of care. Education in Palliative and End-of-life Care7 as well as Respecting Choices8 offer training courses throughout the country at various times of the year. Additional resources are listed in Table 2. AVOIDING COMMON PITFALLS

Studies have shown that people from different cultures respond to bad news in diverse ways, and awareness of this diversity is essential for successful communication.9 Furthermore, clinicians’ own culture may also play a part in how effectively they communicate. Along with cultural differences, social and economic status, education, age, and the sex of either the clinician or the patient can be factors. Communication with family members will also become more important as the patient’s needs increase, so establishing a good working relationship with family caregivers is important. Using the SPIKES protocol to assess family understanding acknowledges the family members’ role in patient’s care. Clinicians must remember the enormous impact that the patient’s illness has on the family structure. Feelings of grief and loss are influenced by the patient’s role within the family social unit, the economic impact of the disease itself, and the effects that loss of a wage earner has on the family’s financial status. Religious values also come into play, with many patients finding redeeming value in their suffering.10 Many patients struggle to find meaning and purpose in their disease process. Prognostication has been shown to be extremely inaccurate even among seasoned clinicians, yet asking for a prognosis is one of the most common of patient questions. In a review of studies, ICU clinicians, including physicians and nurses, not only were poor predictors of survivability, they often disagreed on individual cases.11 One way to avoid giving an inaccurate prognosis is to give a very broad range of time. For instance, “a year to many months,” “months to weeks,” or “weeks to days” can give patients and families some frame • february 2011 • 24(2) • JAAPA 49

CME Communication of reference while still reminding them that clinicians are unable to accurately predict individual clinical courses. Finally, to communicate effectively and honestly, clinicians must be aware of their own feelings about grave illness and imminent death and how these feelings influence their communication style. The medical culture has long viewed death as the ultimate defeat, and clinicians have generally avoided discussing spiritual well-being with patients. Although attitudes are shifting now and death is increasingly being seen as another step in the natural progression of life, each clinician must come to grips with what that means personally. This type of introspection and growth is important when having these conversations with patients. Clinicians must do their own work regarding their own faith, mortality, and grief issues to avoid countertransference with their patient relationships.12 This specific pitfall occurs when clinicians entwine their own struggle with mortality and grief into a patient’s process. jaapa Lisa Davenport is an adjunct professor at South University, Savannah, Georgia, where she team-teaches communication skills in delivering bad news. She has practiced as a hospitalist PA and has served on the medical ethics board at the regional hospital. Georgeanne Schopp is a marriage and

family therapist in Savannah and also team-teaches communication skills in delivering bad news at South University. She was on the Pastoral Assistants Caring Team, a ministry for the ill, dying, and bereaved at Saint Marks Catholic Church, Vienna, VA. The authors have indicated no relationships to disclose relating to the content of this article. REFERENCES 1. Sulmasy D. Spiritual issues in the care of dying patients: “… it’s okay between me and God.” JAMA. 2006;296(11):1385-1392. 2. Ginsberg M. Medical futility and end of life care: an inter-organizational approach. HEC Forum. 1999;11(2):176-191. 3. Todres D, Catlin E, Thiel M. The intensivist in a spiritual care training program adapted for clinicians. Crit Care Med. 2005;33(12):2733-2736. 4. Buckman R. How to Break Bad News. Baltimore, MD: Johns Hopkins University Press; 1992. 5. White D, Engelberg R, Wenrich M, et al. Prognostication during physician-family discussions about limiting life support in intensive care units. Crit Care Med. 2007;35(2):442-448. 6. Five Wishes. Aging with Dignity Web site. Accessed January 6, 2011. 7. The EPEC Project. Accessed January 24, 2011. 8. Hammes BJ, Briggs L. (2004). Respecting Choices Advance Care Planning Facilitator’s Manual. Gundersen Lutheran Programs for Improving End-of-Life Care, Gundersen Lutheran Medical Foundation, 2004. Accessed January 6, 2011. 9. Shrank W, Kutner J, Richardson T, et al. Focus group findings about the influence of culture on communication preferences in end-of-life care. J Gen Intern Med. 2005;20(8):703-709. 10. Nelson S. “Do everything!”: encountering “futility” in medical practice. Ethics Med. 2003;19(2):103. 11. Cohen N. Assessing futility of medical interventions—is it futile? Crit Care Med. 2003;31(2):646-648. 12. Katz R, Johnson T. When Professionals Weep. New York, NY: Taylor & Francis; 2006. 13. Baile R, Buckman R, Lenzi R, et al. SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-311.