Breaking bad news to patients

Paul S. Mueller, MD

VOL 112 / NO 3 / SEPTEMBER 2002 / POSTGRADUATE MEDICINE

Bad news is any information that changes a person's view of the future in a negative way (1). Physicians frequently must break bad news to patients and their loved ones (2). Bad news often is associated with a terminal illness such as cancer.

However, bad news can come in many forms: the diagnosis of a chronic illness (eg, diabetes mellitus), disability, or loss of function (eg, impotence) (3); a treatment plan that is burdensome, painful, or costly; and even information that physicians may perceive as neutral or benign.

In Decorum, Hippocrates (4) recommended that physicians be leery of breaking bad news because the patient may "take a turn for the worse." Thomas Percival gave a similar warning in Medical Ethics in 1803 (5), as did the American Medical Association in its first code of medical ethics in 1847 (3).

Withholding bad news from patients was commonly practiced until recently. A 1961 survey of 193 physicians (6)revealed that 169 (88%) routinely withheld cancer diagnoses. Furthermore, they often used euphemisms such as "growth" to describe cancer. The policy was "to tell as little as possible in the most general terms consistent with maintaining cooperation and treatment." However, the same study found that most patients desired the truth regarding their diagnosis. In fact, many recent studies have found that most patients want to know the truth about their illness (2).

Importance of disclosure

In recent decades, the paternalistic model of patient care has been replaced by one that emphasizes patient autonomy and full disclosure (3,7). Honest disclosure of diagnoses, prognoses, and treatment options allows patients to make informed healthcare decisions that are consistent with their goals and values (8). When physicians withhold bad news, they diminish patient autonomy. Furthermore, it serves little or no purpose to withhold bad news from a patient who eventually discerns the nature of his or her illness. Patients who discover that information has been withheld may no longer trust their physician (9). Indeed, only under rare circumstances is nondisclosure of bad news ethically permissible (8).

Barriers to effective disclosure

Breaking bad news can be difficult for physicians, and phrases like "dropping the bomb" are used to describe the task (2). How bad news is presented may affect patients' comprehension of and adjustment to the news (2,10,11) as well as their satisfaction with their physician (12). Barriers to effective communication of bad news include physician fears--the fear of being blamed by the patient, of not knowing all of the answers sought by the patient, of inflicting pain on the patient, and even the physician's own fear of illness and death. Furthermore, many physicians have had little or no formal training in how to break bad news, and many perceive a lack of time in which to present the news. Patients may have multiple physicians, making it unclear who should break the bad news (1,13-15).

What patients consider important

The most important factors for patients when they receive bad news are the physician's competence, honesty, and attention; the time allowed for questions; a straightforward and understandable diagnosis; and the use of clear language (16). Knowing the physician well and the physician's use of touch (eg, holding the patient's hand) rank lower. Families rank privacy; the physician's attitude, competence, and clarity; and time for questions as important (17). Few trials have evaluated strategies for breaking bad news (18). Instead, most articles on breaking bad news are opinions and reviews by physician scholars (12,18,19).

The SPIKES approach

A review of 67 articles published after 1985 (19) summarized the most common recommendations to physicians for breaking bad news. Baile and colleagues (2) organized recommendations into the mnemonic SPIKES: Setting up, Perception, Invitation, Knowledge, Emotions, Strategy and summary. This approach is intended to help physicians break bad news to patients in a straightforward and empathic manner.

Setting up: Breaking bad news should be done in private; only the patient, his or her loved ones, and members of the healthcare team should be present. The physician should sit down, make eye contact with the patient, and use touch appropriately. Sufficient time should be allowed to answer questions. Interruptions (eg, pagers) should be minimized.

Patient perceptions: Physicians need to discern what the patient knows about his or her illness before breaking bad news. Questions that reveal patient perception include "What have you been told about your condition?" and "Do you recall why we did this test?" Assessing patient perceptions allows physicians to correct misinformation and tailor the news to the patient's level of comprehension.

Invitation to break news: Physicians need to get the patient's permission to share bad news. Getting permission may be especially important for patients from non-Western cultures in which autonomy of the individual may not be paramount and healthcare decision making is shared with others (7). For example, the physician may say, "I'd like to share with you the results of your tests. Is that okay?" Before ordering tests or procedures, physicians need to inform patients about possible outcomes, which prepares patients for potential bad news. Physicians also should ask patients if they want only basic information or a detailed disclosure.

Knowledge: Patients need enough information to make informed healthcare decisions; thus, physicians should convey information at the patient's level of comprehension. For example, the word spread should be used in place of metastasized. To help patients adequately process bad news, small boluses of information should be given. Physicians can check for comprehension by asking, "Am I making sense?" or "Can I clarify anything?" Undue bluntness and misleading optimism should be avoided. Some physicians believe it is unhelpful to give specific time periods regarding prognosis.

Emotions: The empathic physician acknowledges a patient's emotional response to bad news by first identifying the emotion and then responding to it. "I can see that you are upset by this news" is an empathic statement. Deliberate periods of silence allow patients to process bad news and ventilate emotions.

Strategy and summary: After receiving bad news, a patient may experience a sense of isolation and uncertainty. Physicians can minimize the patient's anxiety by summarizing the areas discussed, checking for comprehension, and formulating a strategy and follow-up plan with the patient. Written materials (eg, hand-written notes or prepared materials listing the diagnosis and treatment options) may be helpful. Physicians should assure the patient of their availability to address symptoms, answer questions, and meet other needs.

Empathic communication is key

Use of an empathic communication approach to breaking bad news, such as SPIKES, may improve the physician-patient relationship and reduce the patient's anxiety (20); such an approach does not require much time (10,20,21). Other helpful phrases and questions are "I wish I had better news" (as opposed to "I'm sorry, I have bad news") (22), "I admire your courage," "I will be here for you," and "What gives you hope and strength?" Unhelpful statements include "It could be worse," "We all die," "I understand how you feel," and "Nothing more can be done." How a physician delivers bad news may affect patients' understanding of and adjustment to the news as well as their satisfaction with their physician.

References

1. Buckman R. Breaking bad news: Why is it still so difficult? Br Med J 1984;288(6430):1597-9
2. Baile WF, 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):302-11
3. VandeKieft GK. Breaking bad news. Am Fam Physician 2001;64(12):1975-8
4. Hippocrates. Decorum, XVI. In: Jones WH. Hippocrates with an English translation. Vol II. London: William Heinemann, 1923
5. Percival T. Medical ethics; or, A code of institutes and precepts, adapted to the professional conduct of physicians and surgeons. Manchester, England: S. Russell, 1803:166
6. Oken D. What to tell cancer patients: a study of medical attitudes. JAMA 1961;175:1120-8
7. Mitchell JL. Cross-cultural issues in the disclosure of cancer. Cancer Pract 1998;6(3):153-60
8. Burack JH. Truth telling. In: Sugarman J, ed. 20 common problems: ethics in primary care. New York: McGraw-Hill, 2000:131-48
9. Radovsky SS. Bearing the news. N Engl J Med 1985;313(9):586-8
10. Frankel RM, Morse DS, Suchman A, et al. Can I really improve my listening skills with only 15 minutes to see my patients? HMO Pract 1991;5:114-20
11. Stewart M, Brown JB, Boon H, et al. Evidence on patient-doctor communication. Cancer Prev Control 1999;3(1):25-30
12. Girgis A, Sanson-Fisher RW. Breaking bad news 1: current best advice for clinicians. Behav Med 1998;24(2):53-9
13. Ellis PM, Tattersall MH. How should doctors communicate the diagnosis of cancer to patients? Ann Med 1999;31(5):336-41
14. McLauchlan CA. Handling distressed relatives and breaking bad news. BMJ 1990;301(6761):1145-9
15. Markel H. Cleopatra's syndrome: blaming the bearer of bad news. J Am Acad Physician Assistant 1991;4:669-70
16. Parker PA, Baile WF, de Moor C, et al. Breaking bad news about cancer: patients' preferences for communication. J Clin Oncol 2001;19(7):2049-56
17. Jurkovich GJ, Pierce B, Pananen L, et al. Giving bad news: the family perspective. J Trauma 2000;48(5):865-70
18. Walsh RA, Girgis A, Sanson-Fisher RW. Breaking bad news 2: What evidence is available to guide clinicians? Behav Med 1998;24(2):61-72
19. Ptacek JT, Eberhardt TL. Breaking bad news: a review of the literature. JAMA 1996;276(6):496-502
20. Fogarty LA, Curbow BA, Wingard JR, et al. Can 40 seconds of compassion reduce patient anxiety? J Clin Oncol 1999;17(1):371-9
21. Beckman H, Markakis K, Suchman A, et al. Getting the most from a 20-minute visit. Am J Gastroenterol 1994;89(5):662-4
22. Quill TE, Arnold RM, Platt F. "I wish things were different": expressing wishes in response to loss, futility, and unrealistic hopes. Ann Intern Med 2001;135(7):551-5

SPIKES: A mnemonic for breaking bad news to patients

S	etting up
P	erception
I	nvitation
K	nowledge
E	motions
S	trategy and summary

Adapted from Baile et al (2).

Dr Mueller is a consultant, division of general internal medicine, Mayo Clinic, and assistant professor of medicine, Mayo Medical School, Rochester, Minnesota. Correspondence: Paul S. Mueller, MD, Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905.

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