S-P-I-K-E-S Strategy in breaking the bad news and discussing advance directives in the clinical setting, especially in hospice and palliative care.

1. BREAKING THE
BAD NEWS
Dr. Liza Manalo, MSc.
Palliative Care, Cancer Center
The Medical City

2. Breaking Bad News:
S-P-I-K-E-S Strategy
Community Oncology, March/April 2005
Robert A. Buckman, MD, PhD
University of Toronto, Canada

3. S-Setting
Privacy
Involve significant others
Sit down
Look attentive and calm
Listening mode: silence & repetition
Availability
Community Oncology, March/April 2005

4. P-Patient’s perception
Find out how much the patient or
surrogate decision-maker knows.
“What did you think was going on?”
“What have you been told about all this so
far?”
“Are you worried that this might be
something serious?”

5. I-Invitation
Find out how much the patient or
surrogate decision-maker wants to
know.
 “Are you the kind of person who prefers to know all
the details about what is going on?”
“How much information would you like me to give
you about diagnosis and treatment?”
“Would you like me to give you details of what is
going on or would you prefer that I just tell you about
treatments I am proposing?”

6. K-Knowledge
Share the information
 Warning shot :
• “Unfortunately, I’ve got some bad news to tell you,
Mrs. Dela Cruz.”
• “Mrs. Dela Cruz, I’m so sorry to have to tell you….”
 Pause : Wait for them to take a deep breath
and get ready to hear the bad news
 Use short, simple, clear sentences
 Avoid jargon or technical scientific language
 Tailor the rate at which you provide
information
to the patient/surrogate decision-maker

7. E-Empathy
Step 1: Listen for and identify the
emotion (or mixture of emotions).
• “How does that make you feel?”
• “What do you make of what I’ve just told you?”
Step 2: Identify the cause or source
of the emotion

8. E-Empathy
Step 3: Show your patient/surrogate decision-
maker that you have identified the emotion and its
origin
•“Hearing the results of the tests is clearly a major shock
to you.”
•“Obviously, this piece of news is very upsetting.”
•“Clearly, this is very distressing.”
 Empathetic silence: Wait for them to take a deep breath
and process the bad news
Answer questions patiently
Be sensitive and compassionate
Respond to the patient’s or surrogate decision-maker’s
thoughts and feelings
 Identify the emotionally critical misperception (ECM)

9. E-Empathy
Validation – normalize the patient’s or surrogate
decision-maker’s feelings
•“I can understand how you can feel that way.”
 Let the patient or surrogate decision-maker
know that showing emotion is perfectly normal,
to minimize feelings of embarrassment and
isolation
 Assure non-abandonment: Inform the patient or
surrogate decision-maker that you will be
coaching them through the next steps

10. S-Strategy/Summary
 Educate, summarize, and concretize
plan of action
 Ensure that the patient or surrogate decision-
maker understands the information so that you
and they are both on the same page.
 Summarize the information in your discussion
and give the patient or surrogate decision-maker
an opportunity to voice any major concerns or
questions.
 Outline a step-by-step plan, explain it to the
patient or surrogate decision-maker, and
contract about the next step.

11. Common Communication Error:
Information overload and "medspeak"
Emergency Room:
• Mrs. Dela Cruz: “Doctor, how is my husband doing?”
• Dr. Reyes: “He had a stroke.”
• Mrs. Dela Cruz: “Stroke?” But he is only 51. How big is it?”
• Dr. Reyes: “Pretty big according to the CT scan. It revealed
hemorrhage or a bleed on the right parieto-temporal lobe, with
subarachnoid and intraventricular extension. Problem is that he is
comatose and hypertensive right now. Also, the pupils are equally
dilated and non- reactive and the brainstem reflexes are absent.
Anyway…., the Neuro folks are coming. They will explain things
more. Meantime, don’t worry!”
• Mrs. Dela Cruz: (thinking can-you-talk-to-me-in-English or
Tagalog?): “Doc will he make it? I am so worried….”

12. Breaking the Bad News –
Emergency Room:
BETTER VERSION
• Mrs. Dela Cruz: “Doctor, how is my husband doing?”
• Dr. Reyes: “Mrs. Dela Cruz, let us find a place to sit down.”
• Dr. Reyes: “I am afraid that I have some bad news for you.”
Pause for a few seconds (you may want to count till ten) allowing
wife to prepare herself for the news.
• Dr. Reyes: “Your husband has had a stroke.”
Pause and allow Mrs. Dela Cruz to digest the information.
• Mrs. Dela Cruz: “He had a stroke?”
• Dr. Reyes: “Yes. I am afraid so.”
Pause and allow Mrs. Dela Cruz to digest the information.
• Mrs. Dela Cruz: “Stroke? But he is only 51. How big is it?”

13. Breaking the Bad News –
Emergency Room:
BETTER VERSION
• Dr. Reyes: “I ran some initial tests on him. Looks like it is a rather
big bleed. You did great by bringing him in so quickly.”
• Mrs. Dela Cruz: “Doc will he make it? I am so worried.…”
• Dr. Reyes: “Mrs. Dela Cruz, we already know that your husband has
a stroke and I have started him treatment to remove the pressure on
the brain. I have talked to the neurology specialists. They will be
here momentarily to take over. I’m afraid however that even if we do
everything we can, the damage to his brain is such that I feel we will
not be able to pull him through, I’m sorry.”
Pause and allow Mrs. Dela Cruz to digest the information.
• Dr. Reyes: “How are you doing? What is going through your head?”
Pause and allow Mrs. Dela Cruz to digest the information and
formulate her questions.

14. Phraseology :
Do's and Don'ts
What not to say What to say
• "I know exactly how you • "My past experience with
feel." many patients in this
Sweeping statements that situation has taught me
are not grounded in that you must be in
personal or professional distress right now."
experiences are hard to • "I can imagine how upset
believe. you must be."
http://endoflife.stanford.edu/M19_communic/dos_and_donts.html

15. Phraseology :
Do's and Don'ts
What not to say What to say
• "Your husband have • "Unfortunately, the
failed medical __________ therapy
decompression therapy." does not seem to be
This implies that it is the working very well."
patient's fault that the
therapies are not working.
http://endoflife.stanford.edu/M19_communic/dos_and_donts.html

16. Phraseology :
Do's and Don'ts
What not to say What to say
• "There is nothing else we • "Looks like the ________
can do." is not working very well.
However, you can be
sure that we will do
everything in our power to
make sure that you (your
husband) won't suffer."
http://endoflife.stanford.edu/M19_communic/dos_and_donts.html

17. What not to say
• "There is nothing more that can be done. I am going to
refer you to hospice and palliative care."
What to say
• "Doctor: As we have just discussed, it looks like the ________
treatment we tried is not working. So we have to stop the
________medication.
• Mrs. Dela Cruz: What do we do next, doc?
• Doctor: At this time, I do not have other viable medications that I can
offer to you”
• Mrs. Dela Cruz: .....
• Doctor: I would like to refer you to hospice and palliative care.
Hospice professionals have a lot of expertise in treating symptoms
and increasing comfort and quality of life. They will help your
husband by managing your husband’s ________________
(dyspnea, agitation/restlessness, respiratory secretions, etc).
http://endoflife.stanford.edu/M19_communic/dos_and_donts.html

18. DNR Discussions
with Surrogate Decision-Maker:
Patient With a Life-Limiting Illness
• What not to say
• “Mrs. Dela Cruz, do you want every thing done for your husband?”
• What the doctor might say instead
• Dr. Reyes: “Mrs. Dela Cruz, I want to talk to you more about what we call
advance directives and Do Not Resuscitate orders for your husband.”
(Pause and give the decision-maker time to digest the information.)
• “As you know, your husband had a massive stroke and the medical team
members agree that his prognosis is grave and his chances for survival and
recovery nil.”
• “In thinking about decisions regarding resuscitation there is a whole
spectrum of choices. In event of an adverse situation, some patients would
like to be connected to life support and would like us to do heroic life
sustaining treatments. Others do not want such measures.”
(Pause and give the decision-maker time to digest the information.)
http://endoflife.stanford.edu/M19_communic/dnr_disc_bbn.html

19. DNR Discussions
with Surrogate Decision-Maker:
Patient With a Life-Limiting Illness
• Mrs. Dela Cruz: “But I don’t want my husband to die.”
• Dr. Reyes: Mrs. Dela Cruz, of course you want your husband to live,
but with good quality of life. I do not want you and him to suffer and
as your doctor, I will do what is in my power to help both of you.”
(Pause and give the decision-maker time to digest the information.)
• Mrs. Dela Cruz: “Yes. I do not want him to suffer.”
(Pause and give the decision-maker time to digest the information.)
• Dr. Reyes: “Your husband is now in coma. If his heart were to stop,
putting him on life support will not prolong life. It would only prolong
the dying process.”
(Pause and give the decision-maker time to digest the information.)
http://endoflife.stanford.edu/M19_communic/dnr_disc_bbn.html

20. DNR Discussions
with Surrogate Decision-Maker:
Patient With a Life-Limiting Illness
• Mrs. Dela Cruz: ……
(Pause and give the decision-maker time to digest the information.)
• Dr. Reyes: “Things look grim for your husband and the increasing
intracranial pressure has compressed the brain that at this point,
any life support measures would be ineffective.”
(Pause and give the decision-maker time to digest the information).
http://endoflife.stanford.edu/M19_communic/dnr_disc_bbn.html

21. DNR Discussions
with Surrogate Decision-Maker:
Patient With a Life-Limiting Illness
• Mrs. Dela Cruz: ……
• Dr. Reyes: “In a situation like this, it is my opinion that we should hold
back on futile resuscitative measures, but really focus on making your
husband comfortable.”
(Pause and give the decision-maker time to digest the information).
• Mrs. Dela Cruz:……
(If decision-maker still seems reluctant)
• Dr. Reyes: “I want you to think a little more about this and we can talk
again in a while. I want you to remember that no matter what, I will still
be your husband’s doctor and I am here to help both of you.”
http://endoflife.stanford.edu/M19_communic/dnr_disc_bbn.html

22. Breaking Bad News:
S-P-I-K-E-S Strategy
S – Setting
P – Patient’s Perception
I – Invitation
K – Knowledge
E – Empathy
S – Strategy/Summary
Before you tell, ASK!
“What is your understanding of your illness?”