It was a particularly busy day on the trauma service and the ED was packed. As I was hustling back from the CT scanner to finish up a patient’s note, a concerned tech pulled me aside to tell me that there was a family member in one of the trauma bays “freaking out.”

As I entered the room, I encountered a young man hunched over in the corner, shaking and crying. “What is going on?!” he exclaimed. “Why is there such a mess, and needles… and blood!?” as he surveyed the aftermath of the trauma bay where his loved one had been resuscitated just minutes prior.

I sat the man down as I tried to calm him and explain the gravity of the situation. His fiancée was in a car accident and had needed urgent chest tube placement, imaging, and hospital admission. This situation is just one of the many where it is important to take care and use a systematic approach when breaking bad news to patients and families.

During medical school, many students learn the mnemonic SPIKES for breaking bad news. This guideline is particularly helpful to employ as a physician and resident when, unfortunately, breaking bad news is not uncommon. So, without further ado, here are the six recommended steps to breaking bad news, with pertinent examples for dealing with bad news, death, and dying in the most sensitive manner.

Setting:

This is particularly important as, unfortunately, bad news often must be broken in chaotic environments, such as emergency departments. Try to minimize distractions as best as possible. Turn off the television, close the door, make eye contact. Most importantly, try to sit down and get on the patient and family’s level, if possible.

I remember as a medical student I was working in a busy clinic; the attending, who was several patients behind schedule, came with me to see a patient who had a chest Xray for chronic coughing and weight loss. After reviewing the images, the physician rushed into the patient’s room, stood by the door, and listed a number of possibilities for what he had seen — cancer being one of them. He instructed the patient to follow up with a specialist and to call with any questions, all while one of his hands still rested on the door knob.

I could see the fear in the patient’s face and tears building up in his spouse’s eyes as we left the room. It sounds simple, but the saying “treat others as you’d like to be treated” really does apply. If you or your family member were in a position to receive bad news, imagine how you’d like it to be delivered.

Perception:

This step is often overlooked but is key to breaking bad news as smoothly as possible. Always make sure to ask the patient and family what they know about the situation.

I remember early in my intern year I was working in the ED and during shift change received hand off from another resident about a patient who came in with chronic back pain. CT imaging was obtained and showed multiple masses along the spine, consistent with likely metastatic disease. As the patient had been in the department for a few hours and already received the imaging, I assumed the family/patient had already been informed of the findings. So you can imagine their reactions when I came into the room and informed them that we’d be admitting the patient to the hospital to be followed by oncology for further evaluation of his spine masses.

It’s always important to ask patients and families what they know about the situation. Even if a diagnosis or condition had been thoroughly explained to them, they may have misunderstood key information or need to hear it a second time.

Invitation:

Always ask how much information a patient and family wants to know. Patients have the right to refuse to receive information about a diagnosis, at any time, even if it might seem to go against their best interest.

I remember as a medical student we had a patient come in to review the results of a colonoscopy, which, unbeknownst to him, showed cancer. However, when the patient arrived at the office, he stated that he would not yet like to receive the results as he was leaving tomorrow for a week long vacation to Europe and would instead like to “worry about it” when he got back.

Patients and families need time to cope with difficult situations and may need to hear information on their own terms, when they are ready.

Knowledge:

This step is critical in that it is the step when you tell families what you know. It may seem obvious, but try to avoid medical jargon as best as possible. As physicians, we are engrossed in medical terms on a daily basis, so it can be surprising how easy it is to let that type of language slip out when speaking to patients and families.

Emphasize/Emotions:

Perhaps this is the most important step of the six. Deliver the news as compassionately as possible. Speak slowly and make eye contact. Again, sitting is often a good idea if possible.

Whenever I’m delivering bad news, I pause frequently to give the patient/family some time to think about what I am saying and ask questions whenever they desire. Lastly, when I finish with the news I pause to give them time to take everything in. Sometimes, these several seconds can seem to drag on, but I think this is an important step to allow patients and families to comprehend what you are telling them and ask questions. Not only that, but it shows the patient/family that you truly care and aren’t simply rushing to get to your next task.

Strategy/Summary:

This is the plan of attack. In some situations, this may be a treatment option or plan, such as for a diagnosis of cancer. Even in situations where the prognosis may seem bleak — such as imminent brain death or failed resuscitation — it is always possible to carefully explain to the family what has been or will be done during the treatment process.
While bad news can be difficult to deliver, it can also take a toll on us as providers as well. Debriefing after a particularly difficult situation, whether formally with a team or more informally with colleagues, can be particularly helpful. In addition, self-care after a difficult encounter — such as by making time for activities you enjoy, exercising, spending time with family, etc. — is especially important in order to prevent burn out, maintain positivity, and to allow us to continue to best help our patients.