- Advanced Practice Nursing (APRN) (https://voice.ons.org/topic/advanced-practice-nursing-aprn)
- Palliative care (https://voice.ons.org/topic/palliative-care)
- Oncology nurse-patient relationship (https://voice.ons.org/topic/oncology-nurse-patient-relationship)
- Clinical practice (https://voice.ons.org/topic/clinical-practice)
Break Bad News to Patients With This Step-by-Step Guide
When hearing results from blood work or repeat imaging—regardless of whether they are “good” or “bad”—patients want and deserve to be given information truthfully and objectively. Oncology advanced practice providers are often the bearers of bad news, which can be uncomfortable and stressful. But here’s how you can hold those conversations with finesse, empathy, and respect.
Baile et al. developed (https://theoncologist.onlinelibrary.wiley.com/doi/full/10.1634/theoncologist.5-4-302) the SPIKES protocol in 2000 as a communication tool for breaking bad news specifically to patients with cancer. SPIKES is an acronym for the six phases of a stepwise approach to sharing information that may upset patients.
Setting: Choose a quiet, private setting, typically an exam or consultation room. Sit at eye level with your patient and ensure that they are listening attentively. Allow family members to be included in person or on the phone. Avoid interruptions by turning off your phone or pager. Try not to give results over the phone, but studies have supported its application to telehealth (https://link.springer.com/article/10.1007%2Fs13187-021-01975-7). When those are your options, ask your patient to tell you the best time when they can talk with no other distractions.
Perception: What does your patient know about their disease and oncology history up to this point? Recap their disease and any previous treatment before you explain the results or a new treatment plan.
Invitation or information: Ask your patient how much and what kind of information they prefer to receive. Some patients want all the details, whereas others just want a summary.
Knowledge: Give the news in small, easily digestible chunks using words that fit your patient’s level of comprehension. Allow them to process what you told them before you present more information. Avoid using medical terminology or jargon and phrases that promote helplessness, such as, “There’s nothing more that we can do.”
Empathy: The empathetic response is a four-part process to acknowledge your patient’s emotions, which may be sad, upset, or shocked. Observe their emotions. Identify the emotions. Identify the reason for the emotions (usually the bad news). Tell your patient that you understand the emotions, such as, “I know this is not the news you were expecting today” or “I can see this information is upsetting to you.”
Summarize or strategize: Before discussing a treatment plan or recommendations, make sure your patient is ready. Give clear and precise information about the next steps or available options. If no further treatment options are available or the patient chooses to decline any further therapy, discuss referral to palliative care or hospice. Patients have less anxiety when they know all their options, are involved in decision making, and have a clear plan in place.
Delivering bad news is never easy, but with practice and self-reflection, it can become a smoother process. Using the SPIKES protocol can help make your conversations successful and give patients the dignity they deserve.