Commentary

Giving Bad News

WALTER F. BAILE
Department of Behavioral Science, Department of Psychiatry, and Program for Interpersonal Communication and Relationship Enhancement
(I*CARE), Department of Faculty and Academic Development, The University of Texas MD Anderson Cancer Center, Houston, Texas USA
Disclosures of potential conflicts of interest may be found at the end of this article.

In the practice of oncology, it is difficult not to be impressed by latter point was highlighted in a study by Wallace et al. [11],
the number of clinical situations that necessitate the convey- presented at the annual meeting of the American Society for
ance of unfavorable medical information to patients and Clinical Oncology in 2006. They polled more than 1,000 medical
families. These include the communication of the cancer diag- oncologists about their experiences in giving bad news about
nosis, a poor prognosis, the failure of anticancer treatment, the a poor prognosis (disease progression and death likely in the next
occurrence of unwanted and significant side effects, the 6–12 months) to patients with advanced cancer. Among the 729
ineligibility for a clinical trial, sudden and unexpected death, oncologists who responded, nearly 50% admitted to having
the discussion of hospice, and, more recently, a focus on the strong negative feelings, such as sadness, pain, guilt, heartbreak,
disclosure of medical errors.The estimate thatthese “bad news” and stress. These feelings, repeated over and over again in the
discussions can occur more than 20,000 times during the course workof caring for very ill patients, are surely a recipe for burnout.
of an oncologist’s career [1, 2] underscores the importance of Recognizing this, Morgan and Schapira discussed several
this communication competency for patient care. techniques for mitigating the stress associated with discussing
SPIKES (setting, perception, invitation for information, bad news.These can include reviewing what the patient already
knowledge, empathy, summarize and strategize) is a skills-based, has been told about the prospects of a previous treatment,
best-practices approach to giving bad news. Although not anticipating an emotional reaction, and rehearsing steps, such
formally tested in a clinical trial, the communication skills it as being calm and empathic, for dealing with patient emotions.
proposes, or similar ones, have been found to positively affect Other investigators have made additional and important
patient outcomes in one or more studies [3]. Its steps have refinements to SPIKES, such as addressing cultural factors [12],
been incorporated into guidelines for clinician-patient commu- setting goals of care and checking on what information the
nication [4, 5] and for error disclosure [6] and have also been patient has actually absorbed and understood [13], and using
used in programs for teaching the communication of bad news decision-making tools to help ensure treatment decisions are
to oncologists, medical oncology fellows, and others [7, 8]. more patient-centered [14].
Although the SPIKES protocol has been adapted to many Another important aspect of stress management is the
important “bad news” discussions, Morgans and Schapira in their creation of mindfulness about one’s own emotional reactions and
report in this issue of The Oncologist address the use of SPIKES unhelpfulattitudesaroundgivingbadnews,suchasthefearofbeing
in the context of discussing treatment failure in an era of ever- blamed, fear of unleashing an emotional reaction in the patient’s
expanding treatment options. They are quite correct in pointing family, expressing one’s own emotion, and taking responsibility for
out that this is a particularly “high-stakes” conversation for the the bad news itself [15]. These reactions can drive a wedge in the
patient and loved ones and is often a daunting task for the clini- doctor-patient relationship if the result is the clinician’s distancing
cian. In the original report in which we introduced the SPIKES himself or herself from the patient or attempting to shield the
protocol[2],weciteddatafromasurveyof500oncologists,almost patient from distress. The consequences can be misunderstanding
one half of whom thought that talking about the end of cancer by the patient and family about the purpose of care and/or the loss
treatment was the most difficult aspect of breaking bad news. ofhonestandsupportivecommunicationatatimewhenthepatient
Commenting on the social and psychological dynamics of the needs the doctor the most [16–20].
“war” on cancer, Morgan and Schapira observed that, in the Being mindful is a way of being aware in the moment of
treatmentofcancer,deathisstillseenas“theenemy”andtherefore our own feelings through nonjudgmental observation so we
must be defeated. Not to do so can represent the ultimate thera- can act on them with calmness and wisdom [21]. This can be
peutic failure (perhaps more so when the patient is young or important for clinicians who are particularly sensitive to the
“special” to the doctor). Consequently, the clinician must deal stress of giving bad news [10] or who tend to judge themselves
both with the patient’s and the family’s reactions to the bad too severely. These clinicians might benefit from emotional
news and also with their own strong emotions elicited in self-management strategies such as those described in the
communicating the end of anticancer treatment [9, 10]. This reports by Krasner et al. [22] and McCraty et al. [23].

Correspondence: Walter F. Baile, M.D., University of Texas MD Anderson Cancer Center, P.O. Box 301402, Unit 1426, Houston, Texas 77230-1402,
USA.Telephone: 713-745-4116; E-Mail: [email protected] Received June 23, 2015; accepted for publication July 1, 2015; published Online
First on July 16, 2015. ©AlphaMed Press 1083-7159/2015/$20.00/0 http://dx.doi.org/10.1634/theoncologist.2015-0250

The Oncologist 2015;20:852–853 www.TheOncologist.com ©AlphaMed Press 2015

Baile 853

When delivering bad news, oncologists must also be news. In our workshops for oncology clinicians on end-of -life
prepared to react appropriately to strong patient and family discussions [29], we use advanced role-playing techniques to
reactions, including their sadness, anger, disbelief, and/or encourage participants to recognize the range of both the
denial [24]. In previous correspondence, we pointed out how clinician’s and the patient’s feelings, and their consequences,
patients’ emotions can cause the bearer of bad news to in bad news discussions. Taking on the role of a patient or
flounder because the patient reactions in themselves can elicit family member in receiving bad news can help guide clinician
additional anxiety [25]. This psychological dynamic has been communication by providing insight into the question, “What
called “amygdala hijacking” by Goleman [26], who explains how does this patient and family need from me?” By putting oneself
reacting to others with our “emotional brain” can bring un- in the shoes of the patient, it can become apparent that false
intended consequences. These have been illustrated by Finset reassurance or avoidance might not be the most effective
et al. [27], who found that oncologists often responded to strategy and that the patient might benefit more from honesty
negative emotions in cancer patients by changing the topic, and support [30].
asking a question, providing factual information, or reassuring From the above, we can agree, as Bousquet et al. have
the patient, instead of responding with an empathic phrase, pointed out [31] and as Morgan and Schapira have illustrated,
such as described by Morgan and Schapira. Buckman [28] that in giving bad news, SPIKES is best viewed as a flexible
recommendsa strategy termed “separatingthe messengerfrom guideline to help the physician address individual patient and
the message,” which helps oncologists to not assume re- family needs in a personalized and “patient-centered” manner.
sponsibility for the bad news or the patient’s emotional reaction
to it, but instead to refocus attention on the message itself and DISCLOSURES
the support that the oncologist can provide to the patient. Walter F. Baile: Lilly Pharmaceuticals (C/A).
(C/A) Consulting/advisory relationship; (RF) Research funding; (E) Employment; (ET) Expert
Communication skills training programs can provide aware- testimony; (H) Honoraria received; (OI) Ownership interests; (IP) Intellectual property rights/
ness of emotions and the opportunity to practice giving bad inventor/patent holder; (SAB) Scientific advisory board

REFERENCES
1. Fallowfield L, Lipkin M, Hall A. Teaching senior 11. WallaceJA,HlubockyFJ,DaughertyCK.Emotional 21. Novack DH, Suchman AL, Clark W et al.
oncologists communication skills: Results from phase response of oncologists when disclosing prognostic Calibrating the physician: Personal awareness and
I of a comprehensive longitudinal program in the information to patients with terminal disease: Results effective patient care. JAMA 1997;278:502–509.
United Kingdom. J Clin Oncol 1998;16:1961–1968. of qualitative data from a mailed survey to ASCO
22. Krasner MS, Epstein RM, Beckman H et al.
2. Baile WF, Buckman R, Lenzi R et al. SPIKES—A six- members. J Clin Oncol 2006;24(suppl):8520.
Association of an educational program in mindful
stepprotocolfordeliveringbadnews:Applicationtothe 12. Bou Khalil R. Attitudes, beliefs and perceptions communication with burnout, empathy, and atti-
patient with cancer. The Oncologist 2000;5:302–311. regarding truth disclosure of cancer-related in- tudes among primary care physicians. JAMA 2009;
3. Lundeby T, Gulbrandsen P, Finset A.TheExpanded formation in the Middle East: A review. Palliat 302:1284–1293.
Four Habits Model—A teachable consultation model Support Care 2013;11:69–78.
23. McCraty R, Barrios-Choplin B, Rozman D et al.
for encounters with patients in emotional distress. 13. Back AL, Arnold RM, Baile WF et al. Approach- The impact of a new emotional self-management
Patient Educ Couns 2015;98:598–603. ing difficult communication tasks in oncology. CA program on stress, emotions, heart rate variability,
4. Baile WF, Block S,Yee L. Presented at the Annual Cancer J Clin 2005;55:164–177. DHEA and cortisol. Integr Physiol Behav Sci 1998;33:
Conference of the National Comprehensive Cancer 14. Committee on Improving the Quality of Cancer 151–170.
Network, Ft. Lauderdale, Florida, March 15-19, 2000. Care; Addressing the Challenges of an Aging
24. Morse J. Hearing bad news. J Med Humanit
5. EPEC Education for Physicians on End of Life Population; Board on Health Care Services; Institute
2011;32:187–211.
Care Participant’s Handbook: Module 2: Communi- of Medicine; Levit L, Balogh E, Nass S, et al., eds.
cating Bad News EPEC Project. New York, NY: Robert Delivering High-Quality Cancer Care: Charting a New 25. Baile WF, Buckman R, Schapira L et al. Breaking
Wood Johnson Foundation, 1999. Course for a System in Crisis. Washington (DC): bad news: More than just guidelines. J Clin Oncol
National Academies Press (US); 2013 Dec. 27. 3, 2006;24:716–719.
6. Baile WF, Epner D. Disclosing harmful medical Patient-Centered Communication and Shared De-
errors. In: Surbone A, Rowe M, eds. Clinical Oncology 26. Goleman D. Emotional Intelligence. New York:
cision Making. Available from http://www.ncbi.nlm.
and Error Reduction: A Manual for Clinicians. Oxford, Bantam Dell, 1995.
nih.gov/books/NBK202146.
UK: Wiley-Blackwell, 2015:101–110. 27. Finset A, Heyn L, Ruland C. Patterns in
15. Buckman R. Breaking bad news: Why is it still so
7. Back AL, Arnold RM, Baile WF et al. Efficacy of difficult? BMJ (Clin Res Ed) 1984;288:1597–1599. clinicians’ responses to patient emotion in cancer
communication skills training for giving bad news care. Patient Educ Couns 2013;93:80–85.
and discussing transitions to palliative care. Arch 16. Meier DE, Back AL, Morrison RS. The inner life
of physicians and care of the seriously ill. JAMA 28. Buckman R. How to Break Bad News. A Guide
Intern Med 2007;167:453–460.
2001;286:3007–3014. for Health Professionals. Baltimore: Johns Hopkins
8. I*CARE. Interpersonal communication and relation- University Press, 1992:191–198.
ship enhancement. Basic principles. Available at http:// 17. Owens DA. Countertransference in palliative
www.mdanderson.org/education-and-research/ care and hospice. J Hospice Palliative Nurs 2007;9: 29. Baile WF, Walters R. Applying sociodramatic
resources-for-professionals/professional-educational- 2007–2009. methods in teaching transition to palliative care. J
resources/i-care/complete-library-of-communication- 18. Renneker RE. Countertransference reactions Pain Symptom Manage 2013;45:606–619.
videos/basic-principles.html. to cancer. Psychosom Med 1957;19:409–418. 30. Wright AA, Zhang B, Ray A et al. Associations
9. Friedrichsen M, Milberg A. Concerns about losing 19. Epner DE, Ravi V, Baile WF. When patients and between end-of-life discussions, patient mental health,
controlwhenbreakingbadnewtoterminallyillpatients: families feel abandoned. Support Care Cancer 2011; medical care near death, and caregiver bereavement
A Physicians Perspective. J Palliat Med 2006;9:673–682. 19:1713–1717. adjustment. JAMA 2008;300:1665–1673.
10. Shaw J, Brown R, Heinrich P et al. Doctors’ 20. Weeks JC, Catalano PJ, Cronin A et al. Patients’ 31. Bousquet G, Orri M, Winterman S et al.
experience of stress during simulated bad news expectations about effects of chemotherapy for Breaking bad news in oncology: A metasynthesis.
consultations. Patient Educ Couns 2013;93:203–208. advanced cancer. N Engl J Med 2012;367:1616–1625. J Clin Oncol 2015 [Epub ahead of print].

EDITOR’S NOTE: See the related article, “Confronting Therapeutic Failure: A Conversation Guide,” on page 946 of this issue.

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