Breaking Bad News
Assoc.Prof.Jiranun Weerakul
What is bad news?
“any information which adversely and seriously
effects an individual’s view of his or her future”
Example of medical bad news
Example of medical bad news
• Informing patients that they have cancer.
• Inform the patient that he/she or her child is HIV
positive.
• In form the first degree relative that the patient has
brain death.
• Inform the mother that the child has Down syndrome.
• Inform the patient or relative that he/she need to
amputate.
Why is it important?
• A frequent and stressful task
• Breaking bed news can be particularly stressful
when the doctor is inexperienced, the patient is
young or there are limited prospects for
successful treatment
Buckman R. Breaking bad news: why is it so difficult?. BMJ. 1984;288:1597-9
The patients want the truth
• By the late 1970s most physicians were open
about telling cancer patient their diagnosis
• In 1982 of 1,251 American indicated that 96%
wished to be told if they had diagnosis of cancer
• 85% wished, in case of grave prognosis, to be
giver a realistic estimate of how long they had to
be live
Buckman R. Breaking bad news: why is it so difficult?. BMJ. 1984;288:1597-9
Ethical and legal imperatives
• Clear ethical and legal obligations to provide
patients with as much information as they desire
about their illness and its treatment
• Physicians may not withhold medical information
even if they suspect it will have a negative effect
on the patient
Clinical outcomes
• How bad news is discussed can effect the
patient’s comprehension of information,
satisfaction with medical care, level of
hopefulness, and subsequent psychological
adjustment
Barriers to breaking bad news
• Emotional-anxiety
• Burden of responsibility
• Fear of negative evaluation
Principle of breaking bad news
D Doctor Compression. Loving-kindness, empathy
P Patient Anxiety, fear, Worries
I Information Step-by-step approach depending on the
patient’s capacity to assimilate it
H Hope Always commit to be on the patient’s side, find a
way to help especially psychological well-being
Models of Breaking bad news
• SPIKES model
• Robert Buckman
• Professor of oncology-Toronto
• Trained in Cambridge
• Used world wide
• KAYES model
• ABCDE model
Buckman R. Breaking bad news: why is it so difficult?. BMJ. 1984;288:1597-9
SPIKES Model
Six steps
• S-Setting up the interview
• P-assessing the patients Perception
• I-obtaining the patients Invitation
• K-giving Knowledge
• E-addressing Emotions
• S-Strategy and Summary
Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news:
application to the patient with cancer. Oncologist 2000;5:302-11.
S-Setting up the interview
• Privacy
• Involve others
• Look attentive and calm
• Listening mode
• Availability
Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news:
application to the patient with cancer. Oncologist 2000;5:302-11.
P-Perception
• Ask before you tell
• Find out what the patient know
Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news:
application to the patient with cancer. Oncologist 2000;5:302-11.
I-Invitation
• While a majority of patients express a desire for
full information about their diagnosis, prognosis,
and details of their illness, some patients do not
• How much information would the patient like to
know
Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news:
application to the patient with cancer. Oncologist 2000;5:302-11.
K-Knowledge
• Warming first
• Mirror language
• Avoid jargon
• Small chunks
• Use of silence
• Allow time for emotions
Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news:
application to the patient with cancer. Oncologist 2000;5:302-11.
E-Emotions
• Recognize
• Listen for and identify the emotion
• Identify cause of emotion
• Show the patient you have identified both the
emotion and its origin
Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news:
application to the patient with cancer. Oncologist 2000;5:302-11.
E-Emotions
• Crying
• Anger
• Denial
• Bargaining
• Shock/silence
สุพจน์ พงศ์ประสบชัย, ทักษะการสื่อสารใน Palliative Care
S-Strategy and Summary
• Understanding reduces fear
• Summarizes the discussion
• Strategy foe future care
• Schedule next meeting
• Allow time for questions
• Leaflets
Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news:
application to the patient with cancer. Oncologist 2000;5:302-11.
KAYE’s model
• 10 steps
• Logical sequence
• Not based on rigorous research
• Can be used for any serious illness
Peter Kaye, 1996
1. Preparation
• Know all the facts
• Ensure privacy
• Find out who the patient would like present
• Introduce yourself
Peter Kaye, 1996
2. What dose the patient know?
• Open end questions
• Statements may make the best questions
• “How did it all start?”
Peter Kaye, 1996
3. Is more information wanted?
• Not forced on them
• “Would you like me to explain a bit more?”
Peter Kaye, 1996
4. Warning shots
• Not straight out with it
• “I'm afraid it looks rather serious”
Peter Kaye, 1996
5. Allow denial
• Allow the patient to control the amount of
information they receive
Peter Kaye, 1996
6. Explain if requested
• Step by step
• Detail will not be remembered but the way you
explain it will be
Peter Kaye, 1996
7. Listen to concerns
• “What are your concerns at the moment?”
• Allow time and space for answers
Peter Kaye, 1996
8. Encourage feelings
• Acknowledge the feelings
• Non-judgmental
• Vital step for patient satisfaction
Peter Kaye, 1996
9. Summarizes
• Concerns
• Plans for treatment
• Foster hope
• ? Written information
Peter Kaye, 1996
10.
• Availability
• Information
• Future needs will change
Peter Kaye, 1996
ABCDE technique
• A-Advance preparation
• B-Build a therapeutic environment or relationship
• C-Communicate well
• D-Deal with patient and family reactions
• E-Encourage and validate emotions
GREGG K. VANDEKIEFT. Breaking Bad News. Fam Physician. 2001;64(12):1975-79.
A-Advance preparation
• Arrange for adequate time, privacy and no
interruptions (turn off or silent mode of mobile
phone)
• Review relevant clinical information
• Mental rehearse, identify words or phrase to use
and avoid
• Prepare yourself emotionally
GREGG K. VANDEKIEFT. Breaking Bad News. Fam Physician. 2001;64(12):1975-79.
B-Build a therapeutic environment or relationship
• Determine what and how much the patient wants
to know
• Have family or support persons present
• Introduce yourself to everyone
• Warm the patient that bad news is coming
• Use touch when appropriate
• Schedule follow-up appointments
GREGG K. VANDEKIEFT. Breaking Bad News. Fam Physician. 2001;64(12):1975-79.
C-Communicate well
• Ask what the patient or family already knows
• Be frank but compassionate; avoid euphemisms and medical
jargon
• Allow for silence and tears; proceed at the patient’s pace
• Have the patient describe his or her understanding of the news;
repeat this information at subsequent visits
• Allow time to answer questions; write things down and provide
written information
• Conclude each visit with a summary and follow-up plan
GREGG K. VANDEKIEFT. Breaking Bad News. Fam Physician. 2001;64(12):1975-79.
D-Deal with patient and family reactions
• Assess and response to the patient and the
family’s emotional reaction; repeat at each visit
• Be empathetic
• Do not argue with or criticize colleagues
GREGG K. VANDEKIEFT. Breaking Bad News. Fam Physician. 2001;64(12):1975-79.
E-Encourage and validate emotions
• Explore what the news means to the patient
• Offer realistic hope according to the patient’s
goals
• Use interdisciplinary resources
• Take care of your own needs; be attuned to the
needs of involved house staff and officer or
hospital personnel
GREGG K. VANDEKIEFT. Breaking Bad News. Fam Physician. 2001;64(12):1975-79.
reference
• รัตนา สายพานิชย์. การแจ้งข่าวร้าย. ใน: มาโนช หล่อตระกูล, บรรณาธิการ. คู่มือการดูแลผู้มีปัญหา สุขภาพจิต
และจิตเวชสาหรับแพทย์. นนทบุรี: สานัก พัฒนาสุขภาพจิต กรมสุขภาพจิต; 2544, หน้า 143-56.
• Buckman R. How to break bad news : a guide for health care professionals. Baltimore, Md. : The
Johns Hopkins University Press, 1992.
• Sonny Jerome, Breaking bad news.
• Buckman R. Breaking bad news: why is it so difficult?. BMJ. 1984;288:1597-9
• Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for
delivering bad news: application to the patient with cancer. Oncologist 2000;5:302-11.
• GREGG K. VANDEKIEFT. Breaking Bad News. Fam Physician. 2001;64(12):1975-79
Case study
เด็กหญิงอายุ 10 ปี ได้รับการวินิจฉัยว่าเป็น
มะเร็งกระดูก ( Osteosarcoma) โดยมีก้อนที่
เข่าด้านซ้าย และ มีอาการปวดขาบริเวณก้อน
จนเดินไม่ไหว มา 6 เดือน
•วันนี้ แพทย์นัดมารดามาแจ้งผลการรักษา
หลังจากได้รับยาเคมีบาบัด และ ทา MRI เพื่อ
ประเมินก่อนการผ่าตัด
SPIKES Model
• S-Setting up the interview:
• P-assessing the patients Perception
• I-obtaining the patients Invitation
• K-giving Knowledge
• E-addressing Emotions
• S-Strategy and Summary
