The result of my patient’s right breast biopsy was sitting on my computer desktop. I felt a knot form in my throat and my heart rate speeding up. I knew clicking the result would confirm the diagnosis I suspected when doing her breast exam earlier in the week. Invasive moderately differentiated ductal carcinoma, Focal ductal carcinoma in situ, solid type, grade 2, Core biopsy of lymph node showing extensive involvement by metastatic carcinoma. I took my time digesting the words on this extensive report and thoughts filled my mind.
It all came down to one thing – My patient had breast cancer and I needed to tell her.
Conveying bad news can be a one of the most difficult duties healthcare providers encounter. Studies have shown that without proper training, the discomfort of disclosing bad news can lead to a healthcare provider emotionally disengaging from their patient.
Though this is an area that all healthcare providers will encounter at some point in their career, many healthcare providers have expressed feeling underprepared to deliverbad news, that is, “any news that drastically and negatively alters the patient's view of her or his future” to their patients.
Numerous study results show that patients generally desire frank and empathetic disclosure of a terminal diagnosis or other bad news. Focused training in communication skills and techniques to facilitate breaking bad news has been demonstrated to improve patient satisfaction and physician comfort.
So the question is, How Do I Tell My Patient she has Breast Cancer?
A patient-centered approach has shown to yield the highest patient satisfaction and results in the physician being perceived as emotional, available, expressive of hope, and not dominant.
Thankfully there have been several tools created to help guide clinicians in delivering unfavorable news with a patient-centered empathetic approach. One of those tools uses the acronym SPIKES and has been proven to increase provider confidence in relaying unfavorable news to their patients while allowing them to meet their goals in what is hoped to be conveyed and gathered during the session with their patient.
Step 1: S
SETTING UP the interview
This step involves preparing for the discussion with your patient. Here, you choose where you will disclose your patient’s results. Plan to modify factors that could interrupt the meeting. Arranging for privacy, silencing pagers and beepers and giving anticipatory guidance to the patient about time-constraints and potential interruptions is important. Involve family members and make the room as comfortable as possible, such as having seats for everyone and providing tissues.
Step 2: P
Assessing the patient’s PERCEPTION
Asking the patient an open-ended question such as “What do you know about why we did a breast biopsy?” prior to disclosing the test results can help the provider tailor their disclosure to the patient’s knowledge of the situation. Based on this information you can correct misinformation and tailor the bad news to what the patient understands. It can also accomplish the important task of determining if the patient is engaging in any variation of illness denial: wishful thinking, omission of essential but unfavorable medical details of the illness, or unrealistic expectations of treatment.
Step 3: I
Obtaining the patient’s INVITATION
Obtain permission to discuss the diagnosis or test results. Many patients would like full disclosure of their condition and all information possible regarding treatment, prognosis and follow-up. Some patients however feel less is more. The healthcare provider must communicate with his or her patient to find out where they fall on the spectrum.
Step 4: K
Giving KNOWLEDGE and information to the patient
When a patient of mine had a breast biopsy return positive for breast cancer, I knew I’d need help with the process of telling her the results. As a new Nurse Practitioner I was terrified that I wouldn’t know the answer to one of her questions or I would say the wrong thing. I asked one of the Physician’s for guidance. Like the angel she is, she actually called the patient and placed her on speakerphone. She told the patient that she was a Physician that works with me and that the two of us were on speaker phone because we wanted to talk to her. She asked the patient if she was by herself, and when finding out that her husband was in the house with her, she asked if was possible for her husband to come into the room to be with her. She asked the patient if she was sitting down, because unfortunately she had some difficult news to tell her. This strategy is called forecasting. Warning the patient that bad news is coming may lessen the shock that can follow the disclosure of bad news and may facilitate information processing.
After forecasting, give medical facts while avoiding overt bluntness. Try to use common words and synonyms for medical language such as spread instead of metastasized.
Give information in small chunks and check in with the patient to see how he or she is doing so that you can give news at their pace. Sometimes simply pausing can be the break a patient needs prior to digesting more information.
Step 5: E
Address the patient’s emotions with EMPATHIC responses
Showing empathy can allow patients to feel justified in the feelings they are experiencing. In an empathic response, the provider should first look, understand, and then name the patient’s emotion. If it is unclear due to silence, the clinician can ask “What are you thinking?” Once the clinician has connected to the patient’s emotion, per the protocol, the provider can use a “connecting statement” such as “I’m sorry the biopsy is showing cancer, I know this is not what you wanted to hear today.”
Examples of exploratory, empathic and validating responses can be found here.
Step 6: S
STRATEGY and SUMMARY
In my experience, starting to plan with patients helps them to feel a sense of relief and purpose, if the patient is ready for such a discussion. The clinician can further explore the patient’s wishes and incorporate his or her values into the plan.
It is difficult to summarize the SPIKES protocol in a short blog post, but I encourage you to check out Vital Talk which makes use of the SPIKES protocol and has videos on how to carry out the steps. Learn more here.
With proper training, clinicians can disclose bad news to their patients with confidence. Tool such as this one help the provider to create a positive experience out of an otherwise heartbreaking time in their patient’s lives.
About the author:
Monica Elston FNP-BC is a Maryland-native Board Certified Family Nurse Practitioner in a women's health practice in Washington, DC. Prior to becoming a Nurse Practitioner she worked as a Labor and Delivery nurse for over six years. She believes in providing the best care so that women can live their best lives possible. When not working, Monica can be found traveling the globe with her husband, friends and family. Follow Monica on Instagram!