Break It To Me Gently

It’s not been a good week for me. I’ve had to tell two patients that they need a thyroidectomy because their biopsies showed papillary thyroid cancer. It is not an aggressive form of cancer but still … patients know this is bad news. I don’t know how I would do it if I were an oncologist, having to do this all the time.

The SPIKES protocol (Baile et al) for delivering bad news has six steps:

Step 1. S- SETTING UP the Interview

The setting is important. I’ve had the most difficulty disclosing bad news in the medical ward where patients’ beds are too close together to afford privacy. I have a better clinic set-up now but years back, I only had a cramped cubicle. If I sat on my desk and leaned back, my head would already hit the examining table. It was ok except the upper part of this cubicle was open and it was possible for patients in the waiting area to hear the conversation I was having with the patient.

Step 2. P- Assessing the Patient’s PERCEPTION

This step is necessary for the doctor to find out if the patient is in illness denial. On more than a few occasions though, Dr. Google has beaten me to it and the patient only needs me to confirm his worst fears. At other times, I am the bearer of “relatively” good news, because the situation is actually better than what Dr. Google had predicted.

Step 3. I – Obtaining the Patient’s INVITATION

For Filipinos, it may also require asking for the family’s permission to break the bad news. I could be opening the envelope containing the biopsy result and I would catch desperate hand signals from the patient’s daughter warning me not to say anything bad. Another daughter had my secretary pass me a note saying, Please don’t tell him if it’s bad news.

Step 4. K – Giving KNOWLEDGE and Information to the Patient

I’ve learned how to be careful when using the words “POSITIVE” and “NEGATIVE.” Saying for example that a result is “positive” is actually bad news if cancer cells were seen in the biopsy. Conversely, reading “negative for malignant cells” on the biopsy report has sent some of my patients into a panic.

Step 5. E – Addressing the Patient’s EMOTIONS with Empathic Responses

I’ve seen the spectrum of patients’ reactions – from stoic silence, white-knuckled fear, clenched-fist repressed anger to loud sobs. I have the most trouble with crying. On a few occasions, I’ve found myself getting teary-eyed too – which does not inspire confidence in the patient. It must be THAT bad if even my doctor is crying. Mababaw lang talaga luha ko!

Step 6. S – STRATEGY and SUMMARY

It is important to not leave the discussion hanging. Options should be discussed, though I often worry if the patient is too shell-shocked to understand or even remember what I say.

Let’s discuss breaking bad news to patients at the next #HealthXPH tweet chat on Saturday, 7 Oct 9 pm Manila time.

T1. Do you use SPIKES/other protocol when breaking bad news to patients? If a patient, how would you prefer to be told bad news?

T2. What are the barriers to breaking bad news to patients?

T3. What are your tips for breaking bad news to patients?

In the meantime, check out this 1980s song from Angela Bofill.