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Breaking Bad News to Patients: A Nurse’s Guide to SPIKES

A pair of latex gloved hands holding bare hands that hold a red heart

Although the act of delivering bad news to patients is principally the physician’s role, the follow-up typically falls to nurses and physician assistants, who know the patient on a different level. It’s you who can connect more deeply with them, and it’s you who can listen to them as they process the next steps.

Helping patients after they’ve received bad news might be one of the most difficult parts of being a medical professional. But, by establishing a clear “bad news” protocol early on, you’ll put yourself in a better position to provide your patients with the assurance and support they need.

If and when you find yourself in this situation, you can use the same framework most doctors use to actually deliver the news: the SPIKES framework. The acronym stands for:

  • S - Set Up the Interview
  • P - Assess the Patient's Perception
  • I - Obtain the Patient's Invitation
  • K - Give Knowledge and Information to the Patient
  • E - Address the Patient's Emotions With Empathic Responses
  • S - Strategy and Summary

Using SPIKES to Break Bad News to a Patient

S - Set Up the Interview

Your interaction with the patient will likely not go well if you approach them without having prepared ahead of time. In fact, this first SPIKES step is as much for you as it is for them.

Before you meet with the patient, you’ll need to recognize your role in this process. You’re going to be the patient's guide through this trying time, providing support, answering questions, and doing whatever you can to be empathetic to their situation.

As such, make sure to do your research on the patient’s condition and prognosis, as well as what this might mean for them, their family, and their future. Prior to sitting down with the patient, ask for the doctor's input and mention that you plan to assess how the patient is responding to and processing the news.

For the meeting, find a private place for you to talk with the patient alone, such as an interview room. If any significant others are present, invite them in. Sit down and establish eye contact with the patient. If they allow you to do so, you can try holding their hand as a way to establish a closer connection.

P - Assess the Patient's Perception

For this step of SPIKES, you'll want to ask open-ended questions like "What have you been told about your diagnosis so far?" and “Have you thought about the treatment plan?” These types of questions can help you gauge just how much the patient understands about the situation and whether they’re feeling any kind of denial. Based on the responses to your questions, you can tailor the rest of your conversation to the patient's level of awareness.

I - Obtain the Patient's Invitation

Some patients will want to know more about what’s going on than others. One might want to know every detail of their condition, while another may just want to know how to treat the illness. Ask patients if they want detailed information or a basic, high-level sketch of the situation. Asking them directly ensures that you're both on the same page.

K - Give the Patient Knowledge and Information

In a regular SPIKES process, this is the stage where the doctor would deliver the bad news. In this situation, though, the doctor has already done that. Now it’s your job to simply deliver any additional information or clarification that the patient may need.

While presenting the facts, be as direct and clear as possible, without being unnecessarily blunt. If you think it will help, use a diagram of the body to point out what areas you’re talking about. Also, try to avoid using medical jargon and euphemisms for conditions; for example, try saying that the illness has "spread" rather than "metastasized,” and “cancer” instead of “growth.” Remember to ask questions periodically to make sure the patient understands the information.

E - Address the Patient's Emotions With Empathetic Responses

Sometimes, it’s actually more difficult to respond to the patient's emotions than it is to deliver the bad news. First, attempt to discern what emotion the patient might be feeling, whether it be sadness, anger, or simply shock. If you can't tell, don't be afraid to ask. Explain that you recognize how difficult this must be and validate their feelings. Often, empathy is seen and felt more than it is heard, but here are some helpful empathetic responses you might want to try:

  • “Thank you for trusting me with how you’re feeling.”
  • “I know this will be hard.”
  • “I’m so sorry you are going through this.”
  • “You are so strong.”
  • “I’m going to be here for you the whole time.”
  • “What can we do right now to help set you up for success?”

S - Strategy and Summary

The final step of SPIKES puts you in a position to give patients hope in the face of frustration and doubt. Once you've given them the information they need to know and have addressed their emotions, ask them if they’re in a good place to discuss their care plan and next steps. Although the doctor will have already broached this topic, revisiting the conversation will help patients in several ways:

  1. It will keep the information fresh in their minds.
  2. It will give them another chance to ask any questions they didn’t think of earlier—or didn’t feel comfortable asking their physician at the time.
  3. It will allow them to voice any additional emotions or concerns they may have.
  4. It will give them an opportunity to provide input on their own care plan.

One good way to do this is by giving them a summary of the key points they need to understand: in other words, the "who, what, where, when, and why." Offer encouragement about the treatment options, and make sure that they agree on the plan in place. This will help patients feel like active partners in their own care.

If you’ll be involved in their care going forward, be sure to let patients know that you’ll be available if they have any questions or concerns going forward. If applicable, you should also consider giving them the names and contact information of any support services that may be relevant to their situation.

Bonus Step: Follow Up

Although this step isn’t an official part of the SPIKES framework, it is crucial to building a trusting relationship with your patients. Once you’ve parted ways, try to stay in touch with them on a regular basis as appropriate. You can also send them additional resources via email or snail mail, whichever they prefer. Above all, be sure to treat them with kindness, patience, and understanding during future appointments.

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Last updated on May 03, 2021.

Originally published on Jul 11, 2018.

The views expressed in this article are those of the author and do not necessarily reflect those of Berxi™ or Berkshire Hathaway Specialty Insurance Company. This article (subject to change without notice) is for informational purposes only, and does not constitute professional advice.

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