Breaking bad news: why not SPIKE it?

Don Dizon’s blog this week for the American Society of Clinical Oncology was about how he had to / chose to break bad news to another doctor’s patient. The news was indeed bad: the patient was dying. For me, the most interesting / challenging sentence in Dr Dizon’s blog was “She had expected as much, especially since she had seen herself declining so rapidly.” (Scroll down Dr Dizon’s blog to see my full comment, and his nice response.)

I wondered, just wondered, whether this patient might have been even better served by having had a similar conversation earlier. Apparently, this lady’s oncologist wanted to “alleviate [the patient’s] suffering with chemotherapy”. But the lady told Dr Dizon that the chemo was making her feel worse rather than better!

How lonely and probably frightening it must have been for the patient, ‘expecting as much’ – expecting that she was dying – all by herself.

It’s often said that the transition into ‘comfort’ care is always going to be difficult.

But I think there’s an important question about who finds what difficult.

Doctors definitely find it difficult when they have to give bad news. As well as the empathy / emotional issues; it can also be difficult to have to admit that you’re not the sort of all-powerful, all-curing miracle worker that almost all doctors would like to be. It’s also difficult because all doctors know how important it is not to break bad news badly. And … I could keep on … and on … adding loads more reasons why it’s difficult for doctors.

Of course, however hard it is for the poor doctors, they are not the ones with the personal bad news!

So what to do? The SPIKES model can help doctors break bad news. Read more about it here. But, in summary:

The best part of the SPIKES advice is: Before a doctor talks, they should listen.

The second best part is: I for Invitation. Ask the patient what they want to know. Different ways of asking for the invitation include: “Are you the sort of person who likes the full details?” “How would you like me to handle the information?” After  that, the doctor can tailor their information to the patient.

There’s something else, too.

When I commented on Dr Dizon’s ASCO blog, I was careful to mention the sensitivities around saying anything that might be seen as a criticism of colleagues. I said there, and repeat here,  that my comment was not a specific criticism of anyone. After all, a blog cannot get over all the details of any case.

I never want to be rude to anyone. But this sort of etiquette does seem something like an extension of the pussy-footing around bad news. Why don’t the doctors just get over it?


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