Robert A. Buckman, M.D., Ph.D.
Adjunct professor, Behavioral
Science
The University of Texas M. D. Anderson Cancer
Center
[ Music ]
Dr. Buckman:
Now, let's look at a six-step protocol
that's very useful when you have to break bad news. We devise a rather inelegant
and rather threatening acronym - SPIKES, but SPIKES, as an acronym, at least has
the virtue of being easy to remember. Let's start with a very simple definition
of bad news. Bad news is any news that's seriously and adversely changes the
patient's view or expectations of his or her future. In other words, bad news
refers not so much to the medical reality of the condition, but to its impact on
the patient. Therefore, you can't tell how bad any bad news is. In other words,
how badly it may affect the patient until you've already got some idea of what
the patient's perceptions and expectations of that situation are. And, as you're
going to see in a moment, this is really the central crux of the rationale of
SPIKES. In fact, it makes up the pivotal point of the SPIKES interview which I'm
going to concentrate on right now.
What exactly, then, is the SPIKES protocol? First, it's actually a variation on the standard approach to the medical interview, the CLASS, C-L-A-S-S, approach. In fact, some of the steps are actually the same. The first step in SPIKES, the "S" stands for Setting. What we mean by "Setting" in SPIKES is that you get the physical context right to ensure privacy for someone and as much comfort as you possibly can, and then you switch on your "Listening Techniques" as we outlined above to make sure that you are being perceived as an effective listener. Those are the "C" and the "L" of CLASS. And, we have combined the two to make "S" for "Setting" at the beginning of SPIKES. At the other end of SPIKES, the final two steps are the ones we have met before in CLASS. "E" in SPIKES stands for "Emotion," acknowledging the emotion. Just as in CLASS, the "A" stood for "Acknowledging Emotion" and dealing with the emotions as they arise, same thing. And the final "S" of SPIKES is "Strategy and Summary," the two things that we provide at the close of any medical interview, corresponding to those two separate S's in CLASS, the S of C-L-A-S-S. So, those steps and the way we do them are detailed in what we've already talked about in the CLASS protocol.
So, that leaves the middle of the SPIKES protocol to talk about right now. What's different? What is really different when we are delivering bad news? Remember that I said that bad news is defined by how it impacts the patient and changes their view or expectations. We cannot know that until we know something about his or her understanding of the situation and the expectations that he or she might have, so the "P" in SPIKES is for Perception where we determine this. We ascertain, before we impart any news, what their expectations or perceptions are. Before you tell, ask.
After the "P," "I" for Invitation, again, before we tell the bad news, we find out whether the patient wants to hear it. Then after that invitation, "K" stands for Knowledge that, as it will, represents the actual information that we deliver to the patient. So, let's look at those steps in more detail. "P" for Perception, okay. What you want to know here is really how serious the patient thinks the situation is. The exact phrase doesn't matter, but you might say something like, "When you first got that chest pain" or "When you found that lump in the breast" or "When you started passing those dark stools, what did you think was going on?" Or "What did you make of those symptoms when you first noticed them?" Or "What did you think was happening? Or "How serious did you think it was?" The reason for doing that is it helps you start where the patient is, so that you give your information later on at the point that the patient had reached. Next comes the pivot of the whole interview. When you ask the patient what he or she would like to know about the medical situation. That's the "I" for invitation. Getting as clear an invitation as you can to discuss the medical information that you would like to give if that's what the patient wants. As you will see in the scenarios that follow, there are a whole bunch of different ways of actually phrasing that. "I'd like to go ahead and tell you the diagnosis. Is that okay?" or "Shall I tell you what was actually found in that sample of tissue, is that okay?" The exact phrase is not important. What really matters is that you ask. Neither the patient nor you will ever forget that at that crucial moment, the patient had a true choice to hear the information or not and that you were sensitive enough to ask about it, very important. Now, it happens very rarely these days, maybe, maybe half a percent of cases, maybe even less that the patient doesn't want to know. The patient says, "No, I don't want to know." If they do this, then offer to talk to a relative or friend and tell the patient right then that you will also always answer questions later on if they ask them. But you will never thrust unwanted information down their throat if they don't want it. In fact, many of these patients will later indicate, there are studies that show this, that they will later indicate that they would like the information after all. So, that's okay. That is the "I" of SPIKES. Give a clear invitation.
Then after "I," " K" for Knowledge, giving the patient information. A few simple rules. First, make a conscious effort to use plain English, not medical jargon. Actually, say "sample of the tissue," not biopsy. Never, you never say "space occupying lesion,", actually say "a lump" or something like that. Second, give the information in small chunks and always check that the patient understands what you have said after each small chunk. So, interrupt yourself, "Does that make sense?" "Do you follow me?" "Are you with me so far?" Okay or anything to show that they are on the same page. Observe how the information is being taken in and very, very important, deal with any emotion at that time and place, right then and there. Respond to the emotion as it erupts into the interview as we have outlined elsewhere. Now, something that you're going to see used a lot in the scenarios is we share with you how to use these protocols and an approach that I would like to call the "Narrative Approach," very useful indeed. As you are giving the information or knowledge, as you actually give the bad news, explain it chronologically. Start with a, a sort of recap of events like a story, a narrative in chronological sequence. So, after you've gotten the invitation to or permission to disclose and you say, "The results of a biopsy" rather than just blurting out, "It shows you've got cancer," it's better to start with something now, something that goes like this. "Now, recall when you came in with that pain in your leg, the x-ray showed an abnormal lump there and we ordered a sample of that tissue there in order to find out what kind of lump it was." Then you can go ahead and tell what the biopsy showed, that, as it were, eases both you and the patient into the news and I found that to be a very useful approach for the "K" of SPIKES.
So, let me recap, SPIKES is the basic six-step protocol for breaking bad news. It's a variation of the CLASS basic structure. The same important opening and closing, but with the important pivotal process in the middle, needing to address the bad news part, checking their perception, getting an invitation before delivering the knowledge or information. You are going to see all of those techniques in the clinical vignettes on this site. Remember that these are things that you can put into practice pretty easily and as you do so, I think you'll find they really help in some of the very difficult situations that we encounter in clinical oncology.
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