How I Break Bad News
Dear Friend,
Hope you are having a lovely weekend. This past week I completed my geriatrics 6 month rotation – I have now started my rheumatology placement. This should be very interesting and give me exposure to a lot of interesting conditions like inflammatory arthritis, vasculitis and more.
One important skill that I developed over the past 6 months as part of my geriatric rotation was the ability to break bad news. As a medic, there will be many times you have to break bad news – this might be delivering a new diagnosis such as cancer, or palliating patients who are not responding to medical treatment.
These conversations can be challenging and very emotionally difficult. There is no right way to have these conversations, and many of you will develop your own methods. This, week I wanted to share the SPIKES method of delivering bad news. I hope you find it useful.
Tackle any Breaking Bad News scenario by following the 6-Step SPIKES protocol!
1) Setting
Create the setting by preparing yourself for the interview. Practising will familiarise you with the scenario and therefore reduce some of the situational anxiety. You can also prepare the room beforehand by ensuring privacy and eliminating distractions. Once the interview commences, you may sit with the patient and ask them if they wish to have someone present in the room with them.
Try to connect with the patient by maintaining eye contact and touching them on the arm or shoulder as a way of offering comfort. Offer them your undivided attention by listening and giving them space.
2) Perception – “Before you tell, ask”
Before getting into details about the results, it is important to ask the patient what they know so far. You can then deliver the news based on information provided by the patient.
“What have you been told about your medical situation so far?”
“What is your understanding of the reasons we did an MRI?”
3) Invitation
Each patient is different in the ways they would like to receive information. Some patients want to know every detail about their diagnosis, while others want to know the bare minimum. Therefore, ask the patient how much detail they would like beforehand. If they do not want any details, allow them to ask you some questions.
“How would you like me to give the information about the test results?”
“Would you like me to give you all the information or summarise the results and spend more time discussing the treatment plan?”
4) Knowledge
Letting the patient know that bad news is coming is a more effective strategy than stalling or delivering the news abruptly. It gives the patient time to realise and prepare themselves for what they are about to hear. Explain the news to the patient in manageable chunks by keeping terms simple and avoiding medical jargon. Make sure to check in with the patient often to see if they are understanding the information.
“Unfortunately, I have some bad news…”
“I’m sorry to tell you that…”
5) Emotions
Responding to the patient’s emotions can be the hardest part about breaking bad news. Therefore, it is important to have an appropriate empathic response in place. Start off by observing the patient’s reaction (shock, sadness, silence). You can also identify the emotion by asking the patient what they are feeling/thinking. Explore why the bad news is upsetting them at that moment.
After giving the patient some time to process the news, offer some words of comfort. It will be difficult to discuss the situation further if emotions have not cleared, so continue making empathic responses until the patient becomes calm.
“I know this isn’t what you wanted to hear.”
“I wish the news were better.”
6) Strategy and Summary
Offering a clear plan for the future will make patients less anxious and uncertain. Allow the patient to share their fears and concerns going forward. Even in the case of a poor prognosis, patients may still want ways to alleviate pain, reduce symptoms etc.
Understanding the patient’s goals will allow you to decide what is possible to accomplish regarding treatment.
Drug of the week
Mirtazapine
This drug inhibits negative feedback α2-receptors on 5-HT neurones, which is thought to lead to enhanced noradrenergic and serotonergic activity in the brain.
It is a strong antagonist of serotonin 5-HT2A and 5-HT3.
It is also a a potent antagonist of histamine H1 receptors, a property that may explain its prominent sedative effects.
However, it also blocks the 5-HT receptors in other pathways leading to the side effects of insomnia and sexual dysfunction.
Side effects:
Increased appetite
Weight gain
Sedation
A Brain Teaser
A 70-year-old man presents to A&E with a 4-day history of worsening muscle pain and weakness of his arms. He notes no history of trauma or any other symptoms. On examination, he has weakness of his arm extensor muscles and there is a weakness to abduction (MRC grade 4/5).
He has a full set of bloods taken in the hospital including creatinine kinase. His only past medical history includes late-stage chronic obstructive pulmonary disease and a myocardial infarction 1 months ago.
CK – 45000 units/lite
What is the most likely cause of this mans presentation?
A – Chronic renal failure
B – Adhesive capsulitis
C – Duchenne muscular dystrophy
D – Polymyalgia rheumatica
E – Using a statin
Answers
The answer is E – using a statin
This question is asking about a 70-year-old man presenting with muscle pain and weakness. In this case, the raised creatine kinase and past medical history point towards a statin as the cause of his symptoms. Statins can myalgia and myopathies, but can also go on to cause rhabdomyolysis in serious cases.
If the cause was adhesive capsulitis you would expect the shoulder joint alone to be affected. It is also not associated with the dramatic rise in creatinine kinase. It is also less likely that it would be bilateral as that only occurs in 15% of patients.
Chronic renal failure would be associated with other symptoms such as nausea, vomiting and fatigue. It is also unlikely to cause the pain and weakness in his muscles. With a creatine kinase level of 45,000 units/litre, you would expect some symptoms. There is also no risk factors for chronic renal failure.
Polymyalgia rheumatica is another cause of myalgia. It typically affects the shoulders or pelvic girdle. However one of the main features of polymyalgia rheumatica is that the creatine kinase is normal and not raised. In this case, this rules out this answer.
Duchenne muscular dystrophy is a genetic condition affecting men, however, symptoms typically occur between the ages of 1-3 with difficulty walking. However, the average life expectancy for people with DMD is 27 and thus it would not present in this age group.
