Wednesday, December 2, 2015

Breaking Bad News: A Cynical Look at SPIKES

One thing unique about our role as residents is that we get to be a fly on the wall in all kinds of clinical scenarios. Following residency, we’ll relinquish the opportunities to look over our colleagues’ shoulders and see how they go about doing things. Sure, we’ll still know what their management plans are for patients, as those are openly discussed at rounds. However, it’s the other half of the consult – the non-technical side – where each of us must develop our own style.

It’s here where being that fly on the wall during formative clinical years can be so useful, as try as they might through the ubiquitous “SPIKES” didactic lecture, it is simply not possible for our medical instructors to distill the nuances of conducting difficult discussions into a six-component algorithm.

SPIKES”, a protocol developed by MD and psychologist Walter Baile of MD Anderson Cancer Centre, proposes that unfavourable information be delivered in six steps: 1) setting up the interview, 2) assessing the patient’s perception, 3) obtaining the patient’s invitation, 4) giving knowledge, 5) addressing the patient’s emotions (empathetically), and 6) presenting the strategy and summarizing. One’s first impression is likely that this seems a reasonable strategy. And so I'd thought as well, when I'd first heard of “SPIKES” during a palliative care lecture in second-year medical school. However, the more I’ve thought about it, the more I’ve realized that most things in “SPIKES” are just common sense.

Select an appropriate setting (“S”) – who wouldn’t? Ask what the patient already knows (“P”) – all right, this one’s a good point. Obtain the patient’s invitation (“I”) – I think we should be able to gauge, without explicitly asking, whether a patient would like to receive bad news (and either way, it must be disclosed, so isn’t it a bit pointless to ask whether or not the patient wants to hear it?). I think “invitation” would more appropriately refer to disclosing information surrounding prognosis, where we do encounter differences in what patients would like to know.

Give knowledge (“K”) – obvious. Empathize (“E”) – if you need a mnemonic to remind yourself when to do this, there are bigger communication issues at play that “SPIKES” will not fix. Finally, present a strategy and summarize (“S”) – again, good points, but things that we should do at the end of any clinical encounter, not just in a bad news scenario.

I think “SPIKES” can be distilled down to “KQP plus kindness/empathy”, the “KQP” representing the technical points that must be covered and the “plus kindness/empathy” representing the communication skills that while I don’t think can be explicitly taught, can likely be improved by observing preceptors and mentors.

“KQP” represents know, questions, and plan, three things that I think are applicable to any patient encounter (bad news or not). Notably absent is the “K” in “SPIKES” (give knowledge) as that’s a given (how could any of us forget to give information to the patient?). KQP are three things that could potentially be forgotten, and hence where a mnemonic might be useful:
  • know – What does the patient already know? This is the “P” in “SPIKES”.
  • questions – At the end of the encounter, does the patient have any questions? The opportunity for the patient to ask questions is so important; yet was not granted its own letter in “SPIKES”. Question time is often the point where the patient asks about prognosis; and if they do not, provides the clinician (if appropriate) a segue to ask about whether the patient would be interested in knowing about prognosis, should he or she be hesitant to ask (this is the utility I see in the “I” (invitation) of “SPIKES”).
  • plan – Finally, we know that what many patients find most unsettling is not knowing what is to come. As none of us can properly answer this question, the best we can do to map out the road ahead is to end each visit by clearly laying out the plan (the “S” (strategy) in “SPIKES”). Be it “3 cycles of chemo, CT, 3 cycles of chemo, CT” or “no further recall; follow-up with GP”, it’s information that we often forget to share with patients (sometimes it’s not until the patient is gone, while I’m writing orders in the chart, that I find myself trying to piece together the plan – When should they return? Should they have a CT at that point?). It’s so simple to take 15 seconds to outline the plan and provide the patient with something tangible with which to move forth.

In most cases, the technical side of “SPIKES” (or “KQP plus kindness/empathy”) doesn't present much difficulty; however, the emotional intelligence required to communicate unfavourable information is quite challenging to hone. It is only through observing the subtleties in others’ interactions and being forced to work through challenging encounters of our own that each of us can develop the technical and psychosocial repertoire of skills required to carry us through communicating bad news. I'm very much still learning!

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