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Loyola University Chicago Stritch School of Medicine
AAEM/RSA Social Media Committee
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A variety of patients present in the emergency department (ED), and every ED physician, resident, and even student will encounter patients in critical condition or life-threatening injuries. As a result, it is an essential skill for an ED clinician to be able to give bad news. One of the more helpful mnemonics I have learned and been able to apply when having to break bad news to patients or their families is SPIKES. This mnemonic is often used by oncologists, but can apply equally well in the more acute ED setting.[1,2]
S: Setting. Make sure you are in an appropriate setting to deliver the news. A private room with minimal noise interference is preferable. A recent study showed that there is a discrepancy between patient and physician perspective on the level of privacy achieved during these conversations, indicating that more emphasis could be placed on finding an appropriate setting. [2,3] Also recognize the importance of introducing yourself and your role.[3,4]
P: Perception. Ask the patient and/or their family what their understanding of the transpired events has been thus far. It may be that the patient has been suffering from a chronic disease and they have been preparing for their eventual death for a long time, or this may be a sudden and unexpected occurrence. Many times it may be better to be direct. Overall, keep in mind that every family has different experiences with their loved ones and their diseases that makes each encounter different.
I: Invitation. Determine how much the patient or family would like to or needs to know. It is very important to take into account different cultural views. For example, patients of certain cultures may want to hear bad news with their entire family present, while others may prefer to hear it alone. At other times, family members may wish to exclude the patient from knowing their own diagnosis. [5,6]
K: Knowledge. Tell the patient what they need to know, and give them as much helpful information as you can under the circumstances. This could include explaining how someone’s disease process works, and what specialists they need to see, or what support groups may they have access to. Research has shown that this aspect of the conversation may be perceived equally by both physicians and families. Still other research has shown that patients can leave the ED with poor understanding, so there is likely room for improvement.  It may be emotionally difficult to give information about poor prognoses, but it is more beneficial to be honest than to avoid false hope.
E: Empathy. While the emergency department can make for a challenging environment, it is important to take the time to empathize with how a patient or their family is feeling, and offer what support you can. Let them know that you as a physician are not just there to provide quick treatment and move on, but that you truly care about what happens. For you this is one of many patients throughout your shift, and it may be a case you have seen many times before. But for the patients, this may be one of the most important days in their life, when everything changes. It can be easy to lose sight of that, and this is another aspect of the conversation that has been shown to have a discrepancy in perception between patients and doctors.[2,3] Many EDs have chaplains or equivalent, and if you are at such a hospital, be sure to utilize these resources when appropriate. However, in other instances the ED clinician may be the primary person available to speak with a patient or their family.
S: Strategy or Summary. Include the patient and family in the plan going forward. Ensure that their questions have been answered to their level of understanding, as patients have reported poor satisfaction with their understanding of their disease after physician interactions.
Everyone develops their own strategy for delivering bad news, but hopefully some of these tips can make it a little easier. Research has also shown that development of a curriculum for delivering bad news may helpful for residents.[3,4]
1. W.F. Baile, R. Buckman, R. Lenzi, G. Glober, E.A. Beale, A.P. Kudelka. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist, 5(4) (2000), 302–311
2. G. Toutin-Dias, R. Daglius-Dias, A. Scalabrini-Neto. Breaking bad news in the emergency department: a comparative analysis among residents, patients and family members' perceptions. Eur J Emerg Med. 2016 Apr 20.
3. H.R. Roh, K.H. Park. A Scoping Review: Communication Between Emergency Physicians and Patients in the Emergency Department. J Emerg Med. 2016 May;50(5):734-43
4. C.E. Chumpitazi, C.A. Rees, B.P Chumpitazi, D.C Hsu, C.B Doughty, M.I Lorin. Creation and Assessment of a Bad News Delivery Simulation Curriculum for Pediatric Emergency Medicine Fellows. Cureus, 2016 May 8(5): e595.
5. Mostafazadeh-Bora, M. & Zarghami, A. J Relig Health, 2016 May 3: 1-3.
6. Abby R. Rosenberg, MD, MS; Joanne Wolfe, MD, MPH; Lori Wiener, PhD, DCSW; et al. Ethics, Emotions, and the Skills of Talking About Progressing Disease With Terminally Ill AdolescentsA Review. JAMA Pediatr. 2016;170(12):1216-1223.