Updated: 6 November, 2024
What is the SPIKES model ?
The SPIKES protocol is a structured approach designed to help healthcare professionals break bad news effectively. It guides clinicians through a six-step process, from setting the stage to summarizing the discussion. By focusing on the patient’s emotional needs and understanding their perspective, clinicians can navigate challenging conversations with sensitivity and clarity.
The importance of SPIKES and similar frameworks is shown by a study that indicates that 42% of physicians experience stress after breaking bad news, and the effect lasts from several hours to more than 3 days
This Blog will go in depth about each phase of the SPIKES to give doctors a better understanding why each step matters and how to apply it in a real world scenario. If you just need to refresh your memory about the key points of each phase I recommend looking at this very brief guide.
Settings (S)
The place where healthcare professionals deliver bad news can significantly impact the flow, feeling and outcome of a consultation. Imagine trying to have a sensitive and private discussion about a devastating outcome in a hallway filled with people. Therefore Finding a private location is crucial. If possible it is recommended to have a dedicated interview room designed to comfort your patients. Another option would be an office with the door firmly shut, or even drawing curtains around a hospital bed can be useful if necessary. Not only the location matters but also the consultation room design plays a role:
When designing your doctor consultation room factors such as
- Space and Layout
- Lightning
- Furnishing
- Visible Privacy
Play a crucial role in setting a mood for the conversation and influences the patient’s emotion.
Minimize distractions
It is advised to ask the patient whether you can Turn off the TV, radio or any other distraction to take away anything that might pull the patient’s attention away from the conversation.
Who will be involved?
This depends on the Patient some prefer to have family or friends present when receiving bad news while others want to be alone. If more than one person is attending, politely ask the patient who will be the main speaker during the discussion. This way, you can provide support while reducing the stress of navigating a complex conversation with multiple people.
Perception (P)
The key during the Perspective Phase is to understand the patient’s point of view. It is an important step before communicating bad news. This involves carefully testing their knowledge of the circumstance and the seriousness of the medical problem.
Try to include open-ended questions such as
- “What were your thoughts when you first noticed this symptom?”
- “What have you been told about your condition so far?”
- “Are you concerned about the possibility of a serious diagnosis?”
Pay close attention to what words and phrases the patient uses. Mirroring their language can help you establish a connection while also demonstrating that you really are listening. This also allows you to assess any potential differences between their expectations and the reality of the situation.
If you suspect the patient is in denial about his condition it’s often best to avoid direct confrontation during the initial conversation. Denial can serve as a coping mechanism, and approaching it with sensitivity can help maintain a trusting relationship. Instead, consider addressing it slowly over multiple conversations.
Invitation (I)
Although most patients want to know all the details about their medical situation, you can’t always assume that. Some patients prefer not to know the details as a coping mechanism which has to be respected. In this case it is advised to offer the patient to talk about it at a later time or ask whether it would be okay to talk with his/her Family or friends. Keep the Invitation step in mind throughout the whole conversation to understand whether a patient is ready for the following information.
Knowledge (K)
Before sharing information with patients it is advised to warn them beforehand. This reduces the shock of disclosure. The patients will gain a few extra seconds to prepare themselves mentally. Example for that could be:
Mr. Andrews, could I speak with you about something important?
Mr. Andrews, I’m afraid I have some concerning information
Another Key aspect of knowledge sharing to understand the patients educational level, socio-cultural background, current emotional state. All of these factors should influence your body language, tone of voice and language. Nonverbal communication or body language according to modern research the impact of nonverbal communication is between 70% and 80%. Which means the way we arch our eyebrows, fold our arms, or modulate our voice can carry far more weight than the words we actually speak. In terms of language it is an effective trick to use the same vocabulary as your patient this ensures that the patient will understand the terminology. Importantly avoid using technical or scientific terms!
Also Provide the information gradually and ensure the patient understands each segment before continuing. You may need to repeat information, especially if the patient seems confused or unsure. Ask clarifying questions frequently to make sure the Patient fully understands the situation.
Adjust the pace of communication to match the patient’s comprehension. If they understand the information quickly, move forward. If they struggle, revisit the topic.
Be attentive to the patient’s emotional state. Acknowledge and address any feelings or reactions that arise during the conversation.
Empathy (E)
Another way to phrase the (E) phase, is explore emotions and sympathize. Empathy feels very natural for some people while for others it’s the most difficult part of breaking bad news.
The two most common mistakes physicians make when breaking down bad news are; first of all being too lighthearted. It is very tempting to downplay the seriousness of the symptoms or withholding certain facts, this reduces the stress and burden on both the physician and the patient in the short term. But in the long term it will hurt your reputation and take away credibility. Second off all being too cold and not following the process of acknowledging the patients feelings this skills is technique is called empathetic response and it includes:
- Identifying the emotion: Listen carefully to determine the patient’s emotional state.
- Connecting the emotion to the news: Recognize that the bad news is likely the source of the emotion.
- Expressing empathy: Show that you understand the patient’s feelings and their connection to the situation.
Strategy and summary (S)
Summarize and clarify
To ensure the patient fully understands the information, summarize the key points discussed and offer them an opportunity to express any concerns or questions. If time constraints prevent immediate answers, let them know that these issues can be addressed in detail during a follow-up appointment.
Outline next steps
Before concluding the discussion, outline the plan for moving forward. This should include the next steps to be taken and the roles each party will play in the process.
Learn breaking bad news with the SPIKES framework
To effectively deliver bad news using the SPIKES framework, healthcare professionals require proper training and practice. Self-reflection and peer feedback are crucial for refining communication skills and developing empathy. Platforms like Videolab can facilitate this process by providing a secure environment for recording and analyzing performance. By engaging in role-playing exercises, seeking mentorship from experienced clinicians, and participating in specialized workshops, healthcare providers can enhance their ability to deliver difficult news with sensitivity and clarity. Many medical institutions, such as the Royal College of Surgeons of Edinburgh, incorporate training and assessment of bad news delivery into their curricula, often utilizing communication skills competitions to foster excellence in this area.
