Regie A.

Layug, MD
Department of Family & Community Medicine
Colegio de San Beda Medicina
At the end of the session, the student learners
are expected to:
1. Identify situations considered as bad news
2. Learn a practical method of breaking bad
news to patients
3. Know the components of the SPIKES protocol
4. Formulate and design ways on how to
personally convey bad news to particular
patients
 Any news that adversely and seriously affects
an individual’s view of his or her future
 Imparting information to patients that will
have serious adverse consequences to them
and their families
 Disclosing the diagnosis of cancer
 Discussing cancer recurrence or failure of
treatment to impact disease progression
 Disclosing metastatic disease
 Discussing the presence of irreversible
disease or serious treatment toxicity
 Transitions in care objectives
 Disclosing positive results of genetic tests
 Feeling of helplessness
 Physician’s unwanted need to confront own
feelings about death and the dying process
 Feeling of sadness for the patient
A strategy, not a script
 Highlights the most important features of the
bad news interview
 Suggests methods of assessing the situation
as it evolves and responding constructively to
what happens
 Privacy
 Patient’s mistrust and antagonism may result
simply from a poorly chosen location
 Find a private location
 Close door
 Curtains drawn around a hospital bed
 Ask the patient to turn off the TV or radio to
minimize distractions
 If you have just examined the patient, allow
him of her to dress before the discussion
 Involve significant others
 Family members or friends
 Ask the patient who will act as spokesperson for
the family during the discussion
 Sit down
 Pullup a chair
 Ask permission to sit on the edge of the bed
 Avoid sitting behind physical barriers like desks
 Undo your coat or blazer
 Put down any items that are not critical to the
discussion
 Look attentive and calm
 Psychotherapy neutral position
 Maintain eye contact
 Have a box of tissues or handkerchief nearby
 Adopt other friendly gestures to lessen tension
 Listening mode
 Appropriate use of silence
 Repetition and use of active listening skills
 Availability
 Give your patient a clear indication of your time
restraints
 Make arrangements to avoid frequent
interruptions during the encounter
 In the hospital, check with the nurse working
with your patient to ensure this is a good time
for the discussion
 “Before you tell, ask”
 Find out if your patient has an idea of the
seriousness of the problem

“What do you think was going on with

you when you felt the lump?”

“What have you been told about all this

so far?”
“Are you worried that this might be
something serious?”
 Take note of the language and vocabulary he
or she is using
 Do not confront denial at the first interview
 Obtain overt permission respects the
patient’s right to know (or not to know)
 Offer to answer any immediate questions
that the patient has and make sure he or she
knows that additional questions can be
answered in subsequent interviews
 Ask if the patient wants you to talk to a
family member instead
 “Are you the kind of person who prefers to
know all the details about what is going on?”

“How much information would you like me to

give you about your diagnosis and
treatment?”
“Would you like me to give you details of
what is going on or would you prefer that I
just tell you about treatments I am
proposing?”
 Beforeyou break bad news, give your patient
a warning that bad news is coming
 Use the same language your patient uses
 Avoid technical, scientific language
 Give information in small chunks and
clarify that the patient understands what
you have said at the end of each chunk
 Tailor the rate at which you provide the
information to your patient
 Acknowledge and respond to the patient’s
emotions and reactions as they unfold in
the discussion
 Empathic Response
 Listen for and identify the emotion. If you are
not sure which emotion, use an exploratory
response
 Empathic Response
 Identify the cause or source of the emotion
(most likely to be the bad news that the patient
has just heard)
 Empathic Response
 Show your patient that you have identified both
the emotion and its origin
 Validate your patient’s feelings and relate
the response to you
 Let your patient know that showing emotion
is perfectly normal, to minimize feelings of
embarrassment and isolation
 Ensure that the patient understands the
information you have provided
 Check frequently to make sure that you are
both on the same page
 Summarize the information in your discussion
 Give opportunity for the patient to voice any
major concerns or questions