Breaking Bad News

Having been in oncology/palliative for the past couple of weeks, giving bad news was bound to happen some time.

In medical school, it was always about SPIKES. That’s:

S – Setting – Make sure you’re in the right setting for such a discussion where there is minimal interruption, and plenty of time available for discussion.

P-Perception – Gauge an understanding of what the patient knows to date about their condition so that you know how much you need to tell them.

I-Invitation – This for me seems to be the hardest to get my head around. But the invitation is the time where you essentially ask the patient how much information they want eg “with your recent CT scan, would you like me to tell you everything about it even including the not so nice information, or would you like me to skim through the results and go onto treatment options?”

K-Knowledge – This is essentially the delivery of the detailed information to the patient.

E-Empathy/emotions – Be empathetic and understanding. Essentially, if a patient is crying, offer some tissues. If they look stunned, and shocked, give them some time to process the information.

S-Summary – This is about repetition of the information given beforehand. It’s likely many patients have stopped absorbing information after the initial bad news. Repetition allows them to get the information again.

 

Having been the radiation oncology resident (in addition to the palliative/oncology resident as well – where’s my triple pay?), I was tasked into reviewing radiation oncology patients. There had been this one lady in her 70’s, who had recurrence of vaginal vault cancer, with previous groin lymph node removals for her cancer. She was undergoing radiation therapy with potential curative intent initially.

When the patient was initially admitted under radiation oncology, palliative services were provided, given the patient had pain issues on mobilizing. What didn’t help was this patient had a BMI of 53.

On the palliative ward round, the patient had advised of left hip pain as well. An examination revealed extreme tenderness on passive motion. So a CT hip scan was ordered. And then a CT chest and abdomen were ordered as well (let’s scan everything as well while we’re at it! ). The CT results weren’t good. The left hip pain – completely explained by a pathological fracture at the left hip – specifically the labrum of the hip. And the abdomen – showed that there was a right adrenal gland metastases.

With that CT scan, the patient had gone from “potentially curable” to “incurable”. Of course, being the resident to first see these results, I had the unfortunate job of breaking such bad news. The husband and the patient were lovely people, and were very friendly. Being Italian may have had something to do with it.

So, after reading and re-reading the report numerous times, I prepared to walk over to tell them the results. I was scared though. Scared that I’d break the news terribly. Scared that perhaps the husband might get angry and start shouting at me.

It wasn’t as bad as I had thought, and the patient and husband were very understanding people. On reflection, I don’t think I did invitation in the SPIKES protocol too well. But then, it seems like a really awkward way to ask a patient “if they want to know everything, or only a little of something”. I ended up just telling her “unfortunately, the scan appears to have showed that your cancer has spread to the left hip region, and to the glands sitting above the kidney”. I later explained that given the spread, the prognosis is not too good now compared to her previous well localized cancer.

The husband later ended up telling me how he appreciated my honesty and the straightforwardness of telling them. “You’re not like the last doctors that kept beating around the bush”. Well, I suppose the previous doctors had more uncertainty in breaking the news back then compared to me who had clear results from the scan.

On reflection, I think that it was a very important learning experience. I’m pretty sure as a GP next year, I’ll have lots more of these situations.

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