Based on review of the protocols available for breaking bad news, it would appear the methodology behind them are often intertwine. Different headings may be used, and additional steps added but in principle the outcome is the same.
Below are step-by-step guides for SPIKES Model (2000) and PEWTER (2006). Although in brief, as we read through the guidelines which will focus mainly on the Kaye 10 step approach (1996, updated 2023) you will see how they interlink and, therefore, the benefits of their use to help facilitate a difficult conversation.
SPIKES: The six step Protocol (Baile et al, 2000)
PEWTER MODEL (Nardi and Keefe-Cooperman 2006)
In-depth Look at One Model
Steps to Breaking Bad News: The 10 Step Protocol (Kaye P 1996, updated 2023)
Step 1 – Getting started / Prepare
Get the physical context right
Whenever possible, bad news should be given face to face and not over the telephone.
Prepare the environment so that you can sit down comfortably with the patient and have tissues, etc., available.
Have all relevant results and notes to hand and a treatment plan clear in your own mind.
Ask the patient if the television/radio can be switched off.
Hand over any bleeps or mobile phones to another team member.
Give the patient time to be prepared. For example allow the person time to get dressed following a physical examination if they so wish.
Ensure the patient (and/or relatives) has access to appropriate aids to communication if appropriate. For example hearing aid, interpreters, sign language etc.
If you think that the person may have difficulties making decisions based on the information you are going to give them, refer to local policy/guidance on the Mental Capacity Act, 2005.
If English is not the patient’s first language, refer to local policy/guidance on obtaining an interpreter
If you are disclosing a cancer diagnosis, please be aware of the ‘Cancer Backup’ confidential help lines for information and support in various languages.
If possible, plan what the next steps are for the patient and timings, if you are able to organise them, so that the patient knows when they will be seen next.
Where / Ensure privacy
Ideally, interviews should take place within a private environment such as a separate room that can be free from interruption. Ensure that you will not be disturbed and that mobile phones, etc are turned off. If this is not possible, simple measures to ensure privacy should be undertaken for example drawing curtains around the bed. Remember, however, that curtains and screens are not soundproof: you may want to consider removing any people not involved in the meeting from the room if you can safely do so. Or it may be possible to remove the patient to another room on their bed.
Who should be there?
The first recipient of information should always be the patient, except in exceptional circumstances, i.e., if they are unconscious. The patient should be encouraged to have a family member or carer present, should they so wish. Whenever possible a member of the nursing staff - preferably either a cancer nurse specialist or a member of the team caring for the patient - should be present and remain with the patient after the doctor has left, to provide ongoing support and clarification.
Starting off / Introducing yourself
Introduce yourself and role before ensuring you have the right patient and/or relatives and clearly identify who they are. Unless the patient begins with a question, it is a good idea to start the conversation with some form of question, such as “How are you feeling at the moment?” or “How are things today?”
Step 2 – Find out how much the patient knows
Patients often deny having much knowledge or insight into their situation. Encourage the patient to give you a narrative of events. Use open-ended questions to allow open dialogue. As they talk, you should begin to understand the patient’s perspective and it gives you very useful information about their current concerns.
From the narrative establish the following:
The patient’s level of understanding.
Their main concerns.
Their expectations for the future.
Whether they want more information.
Step 3 – Determine if more information is wanted/How much information does the patient want to know
This stage is important because most patients are frightened about having more information. If patients want more information move to Step 4 - “The Warning Shot”. If the patient is unsure, offer discussion about the pros and cons of having more information. If the patient declines further information, acknowledge this. Make it clear to the patient that when they want to know more information it will be made available. Do not force information on to the patient.
Step 4 – Give a warning shot / Share the information
A warning shot is essential to prepare the patient for serious news, e.g., “We have the results of your tests and I am afraid that it is more serious than we thought”. Alternatively, one could say, “Unfortunately the news is not good.”
New information should be given in clear, concise and unambiguous language, step by step with pauses after each new piece of information. This gives time for the information to be retained, by the patient. They have control over how much information is given to them. Finish with an expression of empathy e.g., “I am so sorry for this” and acknowledge that it is difficult to deal with. However, DO NOT say that you can understand their situation, as it is unique to them.
Step 5 – Allow Denial / Responding to the patient’s feelings
Denial is a way of coping with a threat to the patient and may be necessary for their maintenance of psychological well-being. Therefore, it should be respected as a coping strategy. Buckman (1996) states that the way to respond to denial following bad news is to respect the protective nature of it, and an appropriate response might be: “It must be very hard to accept this”.
Allow the patient to control the amount of information they receive.
Step 6 –Explain if requested / Planning and follow through
The aim is to narrow the information gap between the health care professional’s understanding and the patient’s understanding.
“Do you want me to go over anything”? “What would you like to discuss?”
Be clear and simple - avoid medical jargon where appropriate, but use correct simple medical terms, e.g., “Gleason Score”.
Check the patient understands - “Is this making sense?” For clarity ask the patient to tell you what they have understood by what you have said.
Be as realistically optimistic as possible.
Deal with concerns before explaining details.
N.B. Know when to stop: changing the subject, looking out of the window, fidgeting hands, all may mean the optimum level of information has been passed on.
Step 7 - Elicit Concerns / Listen to concerns
“What is worrying you the most?”
Giving permission to discuss concerns enables the patient to start clarifying the issues, and then prioritising the concerns.
Address concerns whilst avoiding premature unrealistic reassurances.
If concerns are to be discussed with relatives, then the verbal consent of the patient must be gained and this should be indicated in the notes.
Step 8 – Encourage Feelings/ Expression of Feelings
This is a key phase and provides a therapeutic type of dialogue. The aim is to help the patient try to name their feelings.
Acknowledge feelings - Assist by asking, for example, “How does this leave you feeling at the moment”?
Reflect back the patient’s feelings - patients hearing their own words begin to understand their feelings.
Patients may name emotions such as fear or anger, and a prompt may help.
Expressions of feelings can give a sense of control to patients.
The verbalisation of feeling is healing in its own right, provided the patient’s feelings are acknowledged.
Step 9 - Summary and Plan
At this stage the patient may look to the clinician to provide some sort of plan for future care. Therefore, a summary of the patient’s concerns and a treatment plan are necessary.
These should integrate the patient’s main concerns, with the Healthcare Professional’s knowledge of the management options available. Offer information booklets.
It acknowledges the support systems already available.
You should leave 5 minutes at the end to ask if there is something else the patient wishes to discuss.
Step 10 – Follow up / Offer Availability
Offer the patient the opportunity to meet again, suggesting a mutually agreed date and time; and offer appropriate contact details should the need arise before the next meeting. An assurance that the patient’s GP will be contacted and informed is important.
Reasons for availability
Further explanations - details are often not remembered at first
Emotional adjustment – this takes time, and it can be facilitated by even a small amount of listening and counselling
To meet relatives
After the consultation
A letter or Epic documentation summarising the treatment plans and what was discussed during the consultation should be sent to the GP or other hospital teams that are providing care to the patient. It must be recorded in the patient’s records what bad news was given and the manner in which it was received.
Recognise that breaking bad news also has an impact on the professionals involved in giving the news. Try and avoid rushing into the next job, consider taking a short break if possible and appreciate the effect this can have on oneself – seek appropriate personal support if necessary.