It is never easy to deliver bad news to patients, but for the oncologist, this is a major part of the job. Many cancer patients will have recurrences, and some will be faced with imminent death. Although oncologists are well trained in the science of treatment, communication skills necessary for delivering bad news typically are not part of oncology training. Fortunately, some institutions have introduced programs to remedy this situation.

Oncology Fellow Advisor spoke with 2 experts who lead communication skills programs. Walter F. Baile, MD, developed the SPIKES program, which is used as the basis for workshops offered at institutions worldwide.1 Dr. Baile is a faculty member at The University of Texas MD Anderson Cancer Center, in Houston, Texas, and director of the Interpersonal Communication and Relationship Enhancement (I×CARE) in Faculty Development at MD Anderson’s Program in Communication and Relationship.

 
For the past 10 years, Dr. Baile and his colleagues have conducted workshops on challenging conversations in cancer care. The workshops are underwritten by a grant from the National Cancer Institute. During 3-day retreats, doctors participate in small-group simulations in which actors simulate difficult situations and how they should be handled. Video modules demonstrating effective communication techniques in oncology care can be found at www.mdanderson.org/icare.

“Our data show competency improves from these workshops,” Dr. Baile said.2

Principles of SPIKES
S = Setting that fits the patient needs for privacy and comfort. Sit at eye level, and include 1 or 2 significant others chosen by the patient for support. Put pagers and cell phones on “silent,” and give the patient your full attention.
P = Patient’s perception. Ask the patient first what he or she understands before telling him or her anything. For example, say “Tell me your understanding of what you have been told about your cancer.” Gauge the patient’s level of understanding and tailor the message to the patient’s knowledge and emotional state.
I = Invitation. Negotiate goals for the meeting with the patient/family. For example, “Is it OK with you if we discuss results of the CT scan?” “Do you want details or just the big picture?” “Do you want me to include family members?”
K = Knowledge. Present the information to the patient in small chunks and let him or her absorb it. Wait for the patient’s reaction before continuing, rather than delivering a monologue. Give a clear message with no medical jargon.
E = Handling emotions. Recognize the patient’s emotions and your own. Maintain composure and take deep breaths. Respond to emotions with statements such as, “I see that this has thrown you for a loop.”
S = Strategy. Once a patient experiences the oncologist’s empathy, the emotional temperature often goes down and then he or she is ready to absorb the strategy and treatment plan for what is going to happen next.

Dr. Baile explained that higher competencies include having to deal with a patient’s emotions, explaining what the medical situation is without resorting to medical jargon, answering difficult questions, and dealing with family members who don’t want you to tell their loved one that cancer has recurred.

“One higher-level skill is to explore a patient’s concerns in depth. For example, if the patient says, ‘How am I going to tell my husband my cancer has recurred?’ The best response should be aimed at exploring the patient’s concern—‘Tell me about your husband. What are you worried about?’ In this way, you may discover that the patient has the common concern of being a burden to the family,” Dr. Baile explained.

“Communication behaviors that are not helpful include interrupting a patient in the middle of their story, not asking open-ended questions, changing the topic when an uncomfortable topic is under discussion, and giving a patient false or unrealistic hope,” Dr. Baile said.

Memorial Sloan-Kettering Cancer Center offers a curriculum on communication skills for oncology fellows. Oncology Fellow Advisor spoke with Carma Bylund, PhD, director of the Communication Skills and Research Laboratory at Memorial Sloan-Kettering.3,4

Breaking Bad News is 1 of 6 modules in the program; the other 5 are End-of-Life Goals of Care, Discussing Prognosis, Shared Decision Making About Treatment Options, Transitioning to Palliative Care, and Responding to Patient Anger. Each module involves a 2.5-hour workshop, and fellows participate in all 6 modules over the course of 1 year, she said.

The format begins with a didactic presentation on relevant research, followed by a discussion of the necessary skills and video clips of relevant situations for group discussion. For the remainder of the workshop, fellows work in small groups of 3 plus 2 facilitators and specially trained actors; participants role-play difficult scenarios that simulate what an oncologist will experience. After role-playing, facilitators provide feedback and suggestions about how to reframe thoughts. Participants watch video clips of the role-playing and the group discusses nonverbal cues.

“It can be hard to watch yourself on video. We begin by asking the learner how the scenario went and then follow that by getting feedback,” Dr. Bylund said.

Dr. Bylund cited the following major challenge in learning how to deliver bad news:

The balance between giving news too soon and waiting too long: “We work on that in small groups. The doctor needs to set the stage so that it [giving bad news] is not done too abruptly, or on the other hand, so that the doctor is not making small talk for so long that the patient thinks the doctor is just shooting the breeze and is caught off guard,” she said.

The way to word bad news is making sure to allow short periods of silence during the discussion so that the patient can absorb the information he or she has been given so far.

References

     
  1. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-311.
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  3. Back AL, Arnold RM, Baile WF, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med. 2007;167(5):453-460.
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  5. Bylund CL, Brown RF, Bialer PA, et al. Developing and implementing an advanced communication training program in oncology at a comprehensive cancer center. J Canc Educ. 2011 May 4. [Epub ahead of print]
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  7. Bylund CL, Brown RF, Gueguen JA, et al. The implementation and assessment of a comprehensive communication skills training curriculum for oncologists. Psycho-Oncology. 2010;19: 583-593.
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