Delivering Bad News
Matthew Butteri, MD.
Assistant Professor of Medicine
UCI School of Medicine
Impressions
Media Reference
• Think what Dr. House would do and then
simply do the opposite.
• Bonus topic: What about his cane?
Include the key players
• Ask the patient who they want involved in
the discussion of important issues
• Don’t violate HIPPA
SPIKES
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Setting up the interview
Perceptions
Invitation
Knowledge
Emotions
Strategy/Summary
Setting up
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Arrange for privacy
Involve significant others
Sit down and appear un-hurried
Make an emotional connection
Make arrangements to avoid interruptions
- eg. Hand off your pager if possible
Perceptions
• Use open ended questions to assess the
patient and their families perception of the
medical situation.
• Careful not to talk down or above
• What is your understanding of your …
• What have you been told so far?
Invitation
• Explore if the patient wants all the facts or
(as you know in some cultures) they may
say my daughter or son will take care of
everything.
• How would you like me to give the
information about test results?
Knowledge
• A brief warning shot may help
• Warning that bad news is coming may
help lessen the shock.
• Unfortunately I have some bad news to
share then say it clear and concisely.
• Avoid medical jargon:
- say “spread” instead of metastasis
The Patient’s Emotions
• Expect anything:
- silence
- disbelief
- crying
- denial
- anger
- shock
Your Emotions
• Sit and listen, connect with your eyes, hold
their hand - whatever is natural
• I wish the news were different
• Can empathy be learned?
Strategy and Summary
• Make sure “the emotion part” has cleared
enough for this step
• When ready in “broad strokes” talk about the
various treatment options
• Remind them that many specialists will likely be
involved in their care
• Leave them with some kind of realistic hope.
• Let them know you will support them through
this process.
case # 1
• The family says do not tell mom that she
has pancreatic cancer because the news
will destroy her and she will give up hope.
• How do you proceed?
case # 2
• A patient with severe dementia has a
massive CVA and the only daughter lives
out of state.
• How do you proceed?
case # 3
• You diagnose metastatic cancer in a
patient who can not speak for themselves
and there is no DPOA or POLST. The
oldest of many children says ok to shock
and do CPR but do not put my dad on a
breathing machine.
• How do you proceed?
case # 4
• You just updated the family about some
devastating news. The son slams his first
on the table says “I’m going to bust some
heads if anything bad happens to mom”
then storms out of the room slamming the
door on the way out.
• What are your next steps?
case # 5
• It’s 3am and you are the night float and
one of your 50 patients goes into PEA and
dies after a 20 minute code. You learn
from a colleague that their was a delay in
care that might have lead to this outcome.
The husband is at the bedside and wants
to know what happened?
• How do you proceed?
Spikes
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Setting up the interview
Perceptions
Invitation
Knowledge
Emotions
Strategy/Summary
Final Thoughts
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Resolve key issues before delivering bad news
Obtain relevant information before giving news
Choose the appropriate setting
Have support staff available
Be compassionate and empathetic
Be direct (don’t avoid the topic or break it slow)
Be available
Provide Hope
• That is realistic and honest.
Thank you