SPIKES, a Six-Point Protocol, Helps Physicians ‘Break the Bad News’ to Cancer Patients

LOS ANGELES--If the basic protocol for imparting bad news to cancer patients could be reduced to a T-shirt slogan, it would be, "Before you tell, ask," Robert Buckman, MD, PhD, said at an educational session on breaking bad news to cancer patients at the American Society of Clinical Oncology (ASCO) meeting. "Find out the patient’s expectations before you give information," he said.

Dr. Buckman, a medical oncologist at Toronto-Sunnybrook Regional Cancer Centre, and associate professor, University of Toronto, spoke at the session along with Michael Levy, MD, of Fox Chase Cancer Center, and Walter Baile, MD, of M.D. Anderson Cancer Center.

"The essence of what we’re trying to do is to put space between us (the messenger) and the message that we’re carrying, so that the messenger can be supportive and helpful to the patient even though the message is actually quite bad," Dr. Buckman said. He described a six-point protocol for breaking bad news, known by the acronym SPIKES, which he developed with Dr. Baile.

The S refers to the physical setting in which the physician talks to the patient and the physician’s listening skills. He said it is important to establish a quiet and comfortable environment where the interview can take place. "It is impossible to have a conversation in a hospital corridor where porters are pushing food trolleys between you and people are running IV stands over your toes," he said.

Dr. Buckman advised physicians to "get your eyes on the same level as the patient." He said to maintain eye contact at all times when listening, except when the patient is actually crying or is angry, in which case eye contact may be viewed as an aggressive signal.

He said that studies have shown that communication across a desk or table yields a less spontaneous conversation than when people are sitting next to each other. Although he did not advise the physician to sit next to the patient, he did suggest that the physician position the patient across the corner of the desk. "It sends the message there is still a professional/patient interface but that you are trying to reach out across it and communicate with the patient," he said.

Two important listening skills are silence ("When the patient is talking, you shut up. Let them talk. Don’t interrupt.") and repetition, ie, using one word from the patient’s last sentence in your next sentence. "The patient won’t be aware of the technique, but they will be aware that they are being heard," Dr. Buckman said. For example, a patient after being told she has bone metastasis asks, "So what happens now?" and the physician responds, "What happens now is . . ."

The P in SPIKES is for perception. "This is where ‘Before you tell, ask’ comes in," he said. "Before you give any information, find out how the patient perceives the situation." Dr. Buckman suggested asking such questions as, "When you first found the lump in your breast, what did you make of it? Did you think it was something serious?" As the patient replies, he said, "listen to their vocabulary and comprehension. What is their level of understanding?"

The I, for invitation, is the pivotal moment in the interview, he said, "the moment at which, if the patient wants information from you, you get a clear invitation to share it." Again, there are different ways of asking for the invitation: Are you the sort of person who likes the full details about your diagnosis? How would you like me to handle the information? "It only takes about 10 seconds of the interview," he said.

Currently, nearly all patients want full information, he noted, "but they will never forget that you had the courtesy to ask, and that all the information they’ll hear from now on is at their own request."

Most physicians are generally comfortable with the K portion of the protocol: imparting knowledge. He advised physicians to "start at the level that the patient stopped at." For example, if the patient knows she has a 1.8 cm breast lesion, then the physician can say, "Yes, and that is a small T1 tumor," and go on from there. If the patient says, "they told me it was a shadow on the lung, nothing serious," the physician can say, "Yes, but you probably don’t know that shadows can be caused by many different kinds of things in the lung."

Dr. Buckman suggested that physicians give the information in small digestible chunks. "Interrupt your own flow to make sure they understand what you’re saying. You can stop and ask, ‘Do you see what I’m saying. Do you follow me so far? Does this make sense to you?’"

This technique indicates to the patient that the patient’s understanding of the situation is the real objective of the talk, and helps bring patients back into the interview if they "space out" after the first mention of the word cancer.

For the E in SPIKES (emotions), Dr. Buckman said that acknowledging the patient’s emotions (by using the empathic response) is what distinguishes the sensitive listener from the insensitive listener. He stressed that the empathic response is a technique, "not a feeling you have."

The physician identifies the source of the emotion and responds in a way that shows he has made the connection, with a statement such as, "What I have said must be very upsetting," or "It must be awful hearing this."

In a conflict situation, he advised the physician to use the empathic response on the strongest emotion in the room. If the patient is enraged, the physician can respond to that empathically, by saying something like, "This is making you very angry, obviously."

But sometimes the physician may become angry, and then he should do an empathic response on himself. In Dr. Buckman’s example, a physician might say to a patient, "I find it very irritating that every time I try to talk about chemotherapy, you only want to talk about macrobiotic diets." In this way, the physician describes his emotion rather than displaying it, he said.

Finally, he said, wrap up every interview with a strategy and summary. "As you’re giving the strategy, go for feedback; ask whether the patient understands the plan, whether it makes sense," he said. "Involve the patient so they feel that they are part of the decision making." Close the interview with a clear summary of the situation, he said, and ask if the patient has any more questions. "And if you’ve got unresolved areas, try to restate those areas for the patient," he said.

At the close of the session, Dr. Buckman showed a simulated patient/doctor interview from a CD-ROM set he has developed along with Dr. Baile (see box ). The simulated scenarios deal with basic communication skills and include specific sections of interest to oncologists, such as breaking bad news, genetic testing and counseling, and handling emotions. The set includes about 45 simulated patient interviews with simulators who are so effective that "physicians have asked me how we got real patients to do this," Dr. Buckman said. "In fact, the scenarios are unrehearsed and unscripted."

Each scenario illustrates the concepts of the SPIKES protocol, with on-screen notes pointing out the specific communication technique being used by the physician. This unique feature of theCD-ROM brings home the idea that physicians can develop and improve their communication skills, which was, in fact, the message of the ASCO session.