Breaking Bad News Well: Yes, But How?
Few of us enjoy performing a task if we feel that we are not very
good at it. Furthermore, the simpler the task appears to be, the more
embarrassed we feel about our perceived lack of ability. As a result,
we tend to avoid the whole situation and the discomfort associated
This is the central problem that has bedeviled communication skills
in medical practice for the last few decades. We all know what we are
supposed to be doingbecause experts have been reminding us
about it for yearsbut there has been remarkably little
practical guidance about how we should do it. All of this makes the
article by Dr. Walter Baile and colleagues on the most difficult
communication taskbreaking bad newsextremely welcome.
No Universal Script Available
In difficult clinical interviews, there is no such thing as a
universal fix-all script. This is because the main objective of
breaking bad news well is to deal sensitively with this individual
patient facing this particular piece of news and responding with
these particular emotions.
Over the last few years, there have been many excellent suggestions
regarding the principles that should guide usand almost all of
them are of undisputed benefit. We clearly understand from research
studies and from patients that we have to show support for the
patient, use empathy, appreciate the individual patients
particular concerns, and understand and respond to those concerns
honestly and with the appropriate amount of information. These
principles, among others, are beyond dispute.
There has been no real controversy in recent times about what to
dothe real question has become, how do we do it? Fortunately,
there exist some useful guidelines and tips that we can all employ in
clinical practiceand Dr. Bailes group outlines the main
steps with some valuable illustrations.
A Step-by-Step Strategy
This article details a step-by-step strategy for the process of
breaking bad news that, as research now shows, meets the objectives
of carrying out this task well. To some extent, a protocol for use in
a communication task can be legitimately compared to a protocol for
any medical intervention. Protocols used in cardiopulmonary arrest,
diabetic coma, or septic shock, for example, are actually strategies
for coping with medical events. Like all protocols, these present a
sequence of steps for use in a clinical situation as it evolves and changes.
When you analyze their structure, protocols such as these consist of
two elements: (1) sequential steps based on fundamental principles,
and (2) a set of ways in which the clinician responds to what happens
next (in other words, an algorithm). Thus, for example, we are
trained to carry out the first steps of cardiopulmonary resuscitation
(CPR) in an unvarying sequence (ie, establishing a patent airway,
starting chest compressions, getting an intravenous line started) and
then to base the next steps on the patients cardiac rhythm,
restoration of circulation, and so on.
The comparison between a CPR protocol and one for breaking bad news
is not too great a stretch. The fundamental components are the same:
The clinician has to (1) assess what is happening as the situation
unfolds, and (2) have ready a set of techniques that are helpful in
each of those outcomes.
The SPIKES six-step protocol (an inelegant acronym, but not
inappropriate!) presents the main stages for breaking bad news, and
the authors sample dialogue illustrates the communication tasks
and the techniques involved at various stages. In the sample
dialogueand in the discussion that followsDr. Bailes
group provides examples of: assessing the patients knowledge,
describing recent treatment and tests, introducing bad news (using a
warning shot and such words as unfortunately), employing
silence and pauses, repeating a key word that has been used by the
patient, and responding with empathy to an identified emotion. They
also provide many other practical tips and guidelines that can be
assimilated quite easily into oncology practice.
Taking the Mystery and Mystique Out of Communication
The techniques illustrated in the article are not highly specialized.
They are accessible to all of us in medicine, and its helpful
to see them described in detail. Its always reassuring to know
that this is what other practitioners do, and therefore that we have
permission to do it ourselves. That is one of the major
advantages of examples of dialoguethey provide a clear
illustration of the how of breaking bad news. (For those
who would like to see more examples in videotaped form, it may be
worth looking at the CD-ROM set referred to in the article.)
Examples of techniques and practical details take the mystery and
mystique out of communication skillsand thats what
exactly we need in oncology at the moment. The techniques are
becoming less mysterious, and our ability to communicate is gradually
becoming a learnableand crucialpart of our daily job.