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 patients 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 were trying to do is to put space
between us (the messenger) and the message that were 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 physicians 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. Dont interrupt.") and
repetition, ie, using one word from the patients last sentence
in your next sentence. "The patient wont 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 theyll 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 dont 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 youre saying. You can stop and ask, Do
you see what Im saying. Do you follow me so far? Does this make
sense to you?"
This technique indicates to the patient that the patients
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 patients 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. Buckmans 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 youre 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 youve 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."
CD-ROM Set Features Simulated Patient Interviews
"A Practical Guide to Communication Skills in Clinical Practice:
More than 40 simulated interviews are included in sections entitled
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.