Transcript: What To Do When You Have Bad News For Patients

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Liz Rohr:
This SPIKES acronym was developed by Walter Baile, who was a physician that worked at MD Anderson. I don't know a ton about this person. They may still work there, but a little bit of background there.

Well, hey there, it's Liz Rohr from Real World NP, and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients.

In this episode, I want to talk to you about delivering bad news in primary care. This can be really challenging for experienced nurse practitioners, brand new nurse practitioners, just pretty much all of the above. I have to say though, it does get easier and easier with time. However, I've talked to a lot of new grads who struggle with knowing how to approach it, where to go, how to have those conversations, whether you're breaking a new diagnosis of diabetes, for example, or if you have some suspicions that there could be some sort of more ominous process going on, like a cancer or something like that. So in this episode, I want to talk through an established framework called SPIKES that you can use as one option. It's not the only option, but it's a really nice framework to talk about these types of conversations, especially as you begin practicing them or as you continue to practice and get better.

This SPIKES acronym was developed by Walter Baile, who was a physician that worked at MD Anderson. I don't know a ton about this person. They may still work there, but a little bit of background there. So, what is the acronym SPIKES? I'll tell you the steps and then we'll talk about each of them and what it looks like.

Number one is setting up. Number two is perception. Number three is invitation. Number four is knowledge. Number five is E, emotions and empathy. Number six is strategy and/or summary. And so, let's talk about what that looks like. So for example, let's take a new diagnosis of diabetes. This can be very upsetting for patients. It's not necessarily as upsetting as potentially a life-threatening diagnosis, for example. However, it is still upsetting, so you can approach this diagnosis in the same way.

First of all, it's talking about setting up. I have a little bit of an adaptation to add, but setting up in this framework refers to setting up the office environment such that you are ready for a conversation with full attention where somebody feels safe. And so, I did some reading about creating safe spaces, and because it's something that, at this point, is kind of an innate thing that I do. And to be continued, if that's something that you feel like you want more support with, please let me know and I can try to articulate that better of how to practice that thing. A lot of us are really empathetic in primary care as clinicians, and so most of us kind of get a sense of what feels safe and what is not feeling safe as a person ourselves, and so we can do the same things intuitively. Anyway, let me know.

But basically what you want to do is make sure when you have conversations that could be potentially sensitive is that you've been thoughtful about how you're going to have this conversation. Is it something that you must communicate over the phone right away, versus is it something that is more appropriate to bring somebody into the office for? Regardless, if you have to communicate it over the phone, always check with the person, "Do you have a moment where we can talk?" Making sure that they are not distracted, in the middle of childcare, they're picking up the phone because they don't want to miss you, that kind of thing. So, "Are you available for a conversation?" if you have to communicate it by phone.

However, I do recommend most sensitive conversations, as we can, either doing a telemedicine visit or an in-person visit. The more sensitive the topic, I typically have patients come in person if and when possible, because we have support systems at the clinic to be able to support an emotional thing for them if they feel like it's really going to be upsetting, potentially, for them. So, that's the first one is S, is setting up.

The thing that I'll add, which just kind of kicks in at the K later as knowledge, I really tie it into the setting up phase, so let's just skip ahead to that a little bit. Setting up also means us as clinicians being prepared. Are we prepared to have a conversation about X diagnosis? Are we prepared to answer questions, for example, about diabetes? When we tell somebody something, are we prepared for the potential questions they may ask us and potential resources going forward? It also ties in later with strategy, but let's hold that thought. So that's setting up, making sure the environment is a safe space, and the person is prepared and you are prepared as a clinician with the information that you need to communicate to that person.

The next one is perception, and I think this is really impactful and can take an extra step that we don't always think about. But one of the pieces is asking where the person is coming from to begin with. That's how I conceptualize perception is ... It can be asked in many different ways, and this is a framework you can Google. I don't own this IP. This is not my intellectual property. I'm just kind of explaining how I use it, but it's kind of like, "Okay, tell me why you think you're here," or, "Tell me what you understand about this visit," or, "Tell me what you understand about X, Y and Z," depending on how much you've communicated, right?

Because for example, if you called somebody on the phone or you had your team member call them on the phone and asked them to make an appointment to review their lab results, did they have a lot of questions at the time or are they asking all their questions now? So you kind of just meet them where that conversation went. "Tell me what you understand about why you're here today." "Okay, I think the medical assistant told me that I'm here to review my lab results." "Awesome," right, and then you can kind of understand where they're coming from and where their knowledge base is. So that's the core piece of perception, right, because you're just kind of setting a foundation of where they're coming from so you can meet them where they're at. Because a lot of times, especially as a newer clinician, you may be tempted to just launch into, "Hey, so you have diabetes," right? Let's hold that thought for a second.

The next one is I, invitation, and so I love this practice. I think that it is so impactful regardless of if you're giving a difficult diagnosis or not, because it's really, really patient-centered. And what this means is, "Is it okay with you if I review your lab results with you today?" And maybe that sounds like a silly question, especially if you've had somebody come in, you've set the scene, there's a safe space, it's quiet, we have full attention. We've asked them why they think they're here today, "I'm here to review my lab results," and then I ask, "Is it okay if I review your lab results?" That might feel really silly. I just want to acknowledge that. And also, it doesn't have to be super robotic. You can kind of get a sense of how it's going with the patient. But the point here is that we're asking permission, and it might sound really silly and feel really silly and really clunky at first, especially if you're newer to this, but it really makes a difference.

I actually did this as an exercise when I was in my grad program where I was the patient and there was a clinician ... as the pretend patient, and my co-student was the clinician practicing reviewing my DXA results with me. And it was like I was there for that quote, unquote, "appointment," that fake appointment for that reason, but just something about being invited and asked permission, it really emphasizes that it's really about them and they're in control. They're in control of their life, they're in control of their bodies, they're in control of their choices, and so it's a really subtle thing. It may feel funny, but it is so impactful. Like I said, regardless of whether or not you review stuff, I always ask permission. "Is it all right if I listen to your heart and lungs now?" "Is it all right if we review our lab results together?" et cetera, et cetera, et cetera, instead of just telling them the thing.

Okay, so the next part is K, right? We've gone through setting up, setting the scene, setting yourself up, perception, what does the patient understand? Invitation, we've asked permission to share something. The next piece is K, which is knowledge. And this is kind of a tie into that in that next step between, "Is it okay if I share these results with you?" The next piece that's not necessarily in this framework but is in other frameworks that I do include on the next piece going into knowledge, because if you just launch into your questions about what they understand about diabetes, it's kind of a spoiler alert. And so for invitation, it's like, "Is it okay if we talk about your lab results?"

The next piece is, "I'm afraid I have some not great news," or some bad news, or a new diagnosis for you. I don't know. I'm still feeling this out myself. I don't necessarily want to label things as good or bad, but I feel like for patients who are not on the clinician's side, to receive a new diagnosis that's not great, it's okay to say, "I have some bad news for you." It's kind of this foreshadowing piece that leads into the knowledge. And so, "I'm afraid I have some bad news for you," and then you can let them know at that point, "Your lab tests are showing that you have diabetes," and then you pause.

I can't underemphasize ... overemphasize, rather, this enough. We so quickly want to launch into the talking and the sharing and the support and the next steps, but it's so important to remember, even if diabetes, for example, is not life-threatening, somebody needs time to absorb that. So, once you've asked their permission, you've ... kind of do some foreshadowing. You let them know you have a new diagnosis, and then you pause and then you kind of see what's going on with the patient before you launch into the next step, which is knowledge, right? Because then you talk about all of this stuff you want to talk about as a clinician, and so you can gauge their reaction.

And keeping in mind, again, this is a bit of a nuanced thing that requires practice, but you can keep in mind the stages of grief. I don't know if that sounds silly to you, but I think that if we can keep those in mind regardless of whatever the thing is in healthcare, whether it's you perceive it to be like, "Oh, this is not a big deal. Diabetes is fine," for that person, maybe their mother died of diabetes very tragically, had some very tragic complications. So you pause, you see how they're doing, remembering that there are stages of grief. Some people go straight into tears. Some people are deer in the headlights. Some people are in denial. Some people are angry, right? You just kind of keep all those things in mind. You pause, you let them have their space to have their feelings. We're not there to control their feelings. We're there to hold space for it, space for all of them.

And then at that point, you can kind of check in and see how they're feeling. And also, this kind of a nuanced thing between the knowledge and the E part, which is the emotions and empathy part, but, "What do you understand? Tell me what your understanding is of diabetes." Not from a quizzing perspective, just "Tell me what you know about diabetes and what your perception is of diabetes, what your thoughts are about that, what your feelings are right now." It's getting a little bit nuanced tying into the emotions. I really like it to be step-by-step, but it really is kind of like a full thing. You see my notes here. I'll have to [inaudible 00:10:58] those up. So, "What do you understand about diabetes?" And then you can talk about those pieces of answering their questions, if they have questions, and you get into more the details about whatever they want to talk about.

One thing I want to start ... What I want to really emphasize here when we get to the actual knowledge piece is when we are in that place, regardless of where they are in their grief reaction, some people are like, "Oh, whatever. That's fine. I suspected that. I had a feeling. I've been worried about it for a while. I had pre-diabetes last year." Right? If somebody's chilling, then you just launch into the knowledge conversation, have a conversation, asking questions, letting them lead, and then thinking about your three main points you want to tell them, right? It's really, really hard, especially as a newer clinician, to just pick three. What are the top three things you want to tell that person? There is so much to say about diabetes, but it's really hard for people to retain information in a visit. And so, what are your three points?

But then the other piece with that, like I said, if they're not chilling with that diabetes diagnosis, they may be in a trauma response. I have an episode about trauma-informed care. I definitely recommend you watching that if you are not savvy with trauma and trauma responses. But when people are in a trauma response, you might not be able to tell. They might just be like, "Okay, mm-hmm." They may seem totally fine. And when we're in that trauma response, that fight or flight response, we're probably not going to retain information anyway, which is further reason why we only pick three main things that we want to communicate when it comes to the knowledge piece.

The other piece about that is when you're asking what they understand, you know what their baseline information is, right? Are they a nurse practitioner themselves? They have a vast knowledge about diabetes because they also work in primary care, right? Or you have somebody who has never heard of diabetes before. Those are all options that you might see. So, once you get into that, and like I said, this is kind of tied together in real life practice, I tend to jump a little bit into the empathy emotions at the same time, if not before, depending on how the person is doing. But definitely, definitely, you want to include at some point expressing empathy for a patient. "I'm really sorry. I'm really sorry to tell you this. I can see you're really upset." "You seem like you're okay right now. Can you tell me about your feelings, like what you're feeling right now?"

This can be very overwhelming for patients. "How are you feeling right now?" Right? Really normalizing, validating, keeping a safe, open space for them to express their feelings, and expressing your own empathy goes an enormously long way for patients.

And then the next step is the S, strategy and summary. This is, we always want to wrap up with a plan. This is true regardless if we're talking about a difficult conversation where we have to give some bad news or regular visits. We want to plan, what is our strategy? After we've expressed emotions, empathy with them, held space for their emotions, validated their feelings, given our kind of maximum three points of teaching, assess where their knowledge is, where are we going to go?

Because this really, again, it all kind of ties together, because it's like, "You know what? It's really, really hard, but I want you to know we are here for you. I am here for you. The whole team is here for you. We have many people on the team here to support you, take care of you, help you through these next steps, and come up with a plan that works for you and your life." And we also add that summary piece of like, "Okay, so this is where we're at. We have a new diagnosis of diabetes. There's a couple things that we're going to want to do. And this is not a sprint, this is a marathon, and we are going to come up with some concrete steps. We have a whole team to take care of you. Here's what we're going to do next, 1, 2, 3."

And then the other thing to keep in mind that's so important is to think about, can you give additional learning tools for that patient? Some people are auditory learners, some people are visual learners, some people are kinesthetic learners, and so even though we've held space for that conversation, it's a lot. And so, what are the other supplemental things we can bring for a person? Do we have a written summary that they can bring home? Do we have a plan for a follow-up call? Check in with your nurse, for example, to see how they're feeling in terms of the emotional place, just checking in with them. Do we have a community health worker? Do we have a diabetes educator? What are those next pieces, and how can you support that person in their next steps?

You might have a couple reactions to that, right? Number one, you could be like, "Wow, I'm doing a really good job. I do all of that stuff just intuitively." In which case, power to you, my friend. Thank you so much for taking such good care of your patients. If you are not there yet, there's no shame in that either, right? There's always opportunities for improvement, and there's always opportunities to deepen our practice. And really, I was talking about this on my interview with Megan Kavanaugh a couple weeks ago, last week, whenever that was. And we were talking about how the first couple years of practice, months, to that three-year mark is what I always say, that kind of level of real competency, confidence place, you are really focused on safety. Then as you develop in your practice, you get to do more and more things to give more deeper, holistic patient-centered care and develop your skills, right? Because this is a skill. This is not something you hear once and then you're like, "Okay, I'm good."

I've practiced this and I've practiced this and I practice this, and it's also normalize and validate that this is not so easy. It can be scary. It takes a lot of confidence and it can feel very clunky at first, and so the most important thing is that we just try. We let it be messy. We let it be weird. We let it be awkward and clunky, right? If we have tears, tears are okay. I've had tears with patients when I talk about a very hard conversation or a hard diagnosis. I think the one kind of pearl there is just keeping in mind, do we have tears because of our own stuff? Is it a thing where we're kind of bringing our own stuff in there versus we're being there with that patient in those emotions with them? And it depends.

Some patients, it's appropriate to give them hugs. Again, going into that trauma-informed care episode, please, please, please watch that. It might not be on the top of your radar, but it is so important. I always ask permission, "What do you need right now? Can I give you ..." Depending on the rapport with the patient, "Can I give you a hug? Can we call a family member?" Or if the family member is in the room, right, that might be a good idea for the setting-up piece if it's a really difficult diagnosis, right? But, yeah.

Hopefully this episode was helpful. I would love to keep talking about these types of ... I really consider this in the category of leadership and confidence. And really, through Real World NP, I want to talk about the clinical topics. I want to talk about navigating the healthcare system, all those different bits and pieces we got to learn on the job, like procedures and billing and coding and how to order stuff. I also want to talk about this huge role transition, which I really see as personal development and leadership, and really, this is such a leadership type of topic. It takes a lot of courage, a lot of practice, and so I really applaud you for being willing to even listen to this episode and consider practicing. Your patients will absolutely benefit from it, so thank you so much.

If there are other topics in this kind of leadership space you want more information about or anything like that, please let us know. If you haven't grabbed the Ultimate Resource Guide for the New NP, head over to You'll get these episodes sent straight to your inbox every week with notes from me, patient stories, and other special bonuses I really don't share anywhere else. Thank you so much for watching. Hang in there. I'll see you soon.