1. Spikes protocol for breaking bad news
• Empowers patients by allowing them a
greater say in treatment.
What is bad news? Dr. P. Galappaththy
• Any news that seriously and adversely
changes the patient’s views of his/her How to deliver sensitive information effectively?
future. • By being prepared.
• There is a gap between the patients o Consider what needs to be told.
expectations and reality of the patient’s o Ensure adequate and correct information.
medical condition. o Have answers ready for common
• The task is to close this gap. questions. eg:
• Usually applies to situations where there is ;  Treatment options and availability.
o a feeling of no hope.  Costs
o a threat to an individual’s physical and  Prognosis
mental wellbeing.  How long have I got doctor?
o a risk of upsetting an established life  Can it be cured?
style. • Follow a protocol
o a message given which implies a person eg: SPIKES protocol
has fewer choices.
SPIKES protocol
Examples of medical conditions which could be a
bad news S – Setting
• Life threatening illness. • Where to break news.
eg: Cancer, HIV eg: A quiet room preferably not during
• Degenerative conditions. ward round.
eg: Alzheimer dementia • By appointment.
• Chronis illness eg: After ward round, at 3p.m.
eg: Rheumatoid arthritis, Systemic lupus • Ask whether prefers to have relatives. (or in
erythematosus Sri Lanka perhaps first speak to relatives)
• Mental retardation in children • Physical context of interview.
eg: Downs syndrome, Cerebral palsy eg: Sitting down, body language, eye
contact
• Introduce your self and ascertain how
Breaking bad news others are related to the patient.
• Forms part of clinical practice. • Listening skills – open questions to start, do
• A skill that can be taught and improved. not interrupt.
• Patients and relatives appreciate it.
• The degree to which news is bad depends P – Perception of condition/seriousness
on the gap between reality and patient’s • Ask what he already knows about the
perception. medical condition or what he suspects.
• Listen to level of comprehensions.
• Accept denial but do not confront at this
Benefits of learning to break bad news skillfully stage.
• Better psychological adjustment by patient.
• Reduces stress in doctors. I – Invitation from the patient to give information
• Facilitates open discussion among patients, • Ask patient if s/he wishes to know the
relatives and doctors. details of the medical condition and/or
treatment.
• Accept patient’s right not to know.

2. • Offer to answer questions later if s/he • After a few moments you should continue
wishes. talking even if patient continue to cry.
K – Knowledge: giving medical facts
• Use language intelligible to patient. 2. If patient becomes angry
• Give to patient’s level – Consider • Defensive or irritation with patient are
educational level, socio-cultural unhelpful.
background, current emotional state • Acknowledge patient’s position and avoid
• In small chunks talking about it.
• Check whether patient understood what
you said. 3. If the patient refuses to accept the diagnosis
• Respond to patients reactions as they • Explore reasons for patient’s denial.
occur. • Do not be combative.
• Give any positive aspects first. • Appreciate that there is an information gap
eg: Cancer has not spread to lymph nodes, and try to educate the patient.
highly responsive to therapy, treatment • Check that patient has a clear
available locally etc. understanding of the problem.
• Give facts accurately about treatment • Empathize with patient.
options, prognosis, costs etc. • Get family members involved if
appropriate.
• Give time to adjust to new information.
E - Explore emotions and sympathize
• Empathetic response Discussing prognosis
1. Identify emotion. • Identify patient’s concerns.
2. Identify cause/source of emotion. • Be realistic
3. Respond in a way that you have recognized • Avoid giving specific times of survival – can
connection between 1 and 2. say years, months.
4. In empathetic response not necessary for • Provide examples for what patient can
you to feel same emotion or agree to reasonably hope.
patient’s view point. • Eg :- Pain free, Symptom control
Common pitfalls
• Inadequate time / information.
S – Strategy and summary • Failure to elicit patient’s understanding of
• Close the interview. situation.
• Ask whether they want to clarify something • Giving news at doctor’s speed.
else. • Not allowing time for responses.
• Offer agenda for the next meeting. • False reassurances about the future.
eg: I will speak to you again when we have • Allowing denial to remain.
the opinion of cancer specialist. • Removing all hope.
Sri Lankan context
• Does breaking bad news happening
Response to reaction
appropriately in Sri Lanka?
1. If patient begins to cry
• If it is not happening what are the reasons?
• Allow sometime to cry.
• Is it needed?
• Could say, “I can see you are very upset”
• What modifications would be needed to
• Could touch the patient appropriately.
suit our socio- cultural background?

3. • Can we do it?
• Would you do it?