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Integrating Patient- and Family-Centered Care Principles into a Simulation-Based Curriculum: Dartmouth-Hitchcock Medical Center
1. Effective Patient
Communication
Module 2: Sharing Bad News
Module development supported by a grant from the
Picker Institute / Gold Foundation 2010 Challenge Grant
2. Learning Objectives
Define bad news
Demonstrate use of the SPIKES model when
sharing bad news with the patient
During the patient encounter, attend to the major
emotional components of sharing bad news,
especially expressions of fear, anger, sadness,
denial, and guilt
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3. Expected Outcomes
Recognize challenges and supports to effectively
sharing bad news with the patient & family
Demonstrate the SPIKES model communication
strategy when sharing bad news with the patient &
family
Demonstrate empathy when sharing bad news
with the patient
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4. The Task of Breaking Bad News
“If we do it badly, the patients or
family members may never
forgive us; if we do it well, they
may never forget us.”(Buckman, 1992)
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5. What is Bad News?
Information that
negatively alters
the patient’s
view of the
future
(Buckman, 1992) (Tissot, 1872)
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6. Challenges
Lack of:
Guidelines
Training
Experience
Good role models
Concerns of:
The provider
(Siegmund, 2008) The patient & family
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7. Supporting Patient & Provider
Patient & Family are supported by:
Being included in conversations & planning
Being treated as care partners
Provider is supported by:
Training & Practicing good communication skills
Learning ways to effectively cope with emotionally
charged issues
Having another person available who knows the patient
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8. SPIKES Model: The Six Steps
Setting
Perception
Invitation
Knowledge
Emotions
Strategy & Summary
Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A Six-Step Protocol for Delivering Bad News:
Application to the Patient with Cancer. The Oncologist, 5, 302-311; 2000. SPIKES mnemonic used with permission.
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9. Setting the Environment
Provide privacy
Introduce self
Determine who else should be present
Ensure no interruptions
Provide comfortable space
Create welcoming environment
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10. Perception
Prepare before
speaking
Ask about patient’s
perception of what is
going on
(Renoir/ Bjoertvedt, 2010)
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11. Invitation
Ask questions to invite
the patient into
conversation
Ask how much
information the
patient wants to hear
(Pissarro, 1881)
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12. Knowledge
Deliver the message
Use plain language
Be mindful of body language
Get to the point
Give information in small chunks
Pause
Wait for reaction
Use “teach back” to verify that message was
received
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13. Emotions and Empathy
Be prepared for patient’s and family’s emotional
response
Anticipate fear, anger, sadness, denial, guilt
Be mindful of your own response
Comfort the patient
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14. Strategy and Summary
Assess patient’s readiness for planning
Negotiate next steps
Verify support structure
Acknowledge & answer questions
Summarize plan
Use “teach back” technique
Follow-up
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16. Discussion of the Video
How well did the doctor handle the situation?
What worked well?
What could have been handled better?
Have you experienced a scene like the one shown?
What was your role?
Describe the encounter
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19. References
American Academy on Communication in Healthcare (AACH). Enhancing Communication Skills.
http://www.aachonline.org/?page=EnhanceCommSkills. Accessed October 20, 2010.
Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A Six-Step Protocol for Delivering Bad News:
Application to the Patient with Cancer. The Oncologist, 5, 302-311; 2000.
Bjoertvedt. File: Auguste Renoir Conversation.JPG. National Museum Stockholm; 2008. Wikimedia Commons.
http://commons.wikimedia.org/wiki/File:Auguste_Renoir_Conversation.JPG. Accessed December 6, 2010.
Boyle WE, Colacchio TA. Patient and Family Centered Care at Dartmouth-Hitchcock. [DVD]. Lebanon, NH: Dartmouth-
Hitchcock Media Services; 2010.
Bub B. Communication Skills That Heal. United Kingdom: Radcliffe Publishing Ltd; 2006.
Buckman R. How to Break Bad News: A Guide for Health Care Professionals. Baltimore, MD: The Johns Hopkins University
Press; 1992.
Buckman R. Talking to Patients About Cancer. BMJ, 313, 699-700; 1996.
Coulehan JH, Block MR. The Medical Interview, Mastering Skills for Clinical Practice. 5th ed. Philadelphia, PA: F.A. Davis
Company; 2006.
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20. File: James Tissot-Bad News.jpg. National Museum Cardiff; 1872. Wikimedia Commons.
http://commons.wikimedia.org/wiki/File:James_Tissot_-_Bad_News.jpg. Accessed December 6, 2010.
File:Pissarro Conversation.jpg. Tokyo: The National Museum of Western Art; 1881. Wikimedia Commons
http://commons.wikimedia.org/wiki/File:Pissarro_Conversation.jpg.. Accessed December 6, 2010.
Frampton S, Guastello S, Brady C, Hale M, Horowitz S, Smith SB, Stone S. Patient-Centered Care Improvement Guide. Picker
Institute; 2008. http://pickerinstitute.org/wp-content/uploads/2010/06/pcc_improvement_guide.pdf. Accessed October 29,
2010.
Henry Ford Health System Department of Medical Education. Sharing Bad News. [DVD]. Detroit, MI: Henry Ford Health
System; 2009.
Lloyd M, Bor R. Communication Skills for Medicine. 3rd ed. London: Elsevier; 2009.
Mahmud A. File: Serious Discussion image by Ashfaq.JPG. Dhaka University Institute of Fine Arts; 2008. Wikimedia Commons.
http://commons.wikimedia.org/wiki/File:Serious_Discussion_image_by_Ashfaq.JPG. Accessed December 6, 2010.
Rider EA, Nawotniak RH, Smith G. A Practical Guide to Teaching and Assessing the ACGME Core Competencies.
Marblehead, MA: HCPro, Inc; 2007.
Siegmund W. File: Mount Rainier 5839.JPG. 2008. Wikimedia Commons.
http://commons.wikimedia.org/wiki/File:Mount_Rainier_5839.JPG. Accessed December 6, 2010.
Weiss BD. (2007). Removing Barriers to Better, Safer Care, Health Literacy and Patient Safety: Help Patients Understand,
Manual for Clinicians. 2nd ed. American Medical Association Foundation and American Medical Association.
http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf. Accessed December 15, 2009.
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