Station 4: Breaking Bad News
Breaking bad news is a very common PACES station. There are many mnemonics used to remember how to stage these delicate discussions such as SPIKES.
SPIKES stands for:
S: Setting and listening skills
P: Patients Perception
I: Invitation
K: Knowledge
E: Explore emotions and empathise
S: Strategy and summary
Setting and listening skills:
Ensure a private space (obviously you don’t need to worry about this in the PACES exam)
Demonstrate good listening skills, this includes using:
Open body language; which involves leaning forward to look interested and avoiding negative body language like crossing your arms
Active Listening: such as nodding along to the patient and remain good eye contact
Patients Perception:
What do they already know?
Ask them to explain what has happened until this point, help them if necessary.
Invitation:
Ask the patient what they would like to know.
Some patients don’t want to know a bad diagnosis and just want the doctor to treat them in the best way. To ensure this is being thought of, asking if the patient wants to know highlights to the examiner that you understand this.
Ask if they want anyone else to be here, for the discussion such as a family member.
Knowledge:
Give the news in small chunks. Often helps to tell as a story. You had these set of symptoms so we did these set of investigations and these investigations have unfortunately showed ‘XYZ’.
It is important to give a warning shot to the bad news such as saying ‘ unfortunately it isn’t good news’.
On the specifics of the bad news, you have to be clear. If it is cancer you need to say the word cancer and not a tumour, mass or lesion as a lot of patients may not understand what is meant by this. You could use those descriptors as a warning shot but then go on to use the word cancer.
Explore Emotions and empathise:
Allow a pause after breaking the bad news. They need time for the bad news to sink in!
Then empathetically ask how they are feeling, for example: ‘I know I have just given you some awful news, how are you feeling?’
Then go on to tell them about where we go from here.
Strategy and Summary
This is important and often not done well as people feel they have broken the news now and the major issue from the doctor’s perspective is dealt with. But for the patient this is what they want to know. What is going to happen, what treatment is available, will they die?
Talk through the next steps, this may be given to you in the station or you can give a generic explanation. It may be that an MDT is needed before treatment or that you need specialist input.
It is important that the patient knows that they are not alone in this (even if they have no friends or family, there are supportive healthcare workers, Macmillan nurses and other patients that are going through a similar problem and as such there are support groups)
They need a plan even if it is that an MDT is needed to know where we go from here.
Even if you don’t know what the plan is let them know that.
In the station say you will ask a nurse to come sit with the patient.
If you know of support groups tell them about them!
General Tips:
It is important to practice breaking bad news with your colleagues. This is a simulated session and as such empathy may not come naturally to all, as it is not real. As such you need to get good at acting empathy for these stations. If you find this difficult then try recording a video of you simulating breaking bad news to a friend whom is playing the actor, as this may help you to see if you are demonstrating the correct body language and tone needed and providing enough pauses for the scenario.
Don’t take too long to break the bad news. The patient will have more questions and as this is a common station there may likely be another ethical issue in with the station that may need addressing. You should aim to have broken the bad news 2-3 minutes into the consultation.
Don’t finish too early. Once again this comes down to practising the stations with a colleague using a timer. After a while you will get a feel for how long you have left. I used to use a stopwatch attached to my belt facing upwards. I would start this at the beginning of the station. That way with just one glance, which isn’t too obvious, I could know how much time had passed.
Written by Dr Thomas Craven
Resources used to write this document are listed in the references section of this webpage.