Humans in Healthcare: Chapter #10

Hi there!

I hope you’ve had a great week since we met in your inbox last Sunday.

I’ve had a full one — celebrating my son’s 6th birthday yesterday by taking his friends to the movie theatre to watch the new Ninja Turtles movie. My 90’s kid heart always feels satisfied when I create new experiences that bridge the past to the present, with my son. Something about green ooze never gets old!

How are you doing?

Today, I’m sharing the first chapter in the 🗄️Resources for Humans (in healthcare) series.

While this series is being defined in real time, the intention is to share something practical, tactical, or actionable to use in your healthcare experience. Stay tuned for future chapters in this series, including:

• a framework from a pharmacist on challenging the inner critic and imposter in all of us

• tips from a physical therapist turned healthcare recruiter for how to set yourself up for success when looking for non traditional roles as a clinician

• a reverse engineering experiment in the healthcare hiring process

• and much, much more!

👀 Do you have a resource for humans (in healthcare) that you want eyes on? Let me know by completing this form. I’d love to support your mission.

📖 And now for the feature chapter

In light of the last chapter theme of giving and receiving difficult news, I am breaking down a helpful resource on how to do that, sparked by a conversation with my friend, Dr. Michael O’Brien (please check out his newsletter, Clinician Creative!)

This is the evidence-based SPIKES Protocol: A six-step stepwise framework for delivering bad news to patients.

History of the SPIKES Protocol

The SPIKES protocol was developed and officially published in early 2000 by three oncologists: Dr. Robert Buckman of Toronto-Sunnybrook Regional Cancer Centre, Dr. Michael Levy of the Fox Chase Cancer Center, and Dr. Watler Baile of the MD Anderson Cancer Center. It was born out of a rising need to up skill clinicians in how to discuss bad news with patients.

Prior to this, data from surveyed physicians showed that many considered it a disservice to disclose bad news about a diagnosis to the patient. At that time, less robust diagnostics and treatment options were available, so less discussion regarding treatment planning was required.

With the rise of treatment advances, came the rise of more hope — and more complexity in the course of care. Subsequently, physicians were finding the challenges of sharing a wide array of information with patients about their course, including discussions like possibilities of cancer recurrence, spread of disease, failure of treatment, increasing side effects of medication, and discussion of end of life care.

Leading up to the publication of the protocol, the authors surveyed 700 oncologists in an attempt to understand the reasons why it is difficult to break bad news to patients. Participants cited the following reasons:

• How to be honest with the patient and not destroy hope (55%)

• Dealing with patient’s emotions (25%)

• Finding the right amount of time (10%)

Less than 10% said they had formal training in breaking bad news.

So, in an attempt to create an evidence based framework, the SPIKES protocol was developed.

Goals of the Bad News Interview

According to authors, the process of disclosing bad news attempts to achieve 4 goals:

1. Gather information from the patient to help inform the patient's readiness to receive information

2. Provide information in accordance with the patient's needs and desires

3. Support the patient by reducing the emotional impact of experiencing bad or life-changing news

4. Develop a strategy in the form of next steps and treatment plan, in conjunction with the patient’s desires and wishes

Though not every experience of breaking bad news will require all of the steps, meeting these goals will be accomplished by following the stepwise process below.

The six-step framework of the SPIKES protocol

SETTING

Setting and holding the space - for yourself and the patient

Most clinicians prepare for their visits with patients, and this type of visit is no different. Preparation is key to ensure you are meeting the patient where they need to be met. The protocol specifically addresses creating the right space for the patient, but I would also suggest preparing the space for yourself as the deliverer of the news. Take a pause, a breath, find a moment of peace in your mind before you enter the room. This goes a long way in holding the space for them.

It’s not always possible for complete quiet or privacy depending on the setting, but do your best to find a quiet space for you and the patient.

Get to their level. Don’t stand if they aren’t standing — instead sit. Sit with them, sit by them. This eliminates a barrier between you and the patient.

If the patient is comfortable with touch and eye contact, little gestures go a long way in showing you are human. Some will not want this; respect it.

PERCEPTION

Uncovering and discovering before solving

“Before you tell, ask” is the phrase used in the framework. We all make assumptions in our daily interactions, but when breaking difficult news, it’s best to pause before you start the conversation and get a sense for what the patient already knows. This helps both you and the patient in a few ways. You can tailor the level of information to their understanding, help clarify previous misinformation, or add context or correction to missing details or expectations of what has or is to come.

INVITATION

An invitation to tell

While most do, not all patients want to know every detail about the diagnosis, prognosis, or course of illness. It can be overwhelming to receive a life changing diagnosis in one sitting, so it’s valid if a patient does not want to hear all of it right now. Asking how they want to receive the information and how much of it they want to receive today can help guide the conversation and inform future ones. It’s ok to pull family or friends into the conversation with permission of the patient. Importantly, a life changing diagnosis doesn’t just change the patient’s life — often, it can change their family’s life as well.

KNOWLEDGE

Explain in plain language

This step is when you give knowledge and information to the patient including that you are going to be delivering bad news. Simply starting the conversation with that phrase, “I’m sorry to tell you that”…or “Unfortunately, I have some bad news”… can help reduce the shock of it somewhat.

As medical providers, we tend to forget to drop our medical lingo at the door, but here, it’s very important to remember who is in front of you. If they are non medical, using medical lingo may only disconnect them from the actual conversation. A word like ‘metastasize’ is probably better explained as ‘spread’. Be mindful of your words.

EMOTION

Empathy, empathy, empathy. Instead of reacting, observe, and then respond.

Maybe you haven’t ever received a life changing diagnosis yourself, but I can imagine we’ve all had periods in our life of significant emotional turmoil. So while you may not know exactly what that patient is experiencing, you can empathize through shared emotional experiences.

Remember that patients will react in a way that is authentic to them. Some my express shock, others sadness, others disbelief or denial, others, silence. Emotions are valid and we shouldn’t judge or react, only first observe, then respond.

You may need to spend the majority of the visit sitting in the space of emotion with your patient. The reason you should is that patients may not be able to absorb anything further until they do. This is a snapshot in time for you, but a life changing moment in time for them. Honor them where they are.

The response guide below provides some helpful suggestions and empathetic responses that can inform and guide the conversation.

STRATEGY AND SUMMARY

Next steps - one, some, or many

Per the authors, patients who have a clear plan for the future are less likely to feel anxious and uncertain. However, it is important to ask patients if they are ready for such a discussion. They may need to pause and absorb the shock of the news first.

The patient as a shared decision maker is important as is keeping their goals and wishes at the center. It’s not about you. It is about them.

The most challenging part of this conversation may be sharing prognosis and treatment options, especially if they are unfavorable. The balance of reality and hope is a fine line and difficult one. Additionally, the anticipation of how the patient may react on the other side of the conversation can be challenging. It’s normal to experience discomfort here - you are human after all. This is where I gently suggest to lean into your discomfort and let the patient help guide you.

Many patients may have an idea about the seriousness of their illness, but don’t know how to approach it. You can start the discussion first by accomplishing step 2 (knowledge) and gear the conversation toward their understanding.

Level set expectations. If there isn’t a cure, there isn’t one. Be honest about what can be accomplished, even if not curative. Quality of life matters. Many of the patient’s fears and concerns will reveal themselves through this process, so lean into active listening here. If a patient is upset, remember that in most cases, it’s not you they are upset at — rather, the news itself.

Per the authors, “understanding the important specific goals that many patients have, such as symptom control, and making sure that they receive the best possible treatment and continuity of care will allow you to frame hope in terms of what it is possible to accomplish”.

Recap

While oncologists developed this protocol, it’s useful in every focus of healthcare. Many healthcare professionals will likely find themselves in a situation where they have to deliver bad news. It may not be a cancer diagnosis, but a prognosis, update, or life change. The same process can apply.

I found this article discussing the use of the SPIKES protocol in the ER very informative. In the ER, a healthcare professional may not have a previous relationship with the patient, which can make delivering news even more challenging. Give it a read if you have the time.

Thanks for reading! Please check out the downloadable resources below and share with your colleagues if helpful!

📌 Next week, I’m sharing another chapter in the Dose of Humanity 💜 series about a Gen Z’s 6-year journey toward a life-changing diagnosis and how she’s using it to transform healthcare.

In humanity,

Amy

🗄️ Resources for Humans (in healthcare)

Download the guides or click on them to reference the link version!

🔗 links referenced in this chapter in chronological order of appearance:

• Humans in Healthcare: off book chapters

• Humans in Healthcare: Chapter #9

• Conversation that sparked this resource share

• Dr. Michael O’Brien and his newsletter, Clinician Creative

• The SPIKES Protocol

• SPIKES Protocol in the ER

• SPIKES Protocol Resource link

• Response guide link