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Handbook of Palliative Medicine

Communication & Breaking Bad News

A vital component of caring for patients with life-limiting and terminal illnesses is communication. The ability to both impart and hear information enables us to develop a therapeutic relationship which will support our patients in their individualised care; empowering them to have the experiences they want. One population communication model is SPIKES

  1. Setting

    • Invite important people
    • Minimise noise
    • Sit comfortably
    • Allow enough time

  2. Perception

    • What do they know so far?
    • What do they think you might tell them?

  3. Invitation or Information

    • Break it down into sections
    • Give it a little at a time

  4. Knowledge

    • Be direct
    • Use clear language
    • Check understanding

  5. Empathy

    • Active listening
    • Indentify key emotions
    • Respond where you can
    • Accept uncertainty

  6. Summary

    • List key points covered
    • Reiterate plan
    • Recheck understanding

Key areas to focus on when communicating

  • Location and environment
  • Explore patients own understanding
  • Active listening
  • Use of plain language and avoiding jargon
  • Using a combination of open and closed questions
  • Reflecting and summarising the conversation to check understanding
  • Non-verbal communication: for example patients will overestimate the time you spent with them if you were sitting, whereas they underestimate the time spent if you remain standing throughout
  • Use of silence
  • Empathy
  • Answer questions which you can, arrange follow up to answer the ones you cannot
  • Be prepared for negative emotions and responses and allow time for information processing.
  • Accept and acknowledge the difficulties of uncertainty: “I can see this uncertainty is not easy for you” “Although I cannot predict this accurately for you, I can make a best guess given my knowledge of other people with similar conditions” “We may never know the answer to that, can you think of ways we could answer other questions to ease the difficulty of this uncertainty?”

One potential negative response is denial; a basic coping mechanism which can help some people continue to function in the face of difficult information or events. Patients and families exhibiting denial is not therefore necessarily an unhealthy response; indeed, it is frequently simply the first stage of accepting bad news.

Collusion refers to situations where family members and/or professionals intentionally withhold information from a patient. Collusion is often well intentioned, wishing to protect the patient from distress, but can lead to tension between patient and carers; ethically and legally the patient has the right to information and to authorise disclosure, or not, of that information to family. Collusion also risks removing autonomy from the patient, restricting their ability to make important decisions.

We may need to challenge and explore denial and collusion, especially where it has created potentially harmful situations, such as preventing appropriate treatment, adequate symptom control, future planning and preferred place of care or financial support for dependents.