THE SIX STEPS OF SPIKES

STEP 1: S—SETTING UP the Interview

Mental rehearsal is a useful way for preparing for stressful tasks. This can be
accomplished by reviewing the plan for telling the patient and how one will respond
to patients' emotional reactions or difficult questions. As the messenger of bad
news, one should expect to have negative feelings and to feel frustration or
responsibility [55]. It is helpful to be reminded that, although bad news may be very
sad for the patients, the information may be important in allowing them to plan for
the future.

Sometimes the physical setting causes interviews about sensitive topics to flounder.
Unless there is a semblance of privacy and the setting is conducive to undistracted
and focused discussion, the goals of the interview may not be met. Some helpful
guidelines:

 Arrange for some privacy. An interview room is ideal, but, if one is not
available, draw the curtains around the patient's bed. Have tissues ready
in case the patient becomes upset.
 Involve significant others. Most patients want to have someone else with
them but this should be the patient's choice. When there are many
family members, ask the patient to choose one or two family
representatives.
 Sit down. Sitting down relaxes the patient and is also a sign that you will
not rush. When you sit, try not to have barriers between you and the
patient. If you have recently examined the patient, allow them to dress
before the discussion.
 Make connection with the patient. Maintaining eye contact may be
uncomfortable but it is an important way of establishing rapport.
Touching the patient on the arm or holding a hand (if the patient is
comfortable with this) is another way to accomplish this.
 Manage time constraints and interruptions. Inform the patient of any time
constraints you may have or interruptions you expect. Set your pager on
silent or ask a colleague to respond to your pages.
Previous SectionNext Section
STEP 2: P—ASSESSING THE PATIENT'S PERCEPTION
Steps 2 and 3 of SPIKES are points in the interview where you implement the axiom
“before you tell, ask.” That is, before discussing the medical findings, the clinician
uses open-ended questions to create a reasonably accurate picture of how the
patient perceives the medical situation—what it is and whether it is serious or not.
For example, “What have you been told about your medical situation so far?” or
“What is your understanding of the reasons we did the MRI?”. Based on this
information you can correct misinformation and tailor the bad news to what the
patient understands. It can also accomplish the important task of determining if the
patient is engaging in any variation of illness denial: wishful thinking, omission of
essential but unfavorable medical details of the illness, or unrealistic expectations
of treatment [56].
Previous SectionNext Section
STEP 3: I—OBTAINING THE PATIENT'S INVITATION
While a majority of patients express a desire for full information about their
diagnosis, prognosis, and details of their illness, some patients do not. When a
clinician hears a patient express explicitly a desire for information, it may lessen the
anxiety associated with divulging the bad news [57]. However, shunning
information is a valid psychological coping mechanism [58, 59] and may be more
likely to be manifested as the illness becomes more severe [60]. Discussing
information disclosure at the time of ordering tests can cue the physician to plan
the next discussion with the patient. Examples of questions asked the patient would
be, “How would you like me to give the information about the test results? Would
you like me to give you all the information or sketch out the results and spend more
time discussing the treatment plan?”. If patients do not want to know details, offer
to answer any questions they may have in the future or to talk to a relative or
friend.
Previous SectionNext Section
STEP 4: K—GIVING KNOWLEDGE AND INFORMATION TO THEPATIENT
Warning the patient that bad news is coming may lessen the shock that can follow
the disclosure of bad news [32] and may facilitate information processing [61].
Examples of phrases that can be used include, “Unfortunately I've got some bad
news to tell you” or “I'm sorry to tell you that…”.
Giving medical facts, the one-way part of the physician-patient dialogue, may be
improved by a few simple guidelines. First, start at the level of comprehension and
vocabulary of the patient. Second, try to use nontechnical words such as “spread”
instead of “metastasized” and “sample of tissue” instead of “biopsy.” Third, avoid
excessive bluntness (e.g., “You have very bad cancer and unless you get treatment
immediately you are going to die.”) as it is likely to leave the patient isolated and
later angry, with a tendency to blame the messenger of the bad news [4, 32, 61].
Fourth, give information in small chunks and check periodically as to the patient's
understanding. Fifth, when the prognosis is poor, avoid using phrases such as
“There is nothing more we can do for you.” This attitude is inconsistent with the fact
that patients often have other important therapeutic goals such as good pain
control and symptom relief [35, 62].
Previous SectionNext Section
STEP 5: E—ADDRESSING
THE PATIENT'S EMOTIONS WITHEMPATHIC RESPONSES
Responding to the patient's emotions is one of the most difficult challenges of
breaking bad news [3, 13]. Patients' emotional reactions may vary from silence to
disbelief, crying, denial, or anger.
When patients get bad news their emotional reaction is often an expression of
shock, isolation, and grief. In this situation the physician can offer support and
solidarity to the patient by making an empathic response. An empathic response
consists of four steps [3]:

 First, observe for any emotion on the part of the patient. This may be
tearfulness, a look of sadness, silence, or shock.

 Second, identify the emotion experienced by the patient by naming it to

oneself. If a patient appears sad but is silent, use open questions to
query the patient as to what they are thinking or feeling.
  Third, identify the reason for the emotion. This is usually connected to the
bad news. However, if you are not sure, again, ask the patient.

 Fourth, after you have given the patient a brief period of time to express
his or her feelings, let the patient know that you have connected the
emotion with the reason for the emotion by making a connecting
statement. An example:

1. Doctor: I'm sorry to say that the x-ray shows that the chemotherapy
doesn't seem to be working [pause]. Unfortunately, the tumor has grown
somewhat.
2. Patient: I've been afraid of this! [Cries]
3. Doctor: [Moves his chair closer, offers the patient a tissue, and pauses.] I
know that this isn't what you wanted to hear. I wish the news were
better.
In the above dialogue, the physician observed the patient crying and realized that
the patient was tearful because of the bad news. He moved closer to the patient. At
this point he might have also touched the patient's arm or hand if they were both
comfortable and paused a moment to allow her to get her composure. He let the
patient know that he understood why she was upset by making a statement that
reflected his understanding. Other examples of empathic responses can be seen in
Table 2⇓.
View this table:
 In this window

 In a new window

Table 2.

Examples of empathic, exploratory, and validating responses

Until an emotion is cleared, it will be difficult to go on to discuss other issues. If the

emotion does not diminish shortly, it is helpful to continue to make empathic
responses until the patient becomes calm. Clinicians can also use empathic
responses to acknowledge their own sadness or other emotions (“I also wish the
news were better”). It can be a show of support to follow the empathic response
with a validating statement, which lets the patient know that their feelings are
legitimate (Table 3⇓).
View this table:
 In this window

 In a new window

Table 3.

Changes in confidence levels among participants in workshops on communicating

bad news

Again, when emotions are not clearly expressed, such as when the patient is silent,
the physician should ask an exploratory question before he makes an empathic
response. When emotions are subtle or indirectly expressed or disguised as in thinly
veiled disappointment or anger (“I guess this means I'll have to suffer through
chemotherapy again”) you can still use an empathic response (“I can see that this is
upsetting news for you”). Patients regard their oncologist as one of their most
important sources of psychological support [63], and combining empathic,
exploratory, and validating statements is one of the most powerful ways of
providing that support [64-66] (Table 2⇑). It reduces the patient's isolation,
expresses solidarity, and validates the patient's feelings or thoughts as normal and
to be expected [67].
Previous SectionNext Section
STEP 6: S—STRATEGY AND SUMMARY
Patients who have a clear plan for the future are less likely to feel anxious and
uncertain. Before discussing a treatment plan, it is important to ask patients if they
are ready at that time for such a discussion. Presenting treatment options to
patients when they are available is not only a legal mandate in some cases [68], but
it will establish the perception that the physician regards their wishes as important.
Sharing responsibility for decision-making with the patient may also reduce any
sense of failure on the part of the physician when treatment is not successful.
Checking the patient's misunderstanding of the discussion can prevent the
documented tendency of patients to overestimate the efficacy or misunderstand the
purpose of treatment [7-9, 57].
Clinicians are often very uncomfortable when they must discuss prognosis and
treatment options with the patient, if the information is unfavorable. Based on our
own observations and those of others [1, 5, 6, 10, 44-46], we believe that the
discomfort is based on a number of concerns that physicians experience. These
include uncertainty about the patient's expectations, fear of destroying the patient's
hope, fear of their own inadequacy in the face of uncontrollable disease, not feeling
prepared to manage the patient's anticipated emotional reactions, and sometimes
embarrassment at having previously painted too optimistic a picture for the patient.

These difficult discussions can be greatly facilitated by using several strategies.

First, many patients already have some idea of the seriousness of their illness and
of the limitations of treatment but are afraid to bring it up or ask about outcomes.
Exploring the patient's knowledge, expectations, and hopes (step 2 of SPIKES) will
allow the physician to understand where the patient is and to start the discussion
from that point. When patients have unrealistic expectations (e.g., “They told me
that you work miracles.”), asking the patient to describe the history of the illness
will usually reveal fears, concerns, and emotions that lie behind the expectation.
Patients may see cure as a global solution to several different problems that are
significant for them. These may include loss of a job, inability to care for the family,
pain and suffering, hardship on others, or impaired mobility. Expressing these fears
and concerns will often allow the patient to acknowledge the seriousness of their
condition. If patients become emotionally upset in discussing their concerns, it
would be appropriate to use the strategies outlined in step 5 of SPIKES. Second,
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 the physician to frame hope in terms of what it is
possible to accomplish. This can be very reassuring to patients.