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Strategies for breaking bad news to patients with cancer: as seen in the Clinical Journal of Oncology Nursing.

Telling a patient bad news is never easy. Whether sharing information about an initial cancer diagnosis, disease recurrence, evidence of metastatic disease, or a move to hospice care, the healthcare team needs to be sure patients are prepared for the news and understand what it means for them. In the August 2010 Supportive Care department in the Clinical Journal of Oncology Nursing, Kaplan describes two step-by-step methods that will help oncology nurses deliver bad news to patients and respond to patients' emotions upon hearing that news.


SPIKES (see Figure 1) is an acronym for a six-step protocol that outlines important considerations when breaking bad news (Buckman, 2005). Its use can help ease distress for both the patients receiving the news and the healthcare providers who are sharing the news. Setting: Choose a quiet, private setting in which to share bad news. Turn off all phones and pagers (or put them on vibrate) and give patients your undivided attention. Include family members if patients wish. Try to deliver the news while seated, without a barrier (e.g., a desk) between you and patients. Although you may feel anxious sharing the information, try not to let it show in your body language. Show respect for patients by listening to their concerns in a calm and attentive manner.


Figure 1. SPIKES Method

S = setting

P = perception

I = invitation or information

K = knowledge

E = empathy

S = summarize or strategize

Perception: Determine patients' understanding of their medical situation before you deliver any news. Patients may not have a handle on the seriousness of the situation or may be in denial. If so, this may need to be addressed gently over several discussions before breaking the bad news.

Invitation or Information: Ask patients or family members directly what information would be helpful to them. Determine their preferred learning styles and use these during discussions. Some patients may want to know all of the details about their situation whereas others may only want to know where they will go from here.

Knowledge: Give patients a few seconds' warning that bad news is coming by prefacing the news with statements such as "Unfortunately, I have some bad news to share" or "I'm sorry, I have some serious news to tell you." Use clear, lay language rather than technical terms or jargon that may be difficult to understand in times of distress. Make sure patients and family members have time to absorb the information and respond with questions.

Empathy: Acknowledge patients' emotions and reactions and respond to them in an appropriate manner. Use statements such as "I wish the news were better" or "This is obviously distressing news" to show empathy. More information on conveying empathy through the NURSE method will be presented in the next section.

Summarize or Strategize: Ensure that patients understand the information you just presented by summarizing what you told them and giving them the opportunity to ask questions. Present a strategic plan for the next steps the healthcare team or the patient will take. Assess patients' understanding by asking questions such as "Does this make sense to you?" "Are you clear about the next steps?" or "Do you have enough information to make a decision?"


Patients may respond to bad news with a variety of emotions, and often they are looking for an "accepting response" from the healthcare provider rather than an immediate reassurance, rebuttal, or agreement. NURSE (see Figure 2) is a five-step method that may help you provide an empathetic response to patients' emotions (Back, Arnold, Baile, Tuksky, & Fryer-Edwards, 2005).

Figure 2. NURSE Response

N = naming

U = understanding

R = respecting

S = supporting

E = exploring

Naming: Naming an emotion shows empathy for a patient's distress; however, it is better to suggest a name for the emotion rather than declaring it. Saying, "I wonder if you're feeling angry?" is preferred to "You must be angry."

Understanding: Ensure that you have a clear understanding of a patient's fears and concerns before offering a response. Repeat your thoughts to the patient: "My understanding of what you're saying is ..." Although it seems contradictory, even statements such as "I cannot imagine what it is like" show that you understand.

Respect: Empathy and respect go hand in hand. Give patients permission to express their feelings, acknowledge those feelings, and show respect for their expression of emotion. This can be done nonverbally through body language and touch or verbally by matching the intensity of your statements to the intensity of patients' emotion.

Supporting: Share resources with patients and support their ability to cope. Recommendations for support groups can help prevent patients from feeling abandoned and reinforce their coping skills.

Exploring: Asking patients direct questions or clarifying on patients' prior comments can reinforce the healthcare provider's empathy. It also gives patients permission and opportunity to share additional emotions and feelings that they may have hesitated to reveal earlier.

For more information on delivering bad news and responding to patients' emotions, refer to the complete article by Kaplan (2010).

Back, A.L., Arnold, R.M., Baile, W.F., Tuksky, J.A., & Fryer-Edwards, K. (2005). Approaching difficult communication tasks in oncology. CA: A Cancer Journal for Clinicians, 55, 164-177. doi: 10.3322/canjclin.55.3.164

Buckman, R.A. (2005). Breaking bad news: The S-P-I-K-E-S strategy. Community Oncology, 2, 138-142.

Kaplan, M. (2010). SPIKES: A framework for breaking bad news to patients with cancer. Clinical Journal of Oncology Nursing, 14, 514-516. doi: 10.1188/10.CJON.514-516

[By Elisa Becze, BA, ELS, ONS Staff Writer]

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Author:Becze, Elisa
Publication:ONS Connect
Geographic Code:1USA
Date:Sep 1, 2010
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