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SPIKES is an acronym for presenting distressing information in an organized manner to patients and families. The SPIKES protocol provides a step-wise framework for difficult discussions such as when cancer recurs or when palliative or hospice care is indicated. Each letter represents a phase in the six-step sequence. S stands for setting, P for perception, I for invitation or information, K for knowledge, E for empathy, and S for summarize or strategize. Breaking bad news is a complex communication task, but following the SPIKES protocol can help ease the distress felt by the patient who is receiving the news and the healthcare professional who is breaking the news. Key components of the SPIKES strategy include demonstrating empathy, acknowledging and validating the patient's feelings, exploring the patient's understanding and acceptance of the bad news, and providing information about possible interventions. Having a plan of action provides structure for this difficult discussion and helps support all involved.
M.J. is a 68-year-old woman who has been disease free since being treated for stage IIA breast cancer 15 years ago with a right-side modified radical mastectomy and adjuvant chemotherapy, followed by five years of tamoxifen therapy. She has two adult children, four grandchildren, and is newly retired from her job as a school secretary. She and her husband have been making plans to take a month-long cruise. However, M.J. recently had a persistent cough that developed into pneumonia. A chest x-ray revealed several lesions in her right lung. Today she is returning with her husband to the oncology clinic to learn the results of a full-body positron-emission test (PET) and computed tomography (CT) scan.
The medical oncologist and the oncology nurse are aware that the PET/CT scan has revealed areas of increased activity in M.J.'s right lung and liver that most likely represent metastatic breast cancer. They know that this portends a poor prognosis and that M.J. needs immediate definitive tissue diagnosis and treatment. M.J. had been anxious for several years about the possibility of disease recurrence but, in recent years, she thought she "had beat it." The immediate problem for the oncology team is how to break the bad news to M.J. in the most gentle and therapeutic way.
The Intervention: Breaking Bad News
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