Communication of bad news is an inherent component of the physician–patient relationship

 Communication of bad news is an inherent component of the physician–patient relationship, 

and these conversations often occur in a hospital setting where the

treating provider is not the primary care provider for the patient. Many physicians struggle with

providing clear and effective communication to patients who are seriously ill and their family

members. In the scenario presented in this case, it is necessary to have a discussion about the

patient’s poor prognosis and determine goals of care without the input of the patient as her

mental status remains altered. Failure to provide clear communication in the appropriate

environment can lead to tension in the relationship between the physician and patient and may

lead to overly aggressive treatment. The P-SPIKES approach (Table I-49) has been advocated as a

simple framework to assist physicians in effectively communicating bad news to patients. The

components of this communication tool are:

• Preparation—Review what information needs to be communicated and plan how emotional support will be provided. • Setting of interaction—This step is often the most neglected. Ensure a quiet and private environment and attempt to minimize any interruptions. • Patient (or family) perceptions and preparation—Assess what the patient and family know about the current condition. Use open-ended questions. • Invitation and information needs—Ask the patient or family what they would like to know and also what limits they want regarding bad information. • Knowledge of the condition—Provide the patient and family with the bad news and assess understanding. • Empathy and exploration—Empathize with the patient’s and family’s feelings and offer emotional support. Allow plenty of time for questions and exploration of feelings. • Summary and planning—Outline the next steps for the patient and family. Recommend a timeline to achieve the goals of care. Setting a follow-up meeting is not a primary component of the P-SPIKES framework but may be necessary when a family or patient is not emotionally ready to discuss the next steps in the care plan.