Giving Bad News.

In the practice of oncology, it is difficult not to be impressed by the number of clinical situations that necessitate the conveyance of unfavorable medical information to patients and families. These include the communication of the cancer diagnosis, a poor prognosis, the failure of anticancer treatment, the occurrence of unwanted and significant side effects, the ineligibility for a clinical trial, sudden and unexpected death, the discussion of hospice, and, more recently, a focus on the disclosureofmedicalerrors.Theestimatethatthese“badnews” discussions canoccurmore than20,000 timesduring the course of an oncologist’s career [1, 2] underscores the importance of this communication competency for patient care. SPIKES (setting, perception, invitation for information, knowledge, empathy, summarize and strategize) is a skills-based, best-practices approach to giving bad news. Although not formally tested in a clinical trial, the communication skills it proposes, or similar ones, have been found to positively affect patient outcomes in one or more studies [3]. Its steps have been incorporated into guidelines for clinician-patient communication [4, 5] and for error disclosure [6] and have also been used in programs for teaching the communication of bad news to oncologists, medical oncology fellows, and others [7, 8]. Although the SPIKES protocol has been adapted to many important “badnews”discussions,Morgans and Schapira in their report in this issue of The Oncologist address the use of SPIKES in the context of discussing treatment failure in an era of everexpanding treatment options. They are quite correct in pointing out that this is a particularly “high-stakes” conversation for the patient and loved ones and is often a daunting task for the clinician. In the original report in which we introduced the SPIKES protocol[2],weciteddatafromasurveyof500oncologists,almost one half of whom thought that talking about the end of cancer treatment was themost difficult aspect of breaking bad news. Commenting on the social and psychological dynamics of the “war” on cancer, Morgan and Schapira observed that, in the treatmentofcancer,deathisstillseenas“theenemy”andtherefore must be defeated. Not to do so can represent the ultimate therapeutic failure (perhaps more so when the patient is young or “special” to the doctor). Consequently, the clinician must deal both with the patient’s and the family’s reactions to the bad news and also with their own strong emotions elicited in communicating the end of anticancer treatment [9, 10]. This latter point was highlighted in a study by Wallace et al. [11], presented at the annual meeting of the American Society for Clinical Oncology in 2006.They polledmore than 1,000 medical oncologists about their experiences in giving bad news about apoorprognosis (diseaseprogressionanddeath likely in thenext 6–12months) to patientswith advanced cancer. Among the 729 oncologists who responded, nearly 50% admitted to having strongnegative feelings, such as sadness, pain, guilt, heartbreak, and stress. These feelings, repeated over and over again in the workofcaring for very ill patients, are surelya recipeforburnout. Recognizing this, Morgan and Schapira discussed several techniques for mitigating the stress associated with discussing badnews.These can include reviewingwhat thepatient already has been told about the prospects of a previous treatment, anticipating an emotional reaction, and rehearsing steps, such as being calm and empathic, for dealing with patient emotions. Other investigators have made additional and important refinements to SPIKES, such as addressing cultural factors [12], setting goals of care and checking on what information the patient has actually absorbed and understood [13], and using decision-making tools to help ensure treatment decisions are more patient-centered [14]. Another important aspect of stress management is the creationofmindfulnessaboutone’sownemotional reactionsand unhelpfulattitudesaroundgivingbadnews,suchasthefearofbeing blamed, fear of unleashing an emotional reaction in the patient’s family, expressing one’s own emotion, and taking responsibility for the bad news itself [15]. These reactions can drive a wedge in the doctor-patient relationship if the result is the clinician’s distancing himself or herself from the patient or attempting to shield the patient from distress.The consequences can be misunderstanding by thepatient and family about thepurposeof care and/or the loss ofhonestandsupportivecommunicationatatimewhenthepatient needs the doctor themost [16–20]. Being mindful is a way of being aware in the moment of our own feelings through nonjudgmental observation so we can act on them with calmness and wisdom [21]. This can be important for clinicians who are particularly sensitive to the stress of giving badnews [10] orwho tend to judge themselves too severely. These clinicians might benefit from emotional self-management strategies such as those described in the reports by Krasner et al. [22] and McCraty et al. [23].