Hello everyone. I'm Hannah Spero, I am a nurse practitioner and an assistant clinical professor in the Betty Irene Moore School of Nursing, and this presentation is going to be about delivering bad news. Now, this is something that we have to do all the time in health care in a lot of different ways. It's a skill that we can really hone and develop, and is particularly important to be able to do when dealing with caregivers. Here are the objectives for the presentation. We're going to talk about the SPIKES Protocol. We're going to talk about empathetic responses using the nurse acronym. I'm hoping to leave you with some practical resources regarding just delivering bad news, and communication around difficult subjects that come up in health care. Let's start with a really basic question though, and I want you to think about this yourself. What are some examples of bad news you have seen in the clinical setting? I'll give you a few more seconds to think about this. I'm sure you've had some immediately pop into your brain. Here's some examples of bad news that I came up with. This is by no means a comprehensive list. You may have thought of some of these yourself too. Death, miscarriage, blindness, positive STD, cancer. But also things like a new diabetes diagnosis is bad news, that you need hearing aids can be really bad news. I want you to look at this list and start to expand what you think about as bad news. There's so many things in health care that are bad news that aren't death or dying or permanent disability. It's a skill that you can use in a lot of different ways probably, in the work you're doing. Now take a moment to reflect on this question. Why is it hard to deliver bad news? I'll go ahead and talk about some of the answers that come up in my brain. One of the ones is, I don't think any of us really want to disappoint anyone. Even if you know the news is what it is, we still don't want to disappoint people. That's one reason that's delivering bad news is hard. I know that it can be hard to, if you're so worried about the reaction, you're going to get. "Oh my God, if I tell this family x, y, and z, then they're going to be yelling, they're going to disrupt the whole clinic, they're going to write bad reviews of us, they're going to [inaudible] complaints against me." All those different things. I'm sure you're all coming up with many reasons beyond that. There are a lot of reasons that this is really hard to do. Like I said today, a basic framework to start to think about as you continue to deliver bad news, which you will continue to do in different ways in your career. These are the frameworks we are going to talk about. The SPIKES protocol is the big one day and then the nurse acronym for understanding what empathy is, and what it means to be empathetic. Let's start with the spikes protocol for delivering bad news. The first S in SPIKES stands for setting. This is really about the where, the who and the why. Where's the meeting taking place? Ideally, you want somewhere quiet, private, well-lit, clean, distraction free. Ideally everyone sitting. You really want people to be settled and be totally concentrated on what you're talking about. The next is the who. Who will or should be there with the patient? You can think of this as like patient related people and then health care team related people, even though they're all really on the same team. For the patient, is there a family that should be there, a proxy decision-maker, is there a close friend that they want there? I think it's good to, to just normalize having others there. It's really hard sometimes for people to hear bad news all by themselves. But that being said, you really have to consider individual culture. Depending on the background of the patient who in that culture is meant to know the news and is meant to hear different kinds of news. Sometimes it can be a very like individual, private and sensitive thing. You don't want to be a provider encouraging them to bring everyone. Just something to think about. There's also the who on the health care team side of things. Is this like an interdisciplinary issue? Do you need doctors? Do you need your social worker there? Psychologist? A chaplain? Things like that. I think the important thing with thinking about the health care team, is it's really great to have a little pre-meeting and I'm not talking about the whole team from the health care side that's going to be there meeting and figuring out exactly what they're going to say. I'm saying like five minutes outside the door right before the meeting saying, "Hey, we're all going to be on this. This is the message we're going in with right, these are the things we want to get out of it. Okay, great." I've been in situations in the past where I've done that pre-meeting, and I'm thinking specifically about a younger cancer patient I took care of. I was on the palliative care team and it was a hematologist who came to the meeting because we wanted their input on this rare blood cancer. He mentioned, maybe I think I heard of a study. Maybe we can screen her for it. I don't know, and we're like, "You know what? She's in ICU right now. Multi-organ failure, you're about pre-screened her for this. Let's table that for another time." That way you're able to stay focused on what's the news you're trying to deliver. Much in that case was that we were running out of options and we need to talk about what was important to her. The last part of the setting is the why. Considering what the goal is for this meeting and for delivering the bad news, what's the thing at the end of this, you want to get out of it? Do you want to deliver it and have them think about it, or do you need to deliver the news and have them really make a decision immediately? Having a goal is really important in doing this and staying focused. The P in SPIKES, second letter, stands for patient perception. I like to do this through ask-tell-ask. You're basically trying to figure out what the patient knows or understands. Can you tell me what you've already heard from others? Have them tell you what they heard and then ask again to clarify, just want to make sure we're on the same page. Are you understanding that this blood sugar level means, x, y, and z or this has changed? This is an example. You really don't want to assume the patient knows what you know, because they may have no idea what you're about to tell them, or on the other side of things, they may know exactly what you're going to tell them, they've heard it before. You may be getting all ready to have this big spiel about what you're about to say, this bad news, and they already know it. Assessing patient perception is important. The next step in SPIKES protocol for delivering bad news is the invitation. This is where you ask permission to share what you know before actually imparting the knowledge or bad news. You might say, "Is it okay for me to go over the test results with you right now?" That gives the patient maximum of the control in the conversation, and can settle them down and better prepare them to hear the news. But you also want to consider how much the patient wants to know. Sometimes people don't want to know their exact prognosis. It's important to think about too. Is this something like how much do they actually need to know? There are some things, communicable diseases where they might spread it to someone else, where you do have to give them the information. But it also may be that that wasn't a good moment for them. "I am at my sister's baby shower and every family member I have is standing around me, so can we do this another time?" That's okay. You still want to get it to them in a timely manner, but may be you say, "I understand that you're here right now. Are you able to step aside for a minute or something or can you call me back at this specific time?" There are cultural variations to and how much people want to know. Again, just important to ask.