Now comes the meat of the delivering bad news in the SPIKES protocol, the K for knowledge. At this point you know a lot about this patient, you've created the setting, you have the right people, you have a goal for telling them this bad news, this meeting. You've assessed what they understood and now you've gotten their permission to talk about the bad news. And when you do the actual delivering of the bad news, I like to say you want to fire a warning shot, not drop a bomb. And what I mean by that is before you actually say the bad news, say some sort of phrase, whatever you're comfortable with that cures the patient that they're about to hear bad news. So the phrase I use a lot is, the results are not what we'd hoped for, and this does something very important, this makes them basically brace for bad news, this makes them prepared to hear it, it makes it so it's not out of nowhere. And it helps them, taking the news more readily and hopefully be in a better space after they've heard the news to continue the conversation. If you say out of nowhere, you have cancer and that patient just thought they were coming in for a checkup today, they're not going to hear anything you say after that. Especially if you haven't pressed them with, I have some bad news to share with you and I'd like to talk to you about it right now. We're actually delivering the bad news, whatever it is, whether it's new diabetes diagnosis, cancer diagnosis, terminal illness, anything like that you want to be direct. And then after you actually say the news in a direct succinct way you want to allow space for silence, don't say anything. And this I think for anyone in healthcare can be the hardest thing to do, because we want to help and we want to offer all these things we know. But it's really important after you actually deliver the news to allow space for silence. And now we come to the E in SPIKES protocol, you've just delivered the news, you have this moment where it's silent, giving the patient a moment to process. And then we have the empathetic response and I thought for this one we do sort of practice question because I think we talk about empathy a lot and health care but I really want to get down to what it is. So here's the question, you just told a patient, your adult patient, that they have type II diabetes. The patient becomes emotional, crying, says that he ''doesn't know what to do now'', which of the following is the most empathetic response that you could give this patient. You know the first answer A is, don't worry, there are so many drugs for diabetes today, we'll take care of it. Answer B, individuals with diabetes are at risk for blindness and neuropathy, so it's important we start you on metformin immediately to prevent complications. C, let's talk about the treatment plan. And D, I hear you feeling overwhelmed right now, this is a lot to absorb and learn about, and I am going to be here to walk through it with you, what are the thoughts you're having right now? So I think in your mind what the answer is, okay let's go on the next one. So let's talk about what empathy is, so the correct answer is D but let's talk about why the other ones are not empathy. So A, don't worry, there are so many drugs for diabetes today, we'll take care of it and be fine. This is an empathy, this is trying to fix things and this is also providing false reassurance, you don't actually know if everything's going to be fine or what fine actually is to this patient. B, individuals with diabetes are at risk for blindness and neuropathy, so we have to start you on these medications. This is like the patient has just expressed an emotion and this answer is responding to those feelings with facts. These things are all true but it actually doesn't acknowledge how the patient is feeling. Now answer C, let's talk about the treatment plan, I think in healthcare we are very guilty of doing this. We want to get to, okay here's how I'm going to fix it and so in saying this after the patient has just said this emotion is really moving on without responding to the emotion which can make the patient feel dismissed and uncared for. But let's talk about why answer D is correct, so let's talk about why answer D is right and why it is the most empathetic response and we'll do that by talking about what actually empathy is. And you can think of empathy by using the nurse acronym, N, U, R, S, E, so name, understand, respect, support and explorer. So I hear you're feeling overwhelmed right now, naming how they're feeling, this is a lot to absorb and learn about, understanding and respecting them. And then saying, I'm going to be there to walk through this with you, showing your support and then lastly what thoughts are you having right now, exploring how they're feeling with them, that is truly empathetic response. And it makes the patient feel cared for and it helps them process a little bit more. Because if you don't respond empathetically to a patient's emotion, there's a much higher likelihood that they're not going to hear anything you say after they've had that emotion, they're going to be too caught up with and how they're feeling about it. So it's really important to express empathy and truly express empathy and doing all of these parts not just saying, you seem overwhelmed? That's not enough, you really need to do all of these things. And now we've done our empathetic response, we've gotten to the last S in the SPIKES protocol and that S stands for strategy, and this is where you finally get to get to the plan of what you're going to do about this bad news. But before you get into the plan, you want to ask permission, so they just had an emotional reaction, you responded empathetically and it was wonderful. And so before you move into the strategy piece you might say, I've given you a lot of information just now, do you have any questions right now or is it okay if we start discussing what's next. Again, this gives patients back the control to sort of go at their pace and understanding this and puts them in a better place mentally to hear anything you have to say. They may not be ready to talk about the plan that day and again, depending on what type of bad news you're delivering, you can have your judgment about whether they actually need to make a decision today or if it's okay for them to think about it and come back to hear what you have to say. Now when you're delivering the plan, there may still be some emotions there, so it's really important to be clear, concise, and organized. And you want to check for understanding, I just want to make sure we're all on the same page about the plan. Would you share with me what you've understood about our plan for what's happening next and that's just good practice in whatever you do whether or not it's bad news. And then the last part of the strategy is planning for follow-up, and I know some of you may be thinking, my patients don't come back, they see me once and then I send them off to this specialist or this person or anything like that. And so when I say plan for follow-up, what I really mean is just like some sort of contingency plan. It could be, I'm referring you to dietary to talk about weight loss with you, if you don't hear from them in two weeks to schedule appointments, I want you to call back the office and so we can try to follow up on that and make sure you get connected. That could be your plan for follow-up, even if you're never going to see the patient again, you still want them to feel like someone is there to make something happen, should things fall through. Lastly like I said I want to leave you with some practical resources. So the first link on there is the VitalTalk Tips app, that is a really great app to explore some time just for how to have difficult conversations with people generally. It is not just about delivering bad news, has tips and goals of care conversation, it has tips about how to talk to families, about feeding tubes, what to say when you really put your foot in your mouth and it's a great app to just have on your phone. The next one on there is the Serious Illness Conversation Guide, and this is more focused on not only delivering bad news but really related like it says to serious illness. More so on that palliative care or critical care and in the spectrum than just sort of your everyday bad news. And then lastly on there is Fast Facts, this is out of Wisconsin, palliative care now which is in Wisconsin and it's a really great web organization that just has really succinct articles about a variety of topics and palliative care. But also specifically related to the pre-meeting before you have a family meeting or deliver difficult news as a group. About how to deliver difficult news, about how to deal with people who are in denial and also a lot of other palliative care topics, pain management, nausea management hiccup management. So that's a really great way to just get really quick articles about these various topics. And then here are the references I used to create this presentation, and I appreciate you listening in.
