Table 3. SPIKES protocol for delivering life-altering news 24
Step
Key Points
Example Phrases
Setting
Arrange for a private room or area. Have tissues available. Limit interruptions and silence electronics. Allow the patient to dress (if after examination). Maintain eye contact (defer charting). Include family or friends as patient desires.
“Before we review the results, is there anyone else you would like to be here?” “Would it be okay if I sat on the edge of your bed?” “When you felt the lump in your breast, what was your first thought?” “What is your understanding of your test results thus far?” “Would it be okay if I give you those test results now?” “Are you someone who likes to know all of the details, or would you prefer that I focus on the most important result?” “Before I get to the results, I’d like to summarize so that we are all on the same page.” “Unfortunately, the test results are worse than we initially hoped.” “I know this is a lot of information; what questions do you have so far?”
Perception Use open-ended questions to determine the patient’s understanding. Correct misinformation and misunderstandings. Identify wishful thinking, unrealistic expectations, and denial. Invitation Determine how much information and detail a patient desires. Ask permission to give results so that the patient can control the conversation. If the patient declines, offer to meet him or her again in the future when he or she is ready (or when family is available). Knowledge Briefly summarize events leading up to this point. Provide a warning statement to help lessen the shock and facilitate understanding, although some studies suggest that not all patients prefer to receive a warning. Use nonmedical terms and avoid jargon. Stop often to confirm understanding. Emotions Stop and address emotions as they arise. Use empathic statements to recognize the patient’s emotion. Validate responses to help the patient realize his or her feelings are important. Ask exploratory questions to help understand when the emotions are not clear.
“I can see this is not the news you were expecting.” “Yes, I can understand why you felt that way.” “Could you tell me more about what concerns you?”
Strategy and summary
Summarize the news to facilitate understanding. Set a plan for follow-up (referrals, further tests, treatment options). Offer a means of contact if additional questions arise. Avoid saying, “There is nothing more we can do for you.” Even if the prognosis is poor, determine and support the patient’s goals (e.g., symptom control, social support).
“I know this is all very frightening news, and I’m sure you will think of many more questions. When you do, write them down and we can review them when we meet again.” “Even though we cannot cure your cancer, we can provide medications to control your pain and lessen your discomfort.”
Instructions: Spend 5 minutes reviewing the case below and considering the questions that follow. Case Study 2
Terry is the oldest of five siblings. He has been the primary caregiver for his father, Ralph, who is 87 and lives alone following the death of his wife four years previous. Ralph has congestive heart failure, hearing loss, and type 2 diabetes. He was recently admitted to the hospital for pneumonia. While in the hospital, he had a transient ischemic attack, which caused him to become easily confused. Then, possibly due to a micro-stroke, he lost his ability to swallow. Ralph’s attending physician advised the placement of a percutaneous endoscopic gastrostomy (PEG) tube to supply nutrition and hydration. But Ralph had made it clear in his advance directive that he did not want a feeding tube, and he reiterated that desire to Terry. “I’m not afraid to die,” he said. “It’s time to call it quits.” Terry was torn. Some of his siblings were unhappy with the prospect of refusing the tube placement—they were afraid Ralph would die before they got a chance to see him. But Terry knew his father would fight any efforts to force him to change his mind, and Terry didn’t want his last days with his father marred by conflict.
1. What would be a possible response to Ralph’s expression about not being afraid to die that would employ the technique of reflective listening?
2. How could you work with Ralph to establish a set of care goals that would be appropriate for either course of action (i.e., having, or not having, the PEG placed)?
3. If Ralph refuses the PEG, what steps could you take to make his final weeks more comfortable?
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