Although it is vivid enough that people die when their lives end, what constitutes the ending of one’s life is always less clear. Even though we are aware of death and that we will ultimately die, most of us remain in denial that it exists. As part of being human, conceiving our fatalities or even attempts to imagine how we will die is obscure as our conscious does not deem its demise. In dealing with the fear of death, many people use illusion and denial as cognitive defense mechanisms. Moreover, in denial, an individual evades the thought of death until reality renders denial impossible, while illusion constructs an acceptable concept about death to dodge perception of its unpleasant nature. An individual, therefore, depresses their fears of death through repressing the consciousness of their mortality. For this reason, it is vital that a clinician is prudent when conveying the dreadful news to patients and their families.
All patients, to a lesser or greater extent, are distressed about their real prognosis or condition when ill. Therefore, nurses and doctors have a contractual obligation to contribute towards alleviating this anguish and not to escalate it through negative gestures and expressions. To accomplish this, clinicians need to understand that communication is the foundation of decent multidisciplinary medical care and that the impact of conversations about prognosis, diagnosis, treatment, and death is indisputable (Marcus & Mott, 2014). As healthcare providers, nurses and doctors should be able to have difficult conversations that accurately explain treatment goals, diagnostic procedures, and the risks and benefits involved.
The phrase “difficult conversations” refers to any conversation between a clinician and a patient or /with their families, which directly or indirectly uncovers severe or detrimental disorders that could alter their future visions and perspectives (Ferreira da Silveira, Botelho, & Valadão, 2017). Many difficulties that healthcare providers have in breaking the bad news could be justified by their fear of causing distress and harm to their patients, and the fear of having to deal with or being blamed for the strong reactions of their patients. These unpredicted and unexpected reactions may comprise profound suffering, disease, denial and much worse, result to the death of a patient. Although studies have suggested that patients desire compassion, honesty, affectivity, and care, and to have their doubts clarified by doctors, they also demand not only competence in clinical skills and professionalism but also effectiveness in communication (Little & Bolick, 2013). Thus, despite breaking bad news being uncomfortable and unpleasant, it is an essential and complex skill that requires a practical application and didactic learning.
C-L-A-S-S
However, just as the likelihood of distress exists, so does the possibility to change the patient’s perception of their condition through the use of appropriate communication techniques and strategies is presented. Further, guidance on how to systemize difficult conversations and make them less traumatic is provided. The C-L-A-S-S protocol provides five steps in conducting clinical interviews. First, one must understand the context which I the physical set-up of the interview. Second, one should have effective listening skills. Third, one should acknowledge the emotions of the patient or victim. The fourth step is developing a good management strategy that a patient can easily understand. Finally, it is important to provide a summary to ensure the conversation was successful (Anderson, 2014).
S-P-I-K-E-S
The SPIKES (Setting, Perception, Invitation, Knowledge, Empathy, and Summary/Strategy) protocol, a systematic approach that envisages six steps of communication, prepare the clinicians for an awkward conversation with patients and families in the clinical setting (Anderson, 2014).
Setting
The scenario is the first step that requires that a clinician determine the focus of the conversation and prepare a medical environment or space within which they deliver the news. This step involves arranging for a reserved or preferably a private place, thinking through a plan for disclosure, determining who should be present in the meeting – that is a family member and an interpreter, if needed, and addressing the time constraints (Little & Bolick, 2013). The most vital step is to identify the specific message to give for example if the patient has prostate cancer you tell them the diagnosis only and pause as you allow them to process the information, and not attacking them with details of the disease.
Perception
This is the stage where you assess and discover what the patient and caregivers know about the underlying medical condition (Little & Bolick, 2013). The questions relating to the diseases are explored in the discussion and later analyzed. For instance, a lead question to this conversation would be, “What have you heard so far concerning your condition?” It may be strenuous to remember everything and the medical practitioner would take this opportunity to add vital pieces left out and reinforce the previous knowledge (Ferreira da Silveira et al., 2017). The clinician should use open-ended questions as opposed to closed ones for example, “what is cancer?” is inappropriate as the patient is still in shock and not another medical practioner to have the details.
Invitation
At this stage, the patient is allowed to spell out their concerns about the illness. The healthcare providers invite the patients and family to express and ascertain the degree of information that they need on the disease (Ferreira da Silveira et al., 2017). A simple question such as, “How much information would you require on your diagnosis?” can be effective in this case. If for a pediatric case, knowledge is shared with the parents first before being delivered to the child. It is a physician’s responsibility to help the patients make choices in line with their values and withholding no information from them (Little & Bolick, 2013).
Knowledge
At this moment, the patient is enlightened on everything on his/her condition, and they are expecting bad news (Ferreira da Silveira et al., 2017). It is the time when all about the diagnosis is announced. When articulating this information, clear non-verbal and verbal language should be used and jargons need to be avoided. The report requires slow communication to ensure that the patient absorbs everything. It is helpful to initiate this stage with a warning phrase, that a terrible news is coming (Little & Bolick, 2013). An idiom such as “It is with deep sorrow that I inform you…..” followed by a pause to prepare the family and patient that what is to be uttered next is not going to be perceived as pleasant news. It pulls the family to the following statement, which again is simple such as, “Your husbands’ high blood pressure may be as a sign of a severe infection, and we need to run some tests” as opposed to, “Your husband has reactive hypotension as a result of megaloblastic anemia.” The use of complicated medical terms make information unclear and leaves the respondents with unanswered questions (Ferreira da Silveira et al., 2017).
Empathy
At this juncture, the medical officer needs to express understanding. The clinicians are expected to identify with the patient’s feelings, show compassion to their situation and also not to withhold forward-looking information or render false hope to the patient and family (Little & Bolick, 2013). The caretaker would ask, “What kind of tests?” In response, the healthcare provider should use short and clear sentences followed by pauses as the respondents process the information. Extensive practice is needed to enable the care providers to be comfortable with pauses and silence.
Strategy/Summary
At this stage, a brief retrospective analysis is carried out to determine whether the patient has comprehended all the information, a discussion on prognosis is carried out and the establishment of a therapeutic plan with the patient (Ferreira da Silveira et al., 2017). If the bad news were about surgery, the information regarding it would be whether a blood donation is needed, when a surgical date is open, the urgency of the operation and the scheduling of the period to run the examinations (Little & Bolick, 2013). If the patient is a child, a uniform decision arrived at should be on the steps to undertake to inform the child. Such as, “Should child life specialist’s assists with unveiling the diagnosis to the child?”
Conclusion
In conclusion, managing a life –limiting illness is never simple. Thus, helping family and patients make decisions about what enhances ones quality of life is part of a clinician’s most difficult tasks. Through SPIKES protocol, a healthcare provider is able to resolve patient’s ambivalence, reduce a patient’s resistance, and support patient’s autonomy.
References
Anderson, MD. (2014). The complete guide to communication skills in clinical practice. The University of Texas MD Anderson Center. Retrieved from https://www.mdanderson.org/documents/education-training/icare/pocketguide-texttabscombined-oct2014final.pdf
Ferreira da Silveira, F. J., Botelho, C. C., & Valadão, C. C. (2017). Breaking bad news: doctors’ skills in communicating with patients. Sao Paulo Medical Journal, 155(4), 323-331. http://dx.doi.org/10.1590/1516-3180.20160221270117
Little, J., & Bolick, B. N. (2013). Preparing prelicensure and graduate nursing students to systematically communicate bad news to patients and families. Journal of Nursing Education, 53(1), 52-55. https://doi.org/10.3928/01484834-20131218-02
Marcus, J. D., & Mott, F. E. (2014). Difficult conversations: From diagnosis to death. The Ochsner Journal, 14(4), 712–717. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295750/
