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Communicating With Cancer Patients: When the News Is Bad

Authors: Walter F. Baile, MD; Margie MillerFaculty and Disclosures


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Margie Miller: Hello. My name is Margie Miller and I'm the Group Editorial Director at Medscape Oncology. On behalf of the NCCN Clinical Practice Oncology Forum and Medscape, I am very pleased to be joined today by Dr. Walter Baile, Professor of Behavioral Science and Director of the ICARE Program, which stands for Interpersonal Communication and Relationship Enhancement, in the Department of Faculty Development at the University of Texas M.D. Anderson Cancer Center in Houston. Dr. Baile will talk to us today about communicating with cancer patients, focusing on those particularly delicate conversations that take place when the news is bad. Welcome, Dr. Baile.

Walter F. Baile, MD: Thank you, Margie.

Margie Miller: Although all clinicians need to be adept at communicating with patients, oncologists in particular are faced with difficult conversations on a regular basis. Informing a patient about a cancer diagnosis, the fact that a tumor is inoperable, the recurrence of disease, or the progression of disease are daily challenges for many oncologists. Considering the frequency of bad news in the cancer setting, it would seem that communicating in a clear, respectful, and supportive way is a very important skill for oncologists. Dr. Baile, is good communication a natural trait or is it something that can be learned?

Walter F. Baile, MD: I think there is a misconception that you either have good communication skills or you don't have them. However, some of the recent data that we have now shows that good communication is actually a skill which can be learned and taught, and if you don't have good communication, it really doesn't necessarily improve with experience. Even seasoned clinicians may not have learned the appropriate skills for communicating effectively with cancer patients, even after many years of practice.

Margie Miller: Considering that these skills are so important, are they addressed and taught in medical schools?

Walter F. Baile, MD: More and more medical schools are incorporating communication skills into their teaching of students. However, it's also important to recognize that these skills need to be reinforced later on during residency and specialty training because they tend to fade a bit; and because medical students don't often have primary responsibility for patients, it's best that they learn them when they're really in charge of the patient care and have to face some of the very specific challenges that go along with taking care of very ill patients.

Margie Miller: How has the Department of Faculty Development at M.D. Anderson addressed this aspect of patient care?

Walter F. Baile, MD: The Department of Faculty Development created a program called ICARE -- Interpersonal Communication and Relationship Enhancement -- several years ago to address the issue of training our clinicians and offering to clinicians outside the institution a program or series of programs in communications skills. We've created a series of videos, which will soon be on a Website, to explain and show the how-to-do-its of communicating with patients, such as -- as you mentioned -- breaking bad news, talking about cancer recurrence, and end-of-life issues. We've also created programs internally using the workshop model for teaching our clinicians -- and not only clinicians, but other members of our staff, such as patient advocates -- to communicate effectively and to handle very tense emotional situations when patients receive bad news.

Margie Miller: What about nonverbal communication, something we sometimes call body language?

Walter F. Baile, MD: Right.

Margie Miller: Is that something that can be taught?

Walter F. Baile, MD: I think nonverbal communication is the one form of communication that's often overlooked. However, it represents about 60% of the message that we're conveying to patients -- that body posture, eye contact, sitting down when you talk to a patient really sends an important message that you're there to listen, that you're a good listener, that you want to be engaged with the patient, and that you're not going to leave the room after 10 seconds. What we communicate to patients with our body language and other aspects of nonverbal communication is extraordinarily important.

Margie Miller: I understand that there's a developing consensus about the elements that should be part of any discussion with patients and families when sharing bad news. What is the SPIKES protocol, for example?

Walter F. Baile, MD: The SPIKES protocol represents a series of steps for giving bad news. They represent a consensus of what is in the literature with regard to best practices when one has to talk about a very, very difficult bad-news situation to a patient. It's more of a guideline for clinicians as to how they might proceed, in the same way doctors learn how to complete the necessary steps to do a spinal tap, for example, and do it correctly, and to complete it in a way that's safe for the patient. So SPIKES is a series of steps that represent one approach to giving bad news.

Margie Miller: What are the key principles? I assume that SPIKES stands for S-P-I-K-E-S. What is each of those elements?

Walter F. Baile, MD: It's an acronym. The S of SPIKES is for getting the setting right. You don't want to give bad news in a hallway. You don't want to be in the middle of an important discussion with a patient and have your pager go off. It really has to do with setting up the interview so you have a good chance of getting through it and succeeding.

The P of SPIKES means perception. It means finding out what the patient knows about the bad news before you give them information. It's sort of like, ask before you tell. That principle addresses the fact that you want to know something about what the education gap is between the actual medical situation and the patient's understanding of it. With some patients, you may really need to give them a lot of information about the medical situation, and other patients may be totally on board with what's happening to them.

Margie Miller: It sounds like that's very important.

Walter F. Baile, MD: It is important because our studies have shown that there are often misunderstandings on the part of patients about their medical situation and the goals of care. It's important to check that out with the patient.

Margie Miller: And the I?

Walter F. Baile, MD: The I stands for invitation, which means checking in with the patient to see if they're ready for the bad news. Some patients may want to have family there. Others may not be feeling well. It really gives the patient permission to decline the discussion at that particularly moment. The other thing about the I is that it's sort of a goal setting. "I'd like right now to go ahead and talk to you about the results of the CT scan; is that okay?" It really aligns with the patient's desires at that moment.

Margie Miller: K?

Walter F. Baile, MD: The K is knowledge. It represents a reminder that we need to give information to patients in clearly understandable ways. The biggest complaint that patients have about the way that we give information to them is that we use a lot of jargon. Even the word "biopsy" to many patients may not be understandable. K means give information in small chunks and then check with patients as to whether or not they understood it.

E is probably the most important and most difficult part of SPIKES, and that is how to handle the emotional reaction of patients and our own emotions when we give bad news. There are some techniques for doing that, such as using empathic responses when patients get upset and validating their feelings.

That serves to lower the emotional tenor in the room so that the patients can begin to hear the message that we want to give them about the strategy and summary, which is the last step of SPIKES: how to give a treatment plan in a way they'll understand. That's what patients are waiting for -- to hear what we're going to do about their disease.

Margie Miller: Where can clinicians learn more about SPIKES?

Walter F. Baile, MD: On our Website, we have a series of videos which demonstrate a variety of situations in which clinicians are giving bad news: at the time of diagnosis, at disease recurrence, and even end-of-life discussions. That's at

Margie Miller: Let's take a look at an example of a patient who learns that she will have to have adjuvant treatment after surgery for colorectal cancer.

Patient: My understanding at the time was that everything was under control. The surgeon said it was all taken care of and I'm not even sure why they sent me here, to be honest.

Oncologist: Okay. Alright. Now would you like me to explain the situation clearly in some detail with the plan for how we're going to deal with it from now onwards?

Patient: Absolutely.

Oncologist: I don't know whether Dr. Wilson mentioned this to you, but at the surgery-- as you say, it was a cancer of the bowel -- it had gone through the bowel wall and had actually gone into some of the lymph nodes in the area around the bowel. Did he mention that?

Patient: I don't recall that. No, my understanding was that he got it all and everything was okay and just onward and upward from there.

Oncologist: That sounded like, "We're good; we've got it all"? That's what you heard?

Margie Miller: What would you say are the critical messages demonstrated in this interaction about that recommendation for adjuvant chemotherapy?

Walter F. Baile, MD: From the video, one can see that the oncologist, when he checked in with the patient about her understanding about the visit that he was about to have with her and why she was referred, there was an enormous gap between her understanding and the actual medical situation. She thought she was completely disease-free. She didn't quite understand why her surgeon referred her to the medical oncologist, and so there was a lot of catch-up to do in that particular area and in educating her.

The other thing that the doctor did...obviously this patient was reluctant to really take adjuvant therapy, and so he used the biology of the disease in a very straightforward and simple way to explain to her what adjuvant therapy would do for her as opposed to not doing anything.

Before discussing anything factual, he addressed her emotions. "This is really hard for you to hear, I know you weren't expecting that." Because it's really hard to discuss facts with someone who's emotional. Making empathic statements and validating the patient's feelings tends to lower the emotion so patients can begin to hear what we have to say to them.

Margie Miller: It sounds like they both learned something from their interaction.

Walter F. Baile, MD: Yes, and I think they both started to build a partnership also, which is really important.

Margie Miller: Very interesting. I think we have time for another brief vignette. This time the physician is talking with a patient about his prognosis and the patient wants to know how much time he has left.

Walter F. Baile, MD: Yes. That's not an uncommon question from patients. Some patients want straightforward answers because they have business to take care of, things they have to do. But in this particular case, the question really underlined a concern the patient had about an issue. In other words, when asking about how much time he had left, he was really worried about whether or not he, not surviving his cancer, would burden his wife with payments for a condo.

Margie Miller: Let's take a look.

Oncologist: The difficulty is that today, just a few minutes after the first chemo[therapy], I can't yet tell you whether you, Mr. Kerr, are in that two-thirds group that respond or in the one-third group that don't respond.

Patient: How long will it be before you can tell me that?

Oncologist: Exactly. I can answer that question. I will be able to tell you in somewhere between 3 and 6 weeks. In 3 weeks' time, we start the next one.

Patient: That's not what I want to hear. That's no good.

Oncologist: That will not tell you in time to make the decision about the timeshare, will it?

Margie Miller: How would you describe the physician's responses, and why is this approach effective?

Walter F. Baile, MD: It would have been very tempting to give the patient a direct answer, saying "No, I don't think you should buy a condo" or "Yes, why don't you go ahead and we'll take a chance that you're going to get a good response from the [treatment]." What he did was to use the biological behavior of the disease to explain to the patient some likely or possible outcomes; and on the basis of that, again, he helped provide some guidance to the patient in his deciding the choice. In that way, he allowed the patient to really decide on the basis of what his prognosis was, whether or not he wanted to take a chance in buying this condo, making a very important decision in his life regarding himself and his wife.

Margie Miller: Certainly a difficult conversation.

Walter F. Baile, MD: Very, very difficult.

Margie Miller: Again, if a clinician wants to learn more about SPIKES or wants to view additional video examples, would you repeat the Website please for our viewers?

Walter F. Baile, MD: Yes. The Website address is, which stands for Interpersonal Communication and Relationship Enhancement.

Margie Miller: Thank you so much. This is such an important subject for all clinicians who care for patients with cancer. A respectful, compassionate, and comfortable interaction with a healthcare professional can reduce the trauma of bad news and can help patients make rational, informed decisions about their treatment and their lives. On behalf of the NCCN and Medscape Oncology, I'd like to thank you, Dr. Baile, for helping our members in continuing efforts to improve patients' lives.

This activity is supported by independent educational grants from Amgen, Genentech, AstraZeneca, and sanofi-aventis.

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