SPIKES Protocol

 

The SPIKES Protocol is a common template for breaking bad news for different morbid conditions, especially cancer. For the ophthalmologist, this can come handy in dealing with glaucoma patients.

The acronym SPIKES, stands for Setting up, Perception, Invitation, Knowledge, Emotions with Empathy, and Strategy or Summary.

It is helpful to be reminded that, although bad news may be very sad for the patients, the information may be important in allowing them to plan for the future.

S- SETTING UP:

An appropriate setting with as much privacy as possible is required to establish rapport with the patient and/or family. Any disturbing influences such as phones, TV or radio should be turned off. The HCP should ensure that there are no distractions from other staff members. Setting the stage for optimal communication by preparing what to say prior to the conversation is essential to successful communication. The rules of preferred body language for optimal communication including sitting while speaking, maintaining an open posture, and maintaining eye contact apply as the interview environment is considered.

P- PERCEPTION:

The HCP should obtain all relevant information, including medical facts regarding the patient’s condition prior to conducting the interview. It is better to follow the “before you tell, ask” axiom, and ask open-ended questions initially so as to get some idea about the patient’s understanding of the condition. Subsequently, the HCP can correct any misinformation and explain the situation to the patient, especially with regards to the irreversible loss of vision which has already occurred and the expectations for the future. But most importantly the HCP should be in a position to understand the feelings of the patient/family and direct them towards a more honest understanding of the situation. The challenge for all clinicians is to respect the level of information desired, but have the patient and family know enough so that they are able to provide informed consent for further testing and treatment.

I- OBTAINING THE PATIENT’S INVITATION FOR DISCUSSION:

Every person has a different coping mechanism for their illness. A majority might be interested in knowing the problem, why they developed glaucoma, if there are any ways to prevent further visual loss and the types of treatments available. Others do not wish to know the details and inform the HCP that they have faith in their management and would leave all those aspects for the doctor. If the patient does not want to know the detailed results, one must offer to address any queries that they may have in the future, once their mind is at ease, or provide the details with subsequent implications to a care provider or family/friend.

K- GIVING KNOWLEDGE AND INFORMATION TO THE PATIENT:

The first step in actually delivering the news is to “Fire a Warning Shot” and warn the patient and family that the incoming news is not good.

The sharing of bad news must be presented based on the assessed level of patient’s understanding, compliance, and wishes for disclosure. Instead of using technical language regarding tests such as visual fields or OCT, the HCP can devote more time on the basic aspects of glaucoma and how the condition is affecting his visual pathway and what treatment is doing to his condition. The actual sharing of the bad news should be done slowly so that the patient and family understand. Appropriate words, especially in a stage of diverse cultural pool, have to be carefully chosen.

E- ADDRESSING THE PATIENT’S EMOTIONS WITH EMPATHIC RESPONSES:

Responding to the patient’s emotions is one of the most difficult challenges of breaking bad news. Patients’ emotional reactions may vary from silence to disbelief, crying, denial, or anger. This creates a potentially awkward situation for the HCP, but this sense of awkwardness can be diminished through engaging in empathetic communication.

In cases of advanced glaucoma with a risk of snuff-out, the visual prognosis is poor. However, the doctor must avoid using phrases such as total blindness, and rather focus on revised therapeutic goals and expectations.

S- STRATEGY AND SUMMARY:

The main aim of the interview is to present a clear plan or strategy for the patient, keeping in view the patient’s perception of the condition and the prognosis. Studies have shown that patients who have a clear plan for the future are less likely to feel anxious and uncertain. The future management plan should be discussed by the HCP. This is legally binding in some situations.

Sharing responsibility for decision-making with the patient may also reduce any sense of failure on the part of the physician when treatment is not successful. The doctor must check that the patient does not misunderstand the efficacy or purpose of the treatment, e.g., that the vision loss or visual field loss that has already occurred will not be restored by any subsequent intervention. In glaucoma patients the idea that the vision could improve after surgery or laser has to be cleared.

Finally, the HCP can re-cap a summary of the discussion in order to reinforce the ideas discussed with the patient.