History taking: breaking bad news

This station is a favourite amongst ALL OSCE exams throughout training. Whether it is breaking bad news about a new cancer diagnosis or telling a patient they cannot safely drive anymore.

The mnemonic that is commonly used is: SPIKES which stands for : Setting, Perception, Invitation, Knowledge, Emotions and Summary

SETTING:

• Set the scene, get the chairs in the correct format to reduce fumbling in the exam

• ensure private setting (you may need to verbalise this to the examiner!)

• Ask the patient to come in, ask if they have anyone with them that would like to join

PERCEPTION:

• Introduce yourself.

• Ask the patient why they have been asked to come in, i.e. the reasons for the the bloods/chest x-ray/investigation.

  “So why have you been asked to come to see me today?”

  “I have been asked to discuss your chest x-ray, could you tell me what led up to your GP arranging this?”

  • This will allow to a) Building of a rapport b) Get their perception on their symptoms so you can then correlate this to the interpretation of the results, i.e a patient coughing up blood with a suspicious lesion on a chest x-ray. You will use their ‘perception of their symptoms’ later when breaking the bad news.

• DO NOT jump in with giving the information. These 1-2 minutes of getting the patient to speak could make or break the success of this station

INVITATION:

• Let the patient know that you are going to discuss the results/letter etc but BEFORE doing this, ask them WHAT and HOW much they want to know.

• Some patients do not want all the information, some want it all. Again rapport is vital.

  ”Some people do not like to be given all the information at once, whereas others want to know everything. What would you prefer?”

KNOWLEDGE:

• Give a “warning shot”, pause, and then continue.

  ”We have your blood tests results which might explain why you were experiencing night sweats and weight loss, which you were worried about” (link the “perception” here, it will flow nicely)

  ”George, I have the results of your chest xray (pause)..i am so sorry…(pause) it is not good news” PAUSE.

• Provide information in small junks. Give space for the patient to react and acknowledge the information. It is so easy to just plough on with information, BUT the marks are not in your knowledge of lung cancer but in the rapport you built with the patient by how you made THEM feel.

EMOTIONS:

• This means to stop and reflect the patients emotions back to them

  ”I am so sorry, I can see you are understandably upset”

  ”Would you like a tissue?” (Make sure there are tissues otherwise don’t ask!)

• Do not fill the (awkward) gaps with talking, silence is precious. If they are crying, it will not help talking over them.

STRATEGY/SUMMARY

• Leave 1 minute to put a plan together of the next step

• Give a Patient Information Leaflet

• Check their understanding of what has been said (sensitively)

• Ask if they have any questions/anything they did not understand

• Suggest a follow up date after they have absorbed the information/spoken to love ones

I hope you found the information relevant and useful.

We worry about these stations incase we come across as too abrupt or that we will freeze when the actor/patient starts crying… My one advice for success is - just listen and show empathy. It will feel odd sitting opposite someone crying/getting angry, but if you take a step back and listen, the examiner will give you marks for being human.

Stay focused and happy revision :)