A Guide for Conducting a Family Meeting Modified “SPIKES” (original by Baile & Buckman)
May 15, 2015
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Author: Elizabeth Cerceo, MD, FACP
Being able to communicate bad news is a necessary skill set for the medical student, the resident, and the seasoned attending but it is also a very complex task. There is the verbal component of delivering bad news but then we must manage the emotional reactions, support the patient in decision-making while still involving the family, dealing with stress. The SPIKES method was originally developed for disclosing bad news in the setting of oncology. (Original SPIKES: Setting up the interview; assessing the patient’s Perception; obtaining the patient’s Invitation; giving Knowledge and information to the patient; addressing the patient’s Emotions with empathic responses; Strategy and Summary) (1) The goal is to enable the clinician to fulfill the four most important objectives of the interview disclosing bad news: gathering information from the patient, transmitting the medical information, providing support to the patient, and eliciting the patient's collaboration in developing a strategy or treatment plan for the future. Health care providers who have been taught the protocol have reported increased confidence in their ability to disclose unfavorable medical information to patients. (2)
S= Set up the situation
- Review the chart (history and medical issues).
- Get all relevant health care members (MD, RN, SW, palliative care) and family members in the room with one clinician as meeting leader
- Clarify goals of meeting with team.
- Privacy, seating for all, tissues
- Introduce all in attendance.
- Maintain eye contact.
- Establish the overall goal of the meeting: e.g., “I know this is a difficult time for everyone. I would like to review how X is doing and answer your questions.”
- Set ground rules: e.g.,“We have a half hour for discussion today.”
P= Assess patient/family Perception of the medical situation
- Assess what they know: “Let’s start by making sure we are all on the same page. How are you seeing the medical situation at this point? What have you been told?”
I= How much Information is wanted? “Would you like me to give you all the information or sketch
out the results and spend more time discussing the treatment plan?”
- Limit to two points:
- Patient’s illness and treatments
- Prognosis – what you expect re survival, recovery, quality of life
- Hints for how to give the information:
1) Ask for permission: Would you like me to talk about what we think is going to happen?
2) Avoid medical jargon.
3) Beware of physicians’ tendency to talk too much and focus on technical matters.
4) Check frequently on what the family has heard: “What questions do you have about what
I just said?”
5) Be transparent about uncertainty: “I wish I could be clearer about what will happen”
6) Assess questions and concerns: “You just got a lot of information. What questions do you
E= Use Empathic statements when responding to emotions (rather than trying to “solve” them):
- “NURSE” mnemonic: (Tulsky et al.) (3)
N-ame “You seem distressed [or angry or worried, etc.]”
U-nderstand “This must be very difficult for you.”
R-espect “I can see how much you are trying to honor your Dad’s wishes.”
“You are asking a lot of really good questions.”
S-upport “We will be there to help advise you. We can talk again tomorrow.”
E-xplore “Tell me more about what you are thinking/feeling.”
- Don’t fight. Use “wish statements”: “I hear how much you want him to get better.
I wish I could promise things would get better. I hope he gets better too.”
See if the family can hope for the best, prepare for the worst:
“We are doing everything we can in hopes your loved one will get better. I wonder, though, if you have been able to think about what if things do not go well?”
S= Strategy – what is going to be done next
- Elicit goals of all those present but maintain focus on the patient’s perspective: “Given what’s gone on, what would X say if he could see all this and speak to us himself?”
- Explore what the patient valued, his attitudes on critical illness, and what would be in his best interest: “What kinds of things were important to him? What did he enjoy? Did this sort of discussion or situation ever come up in your family?”
- Understand ethnic and cultural influences on communication, decision-making, family relationships, concepts of illness and death. “Can you help me understand what I need to know about X’s beliefs and practices so I can take the best care of X?”
- Take a Spiritual History (4):
- S-piritual belief system
- P-ersonal spirituality
- I-ntegration with a spiritual community
- R-itualized practices and restrictions
- I-mplications for medical care
- T-erminal-events planning
S= Specific decisions
- Defer discussion of specific therapies (e.g., mechanical ventilation) until the general goals are clarified: “It sounds like X’s primary goal was to be able to be study independent. And if that could not happen, he wanted to avoid being stuck on a breathing machine?”
- Offer clear recommendations based on patient and family goals: “Given what we know and have heard, Dr. D could you make a recommendation about what treatments would help?
- Do not speak of withdrawing “care” or “treatment.”
- If appropriate, suggest a therapeutic trial. “It sounds like we should try the treatment for about a week and see if he is better.”
- Offer a brief summary of what was discussed.
- Review what is going to be done to try to achieve the patient’s goals and what will indicate whether the patient is better or worse.
- Offer to answer questions, then or later
- As you think about what we have talked about, you may have questions. Feel free to ask me, now or later.
- Check in to make sure they heard what you wanted them to hear
- I want to make sure we are on the same page. If you were going to tell someone about this meeting, what would you say we talked about?
- Express appreciation and respect for the family:
- I want to thank everyone for being here and for helping to make these difficult decisions.
- Make a clear follow-up plan, including for next family meeting.
Document the meeting in the chart!
1. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000; 5 (4): 302-11.
2. Cook D and Rocker G. Dying with dignity in the Intensive Care Unit. NEJM 370; 26: 2506-14.
3. Pollak KI, Arnold RM, Jeffreys AS, Alexander SC, Olsen MK, Abernethy AP, Skinner CS, Rodrigues KL, Tulsky JA. Oncologist communication about emotion during visits with patients with advanced cancer. J Clin Onc Dec 2007; 36: 5748-52.
4. Maugans TA. The SPIRITual history. Arch Fam Med 1996; 5: 11-16.