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Breaking Bad News Frameworks
| Mnemonic | Six-step outline (what you do) | Anaesthetic-specific tips (how you apply) |
|---|---|---|
| SPIKES (Set-up, Perception, Invitation, Knowledge, Emotions, Strategy/Summary) |
1 Prepare private space, silence phone, invite family. 2 Ask “What is your understanding of why you are here?” 3 “Would you like me to explain the findings?” (respect ‘right not to know’). 4 Warm-up (“I’m afraid I have difficult news”), chunk information, avoid jargon, pause for questions. 5 Name emotion ➜ show empathy (NURSE: Name, Understand, Respect, Support, Explore). 6 Agree next steps, give written plan, offer follow-up contact. |
• Schedule ≥ 10 min in pre-operative clinic; avoid corridor updates. • Sit at eye-level, keep laryngoscope/computer out of sight. • End with “You will not face this alone–the team and I are here.” |
| Kaye’s 10-step | Prepare → What patient knows → More info? → Warning shot → Allow denial → Explain → Listen → Encourage feelings → Summarise → Follow-up | Pair with SPIKES for viva: emphasises warning shot and allowing denial. |
- Evidence notes
- Systematic reviews (2023–2024) show SPIKES training improves clinician confidence and patient satisfaction but requires reinforcement every 6–12 months to sustain skills.
De-escalating an Aggressive Patient (ABCDE)
| Step | Key actions | Rationale / SA guidance |
|---|---|---|
| A–Assess & Announce | Rapid risk scan (weapons, exits); introduce yourself and role. | Mental Health Care Act advocates least-restrictive measures. |
| B–Behavioural boundaries | Speak slowly, 1–2 m distance, hands visible; set clear limits (“I want to help, but I cannot if you threaten staff”). | Avoid physical contact unless safety required; call security early. |
| C–Concerns & Causes | “Tell me what is upsetting you.” Active listening; reflect feelings. | Validating emotions often diffuses 70 % of situations. |
| D–Decide & De-escalate | Offer choices (drink, phone call, sit down); simple factual info. | Respect autonomy; reduces perceived power imbalance. |
| E–Exit / Escalate | If risk escalates: summon help, consider PRN medication, follow hospital restraint/seclusion policy. | SA DoH Policy on Seclusion & Restraint requires continuous observation, 15-min vitals, senior review within 1 h. |
Supporting Patients & Families Through Grief
Kübler-Ross Five Stages (DABDA)
| Stage | Typical emotions | Clinical response |
|---|---|---|
| Denial | “This can’t be true.” | Provide clear facts; keep door open for questions. |
| Anger | “Why me?” | Stay calm; recognise anger at situation, not you. |
| Bargaining | “If I do X maybe….” | Explore hopes; discuss realistic goals. |
| Depression | Hopelessness, withdrawal | Empathic presence; liaise with mental-health team. |
| Acceptance | Peace, planning | Support advance care planning, hospice referral. |
Contemporary Models
- Dual-Process Model–oscillation between loss-oriented and restoration-oriented coping; explain to families that emotions may fluctuate daily.
- Encourage meaning-making (legacy work, memory boxes)–improves long-term mental health outcomes.
Putting It Together–Peri-operative Road-map
- Identify: high-risk discussions (poor prognosis, unanticipated complication, aggressive behaviour).
- Prepare: choose framework (SPIKES/Kaye), private room, translators.
- Deliver: follow steps, document verbatim significant statements.
- Respond: manage emotion (NURSE) or aggression (ABCDE).
- Follow-up: written summary, contact details, involve palliative or mental-health team.
Links
- Research ethics
- Practice guideline
- Practice management
- Never ever events
- Death on table
- Brainstem death
References:
- Szmulewicz, C., Rouby, P., Boyer, C., Benhamou, D., & Capmas, P. (2021). Communication of bad news in relation with surgery or anesthesia: an interdisciplinary simulation training program. Journal of Gynecology Obstetrics and Human Reproduction, 50(7), 102062. https://doi.org/10.1016/j.jogoh.2021.102062
- Baile WF, Buckman R. SPIKES—six-step protocol for breaking bad news. Oncologist 2000;5:302-11.
- Devlin TG, O’Reilly M. Evaluating the effectiveness of the SPIKES model: systematic review. Med Educ 2023;57:120-9. pubmed.ncbi.nlm.nih.gov
- Health Professions Council of South Africa. Guidelines on Mental Health Care & Seclusion 2012. knowledgehub.health.gov.za
- AlGhamdi A et al. Health professionals’ experiences of breaking bad news: scoping review. Front Med 2024;11:1440867. frontiersin.org
- South African DoH. Policy Guidelines on Seclusion and Restraint of Mental Health-Care Users (2012). knowledgehub.health.gov.za
- Kübler-Ross E. On Death and Dying. New York: Macmillan; 1969.
Summaries
Copyright
© 2025 Francois Uys. All Rights Reserved.
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