Delivering 'Bad' vs 'Serious' News to Patients

Neil Chesanow


January 27, 2016

In This Article

What Is the Patient's Perception?

The second consideration in the SPIKES protocol—perception—is asking the patient, "What do you already know about your medical situation?" Dr Back says. "'What did you take away from what the other doctor told you?' It can be really important for the primary care doctor to find out that the patient, in the moment, can't come up with anything that, say, the cardiologist said."

"What that means to me as a news giver is that I don't know whether the cardiologist explained the patient's test results and diagnosis. All I know is that the patient can't tell me, so I should actually go back through the explanation in a step-by-step way."

Questions might include[4]:

  • What do you understand about your illness?

  • How would you describe your medical situation?

  • Have you been worried about your illness or symptoms?

  • What did other doctors tell you about your condition?

That the patient can't summarize what a specialist said does not necessarily mean that the specialist didn't offer an explanation. Even when a doctor takes pains to explain a diagnosis, and even when the doctor attempts to use plain English, nearly one half of all adults in the United States—90 million people—have trouble understanding what the doctor told them about why they are sick, the Institute of Medicine reports.[5]

Even everyday words like "bowel," "colon," "screening test," "mammogram," and "blood in the stool" are widely misunderstood, studies show.[6,7] You may need to explain what, for example, the colon is, where it's located, what it does, why it's important, and its role in the patient's problem.

Does the patient understand the purpose of a test and the meaning of the unfavorable results you are about to discuss? If not, Dr Back explains, these should be clarified. What are the patient's expectations of treatment? What are the patient's goals? Note any denial, avoidance of topics, or excessive optimism on the patient's part and gently correct any misconceptions or misunderstandings.

Encouraging Patient Participation

Once you have a basic grasp of what the patient perceives about his or her condition, the next step—invitation—is determining the best way to get the patient to "opt in" to the conversation, Dr Back says, rather than having you do all the talking and the patient passively listening. "I most commonly ask, 'Can we spend a couple of minutes going through your information?'" he says. "'It doesn't sound like it was very clear.'" Asking permission, and receiving the patient's consent, psychologically involves the patient in the discussion.

It's important to find out how much information the patient wants, Dr Back adds. Many patients welcome as much information as they can get. But this is not universally true. "Patients vary in their preferences regarding the level of detail of the information they want to receive," one team of investigators noted, with some patients being "information-averse" and others being "information-loving." A doctor who fails to understand the patient's preference "may lead to nonadherence to her recommendations."

To learn the patient's wishes, the AMA recommends asking such questions as[4]:

  • Would you like me to tell you the full details of your condition? If not, is there someone else you would like me to talk to?

  • Some people really do not want to be told what is wrong with them but would rather that their families be told instead. What do you prefer?

  • Do you want me to go over the test results now and explain exactly what I think is wrong?


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.