Delivering Bad News

David Ray Velez, MD
The Operative Review of Surgery. 2023; 1:150-154.

Download PDF

Table of Contents

SUNBURN Protocol
SPIKES Protocol
Other Models
General Approach

References

SUNBURN Protocol

Definition

  • Framework for Delivering Bad News in Trauma and Acute Care Surgery
  • Used to Guide Discussion with the Patient and/or Family Depending on the Circumstances

Steps 1

  • S: Set Up – Review the Clinical History and Prepare for the Conversation
  • U: Understand Perceptions – Appreciate What information is Already Known and Correct Any Misconceptions
  • N: Notify (“Warning Shot”) – “I’m Afraid I Have Some Bad News”, Followed by a Pause to Sink In
  • B: Brief Narrative and Break Bad News – Brief Narrative to Provide Context and then Deliver the News Directly
  • U: Understand Emotions – Allow for Silence and Appreciate the Emotional Response
  • R: Respond – Respond to Patient/Family Emotions with Empathy and Care
  • N: Next Steps – Discuss the Next Steps or Strategy Going Forward

Unique Challenges in Trauma and Acute Care Surgery

  • “SPIKES” and Other Protocols Poorly Correlate in Trauma 1
  • No Previously Established Rapport
  • Injury is Often Sudden Unexpected 2
  • Events are Shrouded in Misconception 2
  • Patients are Generally Younger 2
  • Fewer Resources for Grief Support – Often Present on Nights and Weekends (Not Fully Staffed) 3,4

SUNBURN Visual Abstract 1

SPIKES Protocol

Definition

  • Framework for Delivering Bad News
  • Originally Designed for the Use in Oncology Patients at MD Anderson Cancer Center 2
  • The Most Commonly Described Model in Medicine

Factors 5

  • S: Setting – Set Up the Interview
  • P: Perception – Assess the Patient/Family Perception
  • I: Invitation – See What the Patient Wants to Know
  • K: Knowledge – Share Knowledge
  • E: Emotions – Respond to Patient/Family Emotions
  • S: Strategy/Summary – Recap and Decide the Next Plan

Other Models

ABCDE Protocol 6

  • Developed for Use in Primary Care
  • Factors:
    • A: Advanced Preparation – Review History and Prepare
    • B: Build a Therapeutic Environment/Relationship – Ensure Adequate Time and Privacy in an Appropriate Setting
    • C: Communicate Well – Avoid Medical Jargon and Allow for Silence
    • D: Deal with Patient/Family Reactions – Actively Listen and Explore Empathy
    • E: Encourage and Validate Emotions

BREAKS Protocol 7

  • Developed for Oncology and Palliative Care in India
  • Factors:
    • B: Background – Review the Clinical History and Relevant Information Before Hand
    • R: Rapport – Build Rapport and Allow Time to Understand Patient/Family Concerns
    • E: Explore – Determine Patient/Family Understanding of Illness
    • A: Announce – Give a “Warning Shot” and Deliver the News
    • K: Kindle – Address Emotions as they Arise
    • S: Summarize – Summarize the News and Patient Concerns

General Approach

Preparation

  • Take a Moment to Compose Yourself
  • Anticipate and Understand the Details Surrounding the Event and Clinical Course
  • Mentally Prepare What You Will Say
  • Bringing an Experienced Nurse Can Be Helpful
  • Remove Any Blood-Stained Clothing

Setting

  • Use a Quiet Room
  • Have a Safety Strategy to Exit the Physical Space in the Case of a Violent Response
  • Multiple Family Members Can Be Supportive but Avoid Excessively Large Groups
    • Particularly in Pediatric Traumas – Larger Groups May Detract from the Ability to Provide Support to Parents

Delivery

  • Sit Down – Do Not Stand by the Door
  • Make Eye Contact and Look at Who You are Addressing
  • Understand What Information They Already Know to Correct Any Misconceptions
  • Begin with a “Warning Shot”
    • “I’m Afraid I Have Some Bad News”
    • “I Am So Sorry…”
  • Be Honest and Direct, Do Not Beat Around the Bush
    • Give a Brief Narrative for Context and Then Deliver the News
    • If Patient Has Died, Use the Words “Death” or “Dead” and Avoid Euphemisms (“Passed Away”)
    • Avoid Excessively Long Drawn Out Narratives that Delay Delivery – There is No Way to Soften the Impact
  • Avoid Excessive Technical Information or Unnecessarily Gruesome Details
  • Do Not Rush

After

  • Allow Silence for Facts to Sink In
  • Allow for the Bereaved to React to the News – Varied Reactions May Be Seen
  • Provide Tissues
  • Touching/Holding a Hand to Comfort is Generally Appropriate but Should Be Considered in Various Social/Cultural Settings
  • Avoid Platitudes or False Sympathy
    • “You Have Another Son”
    • “I Know What it is Like”
  • Do Not Concentrate on Yourself
    • “I Have a Child Too”
    • “You Know, This Isn’t Easy for Me”
  • Provide an Opportunity for Family to See the Patient – Even if Injuries are Mutilating, Although Cover Wounds as Able

Debrief with the Medical Team

  • “Second Victims” – Traumatic and Adverse Events Can Cause Significant Psychological Distress to the Physicians and Medical Team Providing Care as Well 8
  • Consider a Debrief with the Medical Team to Ensure the Emotional Stability of the Staff
  • Discussions Should be Led by the Team Leader/Physician as Close to the End of an Event as Possible 9
  • Primary Goals of the Discussion: 9,10
    • Review What Happened
    • Analyze the Team Functioning and Evaluate for Necessary Changes/Improvements
    • Create a Feeling of Professional Capability, Resilience, and Trust
    • Enable Expression of Feelings
    • Screening of Team Members for Acute Stress Reactions

Most Important Factors in Trauma (From the Perspective of Family) 11

  • Most Important:
    • Attitude of the News-Giver (72% Consider Important)
    • Clarity of the Message (70%)
    • Privacy (65%)
    • Knowledge/Ability to Answer Questions (57%)
  • Intermediate Importance:
    • Sympathy
    • Time for Questions
    • Location of the Conversation
  • Least Important:
    • Attire of the News-Giver (3%)

References

  1. Velez D, Geberding A, Ahmeti M. SUNBURN: a protocol for delivering bad news in trauma and acute care surgery. Trauma Surg Acute Care Open. 2022 Feb 9;7(1):e000851. (License: CC BY-NC 4.0)
  2. McLauchlan CA. ABC of major trauma. handling distressed relatives and breaking bad news. BMJ1990;301:1145–9.
  3. Kieffer WKM, Michalik DV, Gallagher K, McFadyen I, Bernard J, Rogers BA. Temporal variation in major trauma admissions. Ann R Coll Surg Engl2016;98:128–37.
  4. Smith SA, Yamamoto JM, Roberts DJ, Tang KL, Ronksley PE, Dixon E, Buie WD, James MT, Care WS. Weekend surgical care and postoperative mortality: a systematic review and meta-analysis of cohort studies. Med Care2018;56:121–9.
  5. 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. Oncologist2000;5:302–11.
  6. VandeKieft GK. Breaking bad news. Am Fam Physician2001;64:1975–8.
  7. Narayanan V, Bista B, Koshy C. ‘BREAKS’ protocol for breaking bad news. Indian J Palliat Care2010;16:61–5.
  8. Seys D, Wu AW, Van Gerven E, Vleugels A, Euwema M, Panella M, Scott SD, Conway J, Sermeus W, Vanhaecht K. Health care professionals as second victims after adverse events: a systematic review. Eval Health Prof2013;36:135–62.
  9. Missouridou E. Secondary posttraumatic stress and nurses’ emotional responses to patient’s trauma. J Trauma Nurs2017;24:110–5.
  10. Knobler HY, Nachshoni T, Jaffe E, Peretz G, Yehuda YB. Psychological guidelines for a medical team Debriefing after a stressful event. Mil Med2007;172:581–5.
  11. Jurkovich GJ, Pierce B, Pananen L, Rivara FP. Giving bad news: the family perspective. J Trauma2000;48:865–73.