Post 2: "S"PIKES
Lessons 3 and 4: Importance of preparation (before your open your mouth) for the conversation
CASE 1:
You are a primary care doctor, and you just received a pathology report on a patient of yours that shows “Adenocarcinoma” from a (lung/breast/colon) biopsy.
How would you “set up” this appointment?
____
Is this a “bad” news conversation? Yes, you would want to ensure that the right people are present at the meeting (i.e., there is a caregiver to support the patient).
But how would you make sure of it? Well, you would do that at the time you ordered the biopsy. So, setting up for this week’s conversation requires us to predict the possibility of bad news and tell the patients to bring someone to the next visit.
Wait, if that is the case, then when is the true bad news? It is entirely possible that by ordering the biopsy, we are already communicating "possibly bad” news.
So, reflecting on prior lessons, this is
Lesson 2: Use SPIKES framework at each visit with each patient.
What does setup require?
Right persons to be present
The right information to be available
Right physical setup to conduct the meeting
Who are the right people?
Patients and caregivers in an office setting, loved ones in the ICU setting where patients can not participate, and the right team members (or their representatives or information from them).
What is the right information?
This is key in either an office or a hospital setting. Having done the homework before the visit or before you walk into the door is key. Even today (about 15+ years in practice, I review patient’s chart, pathology reports, and imaging before I walk into the patient room. I may review with them again in the room, but I have done the “homework” before I walk into the room. If there is a potential clinical trial, I would also look up potential eligibility criteria. If you are in primary care and have a patient with a biopsy showing cancer, reach out to your surgery or oncology colleague to get advice on how you can facilitate the next steps.
If this is a family meeting in the ICU, you would want all the appropriate team members to be there. If all the consultants can not be there, then you would want to have a good understanding of the consultant’s opinions and their conversations with the patients/caregivers. Nothing sets the conversation back than not being prepared.
What is the right setup (physical and emotional)?
From a physical perspective, if outpatient, all must be able to sit down. Usually, there are two chairs, an exam table, and a rolling stool in my office. If there are four family members when I walk in, I go get more chairs. Even if family members tell me they “prefer to stand.” I make sure that all in the room are comfortable
And yes, PLEASE MAKE SURE YOU SIT DOWN. This signals to everyone that you are here to stay, that this is their time, and that they are not being rushed.
In the inpatient setting, if there is to be a family meeting, I advocate for a round table or a seating area with a small table —- something that will allow for physical connection to allow for an empathic physical response. If there is a large table with two ends far apart, try to sit alongside the family rather than across from them.
Preparation also involves having tissues with you should you anticipate an emotional reaction.
From an emotional perspective, besides having the information, allow yourself time to be present and thus avoid distractions; silence your phones and ask others to silence theirs.
So, what are the biggest takeaways?
Lesson 3: Sit Down
Lesson 4: “S”PIKES - ensure appropriate persons, information, and physical and emotional setting for the conversation
I would love to hear your thoughts on how you prepare for a family meeting or a visit? How often do you sit down? Does your practice (hospital or office) have enough chairs to facilitate a good meeting?
Leave Comments with your thoughts.
Biren Saraiya MD