Delivering Bad News: A Crucial Conversation

• Delivering Bad News: A Crucial Conversation (333.1 KB)

You take a deep sigh as you look at Max’s hip radiographs. You need to tell Claire that her beloved 6-year-old Lab and hiking partner has severe hip dysplasia. Over the years, you’ve heard about their outdoor adventures and more recently, their long-anticipated trip to Alaska. Now you must tell Claire that Max cannot handle such long and demanding hikes, and you know this news will result in significant changes to their lifestyle, activities, and future together.

Bad news is defined as any news that drastically and negatively alters a person’s views of the future.¹ Clients interpret bad news on an individual basis; their response depends on their relationship with their pets, past experiences, other life stressors, and support systems they have in place. Some clients react to bad news with anger or blame, overwhelming feelings of guilt, shock, disbelief, or sadness, while others may appear calm, stoic, or under control.

A Crucial Conversation
Delivering bad news is one of the most difficult conversations for any member of the veterinary team. You may feel pressed for time or lack specific training or experience. You may take on responsibility for your patient’s illness, worry about your patient’s quality of life, or be concerned about the client’s—and your own—emotional response. Your default mode may be to give a lot of information quickly to get it over with, often leaving behind an overwhelmed and confused client. Preparing yourself for tough conversations can help. While there are no methods to break bad news painlessly to Claire about Max, the following six steps (the SPIKES model¹) foster information exchange and support the veterinarian–client–patient relationship.

SPIKES¹ Model: Six Steps for Delivering Bad News

S: Create a supportive setting
P: Understand your client’s perspective
I: Obtain an invitation to proceed with information-giving
K: Give knowledge and information
E: Address the client’s emotions with empathic responses
S: Strategize and summarize
 

Create a Supportive Setting
Ensure privacy, attend to client and patient comfort, minimize distractions, allow for time, sit down at the same level, and invite supportive individuals.
• Identify who should be present for the conversation. For instance: “I am wondering who else cares for Max and may want to take part in this conversation.”
• Take time to establish initial rapport, using open-ended questions, compliments, and empathy statements. Try statements like: “How is Max doing?” and, “How are you doing?” “It was wise to bring Max in so we can address this problem.”  “It sounds like that last hike was rough on both of you.”

Understand Your Client’s Perspective
• Exploring the client’s perspective using open-ended questions allows you to assess her understanding of the pet’s illness. Customize your information-giving and address the client’s concerns. Ask things like: “What are your concerns regarding Max’s condition?” “What do you think is causing Max’s lameness?” “What seems to make it worse?”
• Determine exactly what your client wants to know. People have different ways of coping with bad news. Some wish to learn as much as they can, so they feel in control, while others prefer not to know and cope by avoiding thinking about it. The goal is to tailor your discussion to your client’s individual needs. For instance: “Claire, I know how involved you are in caring for Max. How much detail would you prefer as we discuss his lameness?”

Ask Permission to Proceed with Information-Giving
• Ask permission to share the information with the client. This act of respect allows the client to ready their minds, be receptive to what you have to say, and pace the conversation with you. Try something like: “Would it be all right to go over the x-ray findings with you?”

Provide the Explanation
• It is important to remember that what may be routine conversations for the veterinary team may be information that clients are hearing for the very first time, so it is helpful to deliver the news in stages.
• Start with a warning shot. Say something that lets the client know where you are headed: “Claire, what I saw on the x-rays isn’t what I’d hoped for.” [pause]
• Continue giving information using the “chunk and check” method. Speak in small, easily understandable phrases, presenting only one to three sentences at a time. Then pause to check if your client understands before proceeding. Sharing small pieces of information allows your client time to absorb the news and checking-in encourages questions. This technique ensures that the client stays with you. For example, “Max has hip dysplasia which is causing his lameness. This is why he’s not been keeping up during his hikes.” [pause]
• Check-in and ask permission to continue. Phrases like: “What are your thoughts?” “Shall I continue?” ensure that the client is ready to learn more.
• Check for the client’s understanding, again using open-ended questions. “What questions do you have at this point?” “What additional information will be helpful to you?” and “How would you like to proceed?” are useful ways to make sure the client is with you and understands the condition.
• Avoid use of technical jargon and remember to define medical terms.
• Offer supplemental resources, such as client handouts, websites, discussion groups, and discharge statements. It is estimated that clients may hear less than 30% of this conversation, so sending information home promotes recall and understanding.
• Offer time for the client to reflect. Each individual processes bad news at different rates and some people need more time than others. If possible, suggest that clients take a break, consult a family member, or sleep on difficult decisions overnight.

Empathize
• Throughout the conversation, express empathy to acknowledge, validate, and normalize the client’s emotional response. Display your compassion through nonverbal cues, such as sitting close, using a gentle, calm tone, slowing your pace of speech, leaning forward, and reaching out through touch. For instance, “I’m here for you, Claire. Take your time.” “I’m so sorry to have to tell you this. I know this changes your plans.” I can imagine how hard this is to hear. Max has been your hiking buddy for so long.”
• Use silence to create time for the client to examine her thoughts and feelings. Practitioners sometimes struggle with finding the right words to say. By simply being a caring presence, your silence and nonverbal behaviors can provide just as much comfort as words.

Summarize and Strategize
• Summarize what has been discussed. “Now that we’ve had a chance to discuss Max’s hip problems, it sounds like you’d like to start with some medications to address his pain.”
• Negotiate a plan for treatment or follow-up. “After we run some blood work, we can start the pain medications. I’d like to see you both in 2 weeks for a recheck. How does that sound?”
• Identify your client’s support system. “If you would like to bring your family in, we can all discuss Max’s condition together.”

Outcomes of Care
Delivering bad news is never an easy task, but these techniques help reduce the burden of these challenging conversations. When bad news is delivered skillfully, difficult decisions are validated, clients’ concerns are heard, and emotions are supported. Compassionate client care promotes enduring veterinarian–client relationships and enhances professional satisfaction.

About the Authors

Erin Allen, MSW, is a clinical counselor at Colorado State University Veterinary Teaching Hospital’s Argus Institute. Jane R. Shaw, DVM, PhD, is director of the Institute.

The mission of the Argus Institute is to strengthen veterinarian-client-patient communication and support relationships between people and their companion animals. Visit argusinstitute.colostate.edu to learn more.

References
1. How to Break Bad News: A Guide for Health Care Professionals. Buckman R. The Johns Hopkins University Press, 1992.