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Pediatric Bioethics: Delivering Serious or Bad News

Column Author: Candyce H Greene, MD, MPH, MSW | Pediatric Bioethics Fellow

Column Editor: Brian S. Carter, MD | Interim Director, Bioethics Center; Department Chair, Department of Medical Humanities and Bioethics

Addressing serious illness and conveying such news is a vital skill for pediatricians. However, many settings may present barriers to delivering it well, resulting in poor communication, misunderstanding and even a lack of trust between the clinician, patient and parents.

Pediatric health care clinicians may find this task challenging for several reasons.

1) Worry about the emotional impact of delivering this serious news to patients and families and how to respond to their emotional response(s).4 This worry may be especially pertinent if they have known the patient or family for only a short period of time (e.g., a new patient in their clinic, emergency department (ED), or on the inpatient team).

2) Fear of being blamed for this diagnosis (e.g., fear that the patient and family may blame them for missing this diagnosis if they have known them for some time).

3) Lack of certainty about their own emotional responses to reporting this serious news.

4) Worry about their ability to deliver this serious news well, perhaps because of a lack of training in communication skills or any frequency of having to deal with these matters. Likely any professional training they did receive in delivering serious news occurred so long ago they do not recall the specifics of it and have not been able to maintain the skills.1,2

Serious news delivered poorly can worsen the emotional and physical distress to the clinician who is delivering it and to the patient and family members who are receiving it. Some clinicians may withhold information or provide an overly optimistic prognosis, which can be confusing to the patient and family member. It may also lead to a patient or family member having difficulty adjusting to the news and interpreting or assigning meaning to it. They may also detect the clinician’s lack of self-confidence and wonder whether they can trust the news.1,2  

Serious news delivered well can mitigate a grief response, provide comfort for the patient and family members, and decrease the clinician’s own emotional distress.1,2  

Some settings make the delivery of serious news more difficult due to time constraints (e.g., in a “routine” or well-child clinic visit versus the ED). Time constraints may impose a sense of urgency which can lead to communicating incomplete or wrong information, which further complicates the emotional and physical distress for all concerned.1,2

To mitigate these stressors, the SPIKES protocol5 – a six-step communication method to deliver serious news in any clinical setting – can be useful:

  • Setting: Have the conversation in a private, comfortable and non-threatening environment (an exam room is uncomfortable; a consultation or conference room would be preferable) where the conversation can be held with your patient and family members.
  • Perception: Ask your patient and their family members what they understand about their medical situation (e.g., their chief complaint, presenting medical problem, the reason they came to the ED, your office, or the hospital where they were admitted, and what medical information they have received to date).
  • Invitation/Information: Ask your patient and their family members what information they would like to know and how they like to receive this information (e.g., Do they want to hear all of the details? Would they prefer to hear the big picture?). 
  • Knowledge: Provide information about their medical condition, including the diagnosis, treatment options and prognosis, based on the level of information the patient and family members would like to hear from you.
  • Emotions: Acknowledge emotions and respond with empathy to their emotions.
  • Strategy & Summary: Discuss next steps, after summarizing the news you have provided to your patient and their family members (i.e., a strategy for how to proceed, based on the patient’s willingness and state of mind and resources needed to achieve this strategy).

This protocol provides health care professionals with a methodical and memorable way to deliver serious news to patients and their family members in any health care setting. It provides a consistent communication anchor for a clinician who does not routinely deliver serious news or is delivering this serious news for the first time as a trainee.

References:

  1. Monden KR, Gentry L, Cox TR. Delivering bad news to patients. Proc (Bayl Univ Med Cent). 2016;29(1):101-102. doi:1080/08998280.2016.11929380
  2. Berkey FJ, Wiedemer JP, Vithalani ND. Delivering bad or life-altering news. Am Fam Physician. 2018;98(2):99-104. https://www.aafp.org/pubs/afp/issues/2018/0715/p99.html
  3. Studer RK, Danuser B, Gomez P. Physicians’ psychophysiological stress reaction in medical communication of bad news: a critical literature review. Int J Psychophysiol. 2017;120:14-22. doi:10.1016/j.ijpsycho.2017.06.006
  4. Barnard C, Sandhu A, Cooke S. When differing perspectives between health care providers and parents lead to “communication crises”: a conceptual framework to support prevention and navigation in the pediatric hospital setting. Hosp Pediatr. 2019;9(1):39-45. https://publications.aap.org/hospitalpediatrics/article/9/1/39/26665/When-Differing-Perspectives-Between-Health-Care
  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. The Oncologist. 2000;5(4): 302-311. doi:1634/theoncologist.5-4-302
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