Communicating Bad News Effectively and Compassionately in the ICU

Breaking bad news is not only difficult, but the news can be received very differently depending on the patient or their family member’s personal perceptions. During a session at CHEST 2020, Robyn Scatena, MD, director of critical care at Norwalk Hospital, outlined 2 communication models to help break bad news in the intensive care unit (ICU).

“Oftentimes, we may feel hesitant to share the whole truth because we want to protect patients or their family members,” she said. “Because we know the information that we're sharing is so sad or so devastating, that we don't want it to be true. We don't want them to have to deal with it. And so, we have to recognize those feelings in ourselves, understand it, and then try to mitigate and go forward.”

She used an example of an 88-year-old woman admitted to the ICU with an intracranial hemorrhage. Her son rushes her to the emergency department and while he’s in the waiting room, she is in a deep coma. After the ICU nurses perform an assessment, they notice her vital signs are changing rapidly and she’s not breathing spontaneously on top of her ventilator. As she goes into cardiac arrest, the team initiates CPR, and now the clinician has to figure out how to discuss the situation with the son, who is still in the waiting room.

Breaking bad news is not usually a single event, Scatena said. Instead, it is a series of interactions because patients and family members have trouble integrating information when they’re emotion or because the situation is changing.

The PEWTER and SPIKES models are designed to assist with these communication challenges.

PEWTER Model

This model begins with “prepare,” which occurs in multiple phases. There is educational preparation about how to communicate bad news; there is a psychological aspect of preparation that involves acknowledging the information is distressing; and there is physical preparation that involves creating a private setting so there are no interruptions.

Next is “evaluate” by assessing what the listener knows. This can be done easily with simple questions: what have you been told? What do you understand about the situation?

The third letter stands for “warning,” which is to prepare the listener for what is coming. This can also be a simple statement that lets the listener know they are about to hear serious information. “This statement allows the listener to engage in a mental shift and to prepare to hear some bad news,” said Scatena.

Next comes “telling.” This is when the information is shared, but Scatena emphasized that it must be shared “in a human fashion” and that the communicator should “avoid medical jargon.” In telling, the communicator should be conveying that they care, while not dancing around or minimizing the truth.

“It's really important to use open-ended questions to make sure that your listener understands what you're sharing,” she explained. “I usually say something like, ‘That's a lot that we just talked about. Please explain back to me what you understand. I want to make sure that I was clear.’”

The “e” is for “emotional response,” which describes how the communicator pays attention to the verbal and nonverbal cues of the listener. This allows the communicator to know when to pause and prevent the listener from becoming overwhelmed by the information until they are ready to be re-engaged.

The last stage is “regrouping.” During this phase, the goal is to move forward to a course of action. This may mean scheduling follow-up meetings if the situation continues to unfold, as well as sharing contacts with social services or other support systems in the community that can assist the listener.

SPIKES Model

The SPIKES Model was initially created for oncology specifically and in the first phase, “setting up the discussion,” this model requires the communicator to decide on the terminology that will be used: metastatic vs spread, for instance. Similar to the PEWTER Model, this step includes finding a private space for an uninterrupted conversation. This phase also requires a decision about which medical team members should be there to help make a care plan or provide support.

Next is “perception,” which asks the communication to consider the listener’s perception. This is similar to the “evaluate” phase in PEWTER. In this step, the communicator is trying to understand what the listener knows, how serious they believe the situation to be, and what outcomes are likely.

“In this phase, you're doing your best to suss out where your listener is, what they know, and where you need to meet them to bring their knowledge to the place it needs to be to participate in medical decision-making,” Scatena said.

The “I” stands for “invitation,” and this is when the communicator asks the patient how much information they want. Most patients want full disclosure, Scatena said, but some want their information delivery differently or may not want all the information right away.

Next is “knowledge sharing,” which has many aspects. This ties back to the perception phase. After the communicator has learned where the listener is starting from, they can “fire a warning shot” to prepare the listener for the new information and then educate the listener. Just as with the PEWTER Model, the communicator should use open-ended questions to check how the listener is understanding the information.

Mirroring the PEWTER Model, next is “emotional response,” which should be observed and permitted, Scatena said.

The final step in the SPIKES Model is “strategy and summary.” During this phase, a plan gets made for what happens next. It might be that the patient will meet with another team for the next step in treatment or the palliative care team. In addition, this is where the communicator can find out what the patient’s support system is like. This is not just an important step for the patient, but also for the communicator.

“It's important for you to summarize for yourself and to reflect on how you feel,” Scatena said. “Take time to regroup for yourself, and kind of reset yourself before you move on to do the next stressful thing in your day.”

In the earlier case of the 88-year-old woman in the ICU, Scatena explained she would use the SPIKES Model to speak with the son while his mother was undergoing CPR. She would take the son out of the waiting room and into a private meeting room, ask him to have a conversation, and first ask him what he understands about his mom’s situation. After she gains an understanding of his perception of the situation, she would ask him if she can share some information with him that could be hard to hear.

“I was just in the intensive care unit with your mom, and her situation is changing,” she said as an example.

Once she gains his permission, she’ll explain that they are currently performing CPR and if the situation is life-threatening, and then she’ll ask him to repeat it back as he understood it. In this scenario, there is an active event in the ICU, Scatena explained, so after sitting briefly with his emotions, they will quickly move to the “strategize and summary” step to discuss what the options are.

“When you're sharing bad news and see how it goes, you may choose that you're going to integrate both of the models and find the things that really work for you,” Scatena said. “But it's a really good starting point.”