Which Medical Specialist Should Discuss Death with Patients? Is That the Right Question?

I recently saw the Boston Globe report saying that physicians have received “remarkably little instruction on how to discuss death” with their patients (at link http://www.boston.com/lifestyle/health/articles/2011/07/24/at_mass_general_palliative_care_changes_patients_lives/?page=full) [1]. It’s led to the rise of palliative care as a subspecialty in the development of teams to “live with serious illness–and cope with its toughest decisions.” Palliative care programs grew from 658 of 2,489 US hospitals to the current 1,500 according to figures from the Center to Advance Palliative Care.

One our talented resident physicians gave a presentation at our weekly case conference about how to give patients difficult news utilizing the SPIKES protocol [2]. You can find the video presentation by the University of Iowa’s own Dr. Marcy Rosenbaum on how to put SPIKES into practice, including a little role-playing exercise, on this blog site and at the site where the video originated, the Iowa Geriatric Education Center, the link for which is also above under the Humanism in Medicine menu heading. NOTE: if the IGEC site link doesn’.t work, see below). It doesn’t make difficult conversations about death and dying and other jugular issues with patients any easier.

But it’s a place to start. There’s a whole lot more to SPIKES (an acronym of the 6 steps of an ideal interview for giving bad news to a patient) than just the steps:

Setting up the interview

Evaluating the Perception of the patient regarding his/her illness

Getting the patient’s Invitation to disclose bad news

Sharing the doctor’s Knowledge (bad news) with the patient

Evaluating and Empathizing with the patient’s emotional response

Strategy for dealing with the patient’s diagnosis, and summary of encounter

Probably the most difficult step is empathizing, strange as that sounds. Another study the resident presented outline the difficulty in doing research on communication skills training for physicians, noting that this really didn’t significantly change the patient’s anxiety level after medical consultation [3].

Is the goal to eliminate anxiety–or sit in the chair and share it with the patient? And will there ever be enough Palliative Care subspecialists to assume this role? I think once upon a time there was a special group of medical professionals who carried this burden. We called them “doctors.”

1. Burge, K. (2011) “A better kind of care.” The Boston Globe.

2. Baile, W. F., R. Buckman, et al. (2000). “SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer.” The oncologist 5(4): 302-311.

3. Lienard, A., I. Merckaert, et al. (2006). “Factors that influence cancer patients’ anxiety following a medical consultation: impact of a communication skills training programme for physicians.” Annals of oncology : official journal of the European Society for Medical Oncology / ESMO 17(9): 1450-1458.