Breaking Bad News and Discussing Prognosis
Domain 4: Breaking Bad News and Discussing Prognosis
This domain tests structured delivery of serious news, responding to emotion, and prognosis conversations under uncertainty.
Core rules
- SPIKES: Setting (private, seated, tissues, key people present), Perception ("What have you understood so far?"), Invitation ("How much would you like to know?"), Knowledge (warning shot, then plain language), Emotions and empathy (respond before giving more information), Strategy and Summary.
- Fire a warning shot: "I'm afraid I have some difficult news." Pause and let the patient prepare.
- Use ask-tell-ask, not tell-tell-tell. Give one piece of information, then check.
- Expect and name emotion using NURSE: Name, Understand, Respect, Support, Explore. Tears and silence are not failures; stay present.
- Wish statements ("I wish I had better news") acknowledge without false hope.
- Prognosis: ask before giving it, offer a range, and use best case / worst case / most likely. Pair "hope for" with "worry about".
- Reassure against abandonment: "We will keep treating your symptoms and support you whatever happens."
Worked example
A 62-year-old with metastatic pancreatic cancer asks, "How long have I got?" First check the invitation and what the question means to him - his daughter's wedding is in four months. Then: "For someone in your situation, the most likely time is months rather than years; some people live longer, some shorter. I can't be precise." Follow with "What is most important for you in that time?" and plan around the wedding.
Traps
- "There's nothing more we can do" - replace with what will be done.
- "Don't worry" or "you'll be fine" - false reassurance destroys trust.
- Giving a prognosis you were not invited to give, or giving a single number.
- Colluding with relatives who say "don't tell her" without exploring why; the patient's right to know usually prevails.