Breaking bad news to families in the covid-19 pandemic: how do we adapt our practice?

Virtual consultations require us to consider our approach when breaking bad news to families during the pandemic, argue these authors

The ability to communicate serious news to families compassionately is a core skill for all medical professionals. Within specialist palliative care we view ourselves as experts in this field and routinely break bad news in accordance with well-developed frameworks, while relying on our own professional experience and intuition. For the first time in our careers we are suddenly challenged with how to effectively deliver bad news to families in a humane manner.

Due to the covid-19 pandemic, it is no longer always possible to sit down in person with families to communicate challenging news. Visiting restrictions secondary to the covid-19 pandemic have impacted healthcare services globally. With the need for ongoing widespread visiting restrictions, how can we adapt our approach to ensure we preserve core principles and break bad news to families in a compassionate manner on the phone or via video calls? 

The SPIKES model for breaking bad news is the most commonly used and cited model in the literature. It is often used as the cornerstone for complex communication processes which involve discussing challenging issues with families. When faced with the need to communicate bad news to a family through a virtual format, is this framework helpful and how can we deliver best practice while acknowledging the limitations of such an approach?

Setting—As with other medical specialties, we have now adapted our practice in specialist palliative care to communicate serious news to families virtually, either by phone or by videoconference. Our experience has taught us that planning and preparation are more important than ever. Steps to create the right virtual setting need to occur: make an appointment with the family, decide on the appropriate medium (phone/video), allow adequate time protected from interruptions, find a quiet place, be clinically prepared. Visiting restrictions are altering how clinician-family relationships are fostered over time. If possible, developing the clinician-family relationship through virtual means early in a patient’s disease trajectory is advisable. Formal introduction of healthcare professionals conducting the meeting and all family members involved should continue as normal.

Perception—Establishing the families’ understanding of their relatives’ condition early in your engagement is vital. Facilitating video calls with the patient and families before the meeting could be considered where deemed appropriate. Enabling the family to see their loved ones’ physical changes may form part of a warning shot to receive bad news. 

InvitationObtaining permission to proceed with a clinical update is an important part of breaking bad news. Irrespective of the mode of communication, this step should not be forgotten. 

Knowledge—Communication of bad news should be preceded by a warning shot. Delivering information in small chunks with easily understood language is crucial. Equally it is imperative to check understanding as one proceeds. The use of silence and pacing enable family members to process information. It’s important to acknowledge that for the healthcare worker this can feel uncomfortable over the phone or by video. Our practice has always been to sit with families through their distress and be present. Adapting to continuing this approach virtually is possible albeit difficult.

Emotions—Responding adequately to emotions in an empathic manner during a virtual consultation can be challenging. Body language cues can be missed. Vulnerable family members may not be easily identifiable. If possible, encourage family members to express their emotions. Transparently acknowledge their distress—in virtual mediums this needs to be done verbally, in usual practice this is often done in a nonverbal manner. Being compassionate throughout your engagement, addressing emotions and following up with family members after meetings by phone or video to provide ongoing support help to alleviate family distress.

Strategy and summary—A summary of the information shared and plan going forward is essential for virtual family meetings. As always, meticulous documentation is key. This is important both for the continuity of care but also if family members need to review medical notes to help in their grieving process. The impact current visiting restrictions will have on bereavement is difficult to fully comprehend at present. It is the responsibility of all medical professionals to ensure these challenging conversations are conducted following best practice frameworks in a compassionate manner to limit adverse grief reactions in the future.

It is more important than ever to acknowledge how challenging breaking bad news via online platforms can be for ourselves and our colleagues. Many emotions may surface as we empathise with families. Self-care, reflective practice, developing competence and debriefing with colleagues all aid in preventing burnout. During these challenging times, the SPIKES model provides a framework to enable all healthcare professionals to perform an extremely difficult task in the best manner possible. 

Áine Ní Laoire, Consultant Physician in Palliative Medicine, University Hospital Waterford, Ireland. 

Hannah O’ Brien, Specialist Registrar in Palliative Medicine, Marymount University Hospital and Hospice, Ireland. 

Fiona Kiely, Consultant Physician in Palliative Medicine, Marymount University Hospital and Hospice, Ireland. 

Competing interests: none declared.