12 SPIKES, NURSE, VALUE, ASCEND, UFO-UFO
“VALUE”
- Value Patient/family statements
- Acknowledge emotion/uncertainty
- Listen
- Understand
- Elicit questions
“ASCEND”
- Anticipate (pre-planning)
- Summarize (understanding)
- Concerns (acknowledge)
- Explore, Explain (information, goals)
- Next steps
- Document
“SPIKES”
“Bad News” format (and a “roadmap” for PCC communication event)
| Letter |
Meaning |
Notes/Steps |
| S |
Setting |
- “Set-up”: Preparation/Planning
- Environment/Comfort
- Avoid Distractions
- Participants/Introductions
- “Warning Shot”
|
| P |
Patient/Family Perspective |
- ? Perception of current status
- ? Expectations
- ? Misunderstanding/Misconception/Denial
- Values/Goals
|
| I |
Invitation |
Type/Extent of Information (Prognosis) |
| K |
Knowledge |
- Gauge to individual
- Direct/Avoid
- Jargon
- Small “Chunks”
- Ask-Tell-Ask
- Relate information to values/goals
- Address decision points
- Overall goals
- Necessary specifics (eg DNR)
|
| E |
Emotion/Uncertainty |
- Respond to Emotion (NURSE mnemonic)
- Manage
- Uncertainty
|
| S |
Summary |
- Summarize
- Assess
- Understanding
- Strategy/Next
- Steps
- Follow-up
- Nonabandonment
|
“NURSE”: Responding to Emotion
| Letter |
Meaning |
Notes/Steps |
| N |
Name |
- Suggestive rather than Declarative
- Active Listening
- Restate/Summarize
|
| U |
Understand |
- Exploration/Active Listening/Appropriate Silence
- (“I’m understanding you to say……”)
- (“I cannot imagine what it is like….”)
- Avoid Premature Reassurance
|
| R |
Respect |
- Acknowledge/Respect Intensity of Emotion
- Normalize
- Praise Coping Skills
- Non-Verbal Cues Important
|
| S |
Support |
- Expression of Concern
- Articulate Understanding
- Willingness to Help/Partner
- Nonabandonment
|
| E |
Explore |
- (“tell me more….”)
- Empathy (contrasted with sympathy)
|
“UFO-UFO”
| Letter |
Meaning |
Notes/Steps |
Example Statements |
| U |
Understand: elicit patient’s understanding of their medical situation |
- Listen for gaps in knowledge, mixed messages
- Choose your words to match theirs
- Listen for concrete vs abstract thinking styles
|
- “I’m wondering if you could tell me what you already know about your illness”
- “What have the doctors told you about your father’s condition?”
|
| F |
Fill in Gaps: add your understanding of the situation |
- May need to break bad news
- Take time to support emotions
|
- “Let me fill in some details”
- I have some new information…….”
|
| O |
Outcomes: elicit the range of patients desired outcomes; explore values, hopes, fears, expectations |
- Have patient describe an acceptable quality of life and function
- Test the lower limit carefully
|
- “Paint me a picture of what you would be able to do and enjoy”
- “If things were a bit worse such as ______ would that be acceptable?”
- “Are there health situations you are worried about getting stuck in?”
- “Is there a quality of life your mother would find intolerable?”
- “Given everything that has gone on, how do you think this will most likely turn out?”
|
| U |
Understand: find out more about the patient as a person and why they want what they want |
None |
- “Help me understand your decision-making”
- “Can you tell me about yourself that will help me understand you and where you’re coming from”
- “What things are most important to you right now”
- “Has your father or anyone in his family ever had experiences with severe illness – did he make any comments about his wishes then?”
|
| F, O |
Feasible Outcome: describe the range of outcomes you think are possible with treatment |
- May need to break bad news
- Take time to support emotions
|
- “Here is what we think are the possible results/outcomes of treatment – the best case scenario is ________, unfortunately there is a real possibility that _______ might happen, at this point what I think is most likely to happen is ________”
|
If there is overlap between the lowest acceptable QOL and the feasible outcomes:
“Since you are telling me you (your ___) would be OK even if the best we could do is get you out of the hospital to a nursing home, I recommend we try the _______, here is the plan I would recommend……….., what do you think? OR Am I understanding you correctly?”
If there is NO overlap between the lowest acceptable QOL and feasible outcomes:
“We think the best we can hope for with the most aggressive continued treatment is to get your ______ out of the hospital but would still need 24 hour care in a nursing home, probably for the rest of _____ life, but ___has said this would not be acceptable. In that case, I’m sorry to say that I cannot recommend that we continue the current level of treatment. We will not be able to get _____ to a life _____ would accept. I recommend that we focus on things we can accomplish, like ensuring the absence of pain and other symptoms.
