By Aakash Desai, MBBS, MPH, and Turab Mohammed, MD

For trainees, the SARS-CoV-2 health care catastrophe has radically transformed the whole residency and fellowship training experience. The loss of human lives, especially in the United States, has been unprecedented. The pandemic has emphasized one of the most challenging yet quintessential skills needed for a health care provider: the ability to break bad news compassionately to families.

As health care facilities implemented strict visitor restrictions during the peak of the pandemic, this largely restricted the traditional way of communicating serious news, sitting down with families face to face. Furthermore, communication via telemedicine, masking, and inability to gather non-verbal cues made this task even more difficult, a situation most medical students were not prepared for during their medical school training.

For patients with cancer and their physicians, sharing and discussing bad news is often an overwhelming experience, especially if done virtually. Given the increasing preference for virtual consultations, we as trainees must focus on ways to narrow this gap created by lack of human contact. Recently, one of us (Dr. Desai, on Twitter @ADesaiMD) crowdsourced tips on social media from oncology peers on communicating bad news (#BreakingBadNews). These tips are valuable for difficult conversations in the context of an actual in-person visit, and hold truer when we are already limited by lack of personal touch.

Here, we summarize a list of helpful approaches with sample statements for delivering bad news in the context of the classic SPIKES model adjusted for the digital platform. As developing our “webside” manner becomes more important, we hope that these scripts will assist trainees in overcoming the challenges posed by the virtual format and simultaneously preserve humanity, compassion, and dignity while discussing complex and sensitive health information.

Prior to the Visit:

Before you start the visit, tell your staff to minimize interruptions to emergencies only. Find a quiet room where you will not be interrupted during the conversation. Avoid having anything important scheduled immediately after such visits, if possible. Be prepared with all the necessary health-related information and additional details like hospice centers in the area. Right before walking into the room (or getting on a videoconference), pause for a brief moment and actively envision being the patient or imagine being the family of the patient. Doing this will help you to be completely present with the patient and the family. If you always treat people like you would want to be treated (in every situation), you will not go wrong. The hard truth is that we will all be in the patient’s shoes at some point in life.

Setting the Stage:

In a virtual visit, always begin the conversation by taking a moment to briefly explain why you could not do this in person. Make a connection with the patient and family. If needed, consider doing it over a video conference call, with not only the patients but also their loved ones who can see and support each other during such difficult conversation. It is often helpful to discuss the spectrum of current diagnosis right from the beginning and readdressing them intermittently during various stages of care delivery, like discussing radiology and biopsy results, as an attempt to set the stage for this type of difficult encounters which in turn can reduce the burden of the devastating bad news.

Sample Statements:

• Introduce yourself and your role: “Hello, I am Dr. [Name]. I care for your family member as their primary oncologist/hematologist.”
• Break the ice: “How are you feeling today?” or “How are you doing today?”
• Ask permission to discuss their disease: “If it is okay with you, I would like to talk to you about your illness.”

Establishing the Perception:

Fostering an early healthy relationship between the physician and the family through timely communication over the phone on health updates about the patient is vital. For certain hospitalized patients, arranging for a video call where the family members can see their loved one’s current physical condition can offer valuable context and help families understand the current clinical status of the patient and the physician’s direct further discussion with regards to goals of care. Use this opportunity to correct misinformation at the family's end and channel their thoughts to prepare their minds and ease the processing of the incoming bad news.

Sample Statements:

• “What is your agenda for today? My agenda for today is…”
• “I would like to know your understanding of the current situation?” or "A lot has happened in the last 24 to 48 hours. Tell me what you’ve been told, so I can make sure we are on the same page.”

Invitation for Information:

This is an important and often underappreciated step in divulging the bad news. Even during virtual visits, it is pertinent to ask permission before breaking bad news and ask about the extent to which they want to know about the severity of their loved one’s illness.

Sample Statement:

• “I would also like to know how much information you would like me to discuss today?” 

Impart Knowledge:

Communicating sensitive information could be a difficult task for the providers, especially during a phone conversation when verbal and non-verbal cues may be misunderstood or missed by either of the parties. Deliver the message with clear information, in the same manner you would deliver during a personal visit using simple terms in short sentences. Use words like “wish” and “hope.” Avoid medical jargon. Speak slowly and clearly, filled with empathy and compassion. Throughout this phase, look straight into the webcam while doing it over a video conference and be as direct as possible while still being kind and compassionate. When you see tears in the room, stop talking. Allow silence and give them space to grieve. Offer to leave and join back later if needed. Make sure to ask for any possible questions they may have and answer them with honesty but make sure to not sound blunt. Avoid looking at your phone or pagers unless absolutely necessary. If you need to look away to review patients’ chart for information, briefly explain what you’re doing to the family before you do so, and re-engage quickly. Consider sharing your screen to show tests results. Reviewing the CT, PET, and MRI results makes the situation easier to understand for the patients and families.

Sample Statements:

• Start with statements like “This is not what we hoped for,” or “I’m sorry this is happening to you," or "Test results are not what we were hoping for." 
• “I want to share with you my understanding of where things are with your illness.”

Engage Empathically, Explore and Address Emotions:

Addressing the emotions is one the most challenging steps while breaking bad news, especially during a virtual visit. Be proactive in identifying the vulnerable members of the family who may be easily missed. Do not intellectualize emotions. Transparently observe the responses and address them with utmost compassion and respect. The emotional response could range from remaining silent to bursting out in anger and denial. Explore key aspects like fears, worries, and beliefs. Attempt to identify the reason behind their ongoing response and be sure to acknowledge it. Give pauses to allow the patient to gather themself and ask exploratory questions to appropriately respond to patients’ emotions while offering much-needed support and solidarity.

Sample Statements:

• “What are your most important goals if your health deteriorates?”
• “What are your biggest fears and worries in terms of your health and future?”
• “How much does your family know about your priorities and wishes?”

Summarize the Session and Offer Strategy:

After making sure that the patient and the family have composed themselves, ask if they want to talk further during the same visit or they would like to have another conversation at a later point in time to discuss the further plan of care. Either way, summarizing the information before ending the discussion is very essential for adequate closure, especially during virtual consultation.  Let them ask questions and ensure they know next steps, once the patient and family are ready. They will ask you the details. Now you can re-engage. As the discussion concludes, write the plan down for them so they don’t have to remember everything from this challenging conversation.

Sample Statements:

• "I am always here for you and just a phone call away. We are in this together." 
• “I will be honest with you at all times.”
• “Now that I know what is most important for you and your family, we will work together and make sure that your treatment plan aligns with your wishes and what is important to you.”

After the Encounter:

At the end of the virtual consultation, since the hug is missing, affirm your commitment to the patient’s care and make a follow-up call later to check in and offer additional support. Plan a second visit if needed before making a final decision. This can help further mitigate family distress and assist with their grieving process. Detailed documentation of the conversation, inclusive of any treatment options discussed, is crucial for the continuity and further care planning. It also allows the patient and their family to review the notes and gather any additional information that may have been missed.

Lastly, make sure to take care of yourself. Practicing this kind of medicine and repeatedly engaging in such emotionally challenging conversations can be tough on us. Talk to friends, family, colleagues, and share thoughts. 

We hope that this serves as a framework for our colleagues and other trainees who will be starting their training during and after the pandemic, where telemedicine will likely play an important role.

Following a customized version of the SPIKES stepwise protocol to guide the sensitive conversations with the family members about their loved ones is even more pertinent so that we continue to maintain compassion and remain while breaking bad news to the families.

Dr. Desai is a first-year hematology-oncology fellow at Mayo Clinic, Rochester. He holds a master’s degree in public health from the University of Texas Health Science Center in Houston and a certification in Health Professions Education from University of Connecticut. He also serves as a secretary for the Minnesota State Medical Association Resident and Fellow Section. Dr. Desai is the recipient of a 2021 Young Investigator Award from Conquer Cancer, the ASCO Foundation. He is the new social media editor for JCO Clinical Cancer Informatics (@ASCO_pubs) and a member of the ASCO Trainee and Early Career Council. His professional interests include evidence base in oncology, clinical trials, drug development, cancer care quality, and health care delivery. He is also one of the founding members of the grassroots consortium focusing on COVID-19 in patients with cancer now known as the COVID19 and Cancer Consortium (CCC19; @COVID19nCCC). Follow him on Twitter @ADesaiMD. Disclosure.

Dr. Mohammed is a second-year internal medicine resident at University of Connecticut, Farmington. He is also pursuing a graduate program in clinical and translational research from University of Connecticut alongside his residency to prepare for a career as clinical investigator after his fellowship. His professional interests include clinical trials, equity in cancer care delivery, and innovations to tackle adverse effects of anticancer therapies. Dr. Mohammed will be applying for hematology-oncology fellowship this summer. Follow him on Twitter @DrTJM_MD. Disclosure.

Acknowledgments: We thank the following people for their insights and recommendations for how trainees should approach difficult discussions:

• Mark Lewis, MD @marklewismd
• Sam Rubinstein, MD @rubinstein_md
• Devika Das, MD, MSHQS @DevikaDasMD
• Tatiana Prowell, MD @tmprowell
• Amar Kelkar, MD @amarkelkar
• Rahul Banerjee, MD @RahulBanerjeeMD
• Jonathan Marron, MD, MPH @JonMarronMD
• Natasha Dhawan, MD @NatashaDhawanMD
• Amer Zeidan, MBBS, MHS @Dr_AmerZeidan
• Brandon Huffman, MD @BHuffmanMD
• Narjust Duma, MD @NarjustDumaMD
• Petros Grivas, MD, PhD @PGrivasMDPhD
• Luis Castelo-Branco, MD, PharmD @LuisCB_MedPharm
• Jason John, MD @jasonjohnmd
• Nicole Kuderer, MD @NicoleKuderer
• Keith Stockerl-Goldstein, MD @CyclingDoctor
• Jame Abraham, MD @jamecancerdoc
• Brian Grieb, MD, PhD @BGriebMD
• Kelly Shanahan, MD @stage4kelly
• Katie Fitzgerald Jones, BSN, MSN, APN @kfjonespallnp
• Raj Chakraborty, MD @rajshekharucms

The authors recommend reviewing the Vital Talk course and the article “Tell It Like It Is” (from the Journal of Clinical Oncology’s Art of Oncology: When the Tumor Is Not the Target series) as resources to improve one’s ability to break bad news.