key: cord-0853616-ssivmue0 authors: Vitto, Christina; Del Buono, Benedict; Daniel, Lily; Rivet, Emily; Cholyway, Renee; Santen, Sally A. title: Teaching Toolbox: Breaking Bad News with Virtual Technology in the Time of COVID date: 2021-04-14 journal: J Cancer Educ DOI: 10.1007/s13187-021-01975-7 sha: 489575c4f4477d6c89466007cd2f91f54c703e0c doc_id: 853616 cord_uid: ssivmue0 Breaking bad news is a key component of the physicians’ work. Traditionally, breaking bad news has been encouraged to be performed in person whenever possible (Monden et al. Proc (Bayl Univ Med Cent) 29(1):101–102, 2016; Nickson 2019). The common practice prior to the pandemic can be summarized by “The first rule of breaking bad news is: do not do it over the phone.” It is important to be present with the family and provide support through compassion and empathy. Until recently, virtual communication technology for serious medical discussions was rare and primarily used when compelled by circumstances such as distance. The COVID-19 pandemic has transformed our ability to deliver news in person and has required the medical community to increase the utilization of telephone and video conferencing to communicate with patients and their family members. Breaking bad news through virtual media is a new skill in need of further guidance and education regarding how to set up the conversation, provide empathy, and lend support (Wolf et al., Oncologist 25(6):e879–e880, 2020). Therefore, we have created a teaching toolbox to help educate healthcare providers on how to deliver bad news by phone or video. There are various frameworks that provide guidance and steps for delivering bad news. One is the SPIKES framework, which includes setting, immediate concerns, knowledge, empathy, and summary/second touch [4] . It has been demonstrated in prior studies that physicians' confidence and skills in delivering bad news can be improved using the SPIKES framework along with scenarios conducted in a simulated environment [5] [6] [7] . Given the increasing need to deliver bad news over virtual media platforms, we have created a teaching toolbox to adapt the traditional SPIKES model for use during virtual encounters (Table 1 ). In addition, our institution has added the "prep" portion to emphasize the importance of preparing for the conversation. Breaking bad news inperson is already difficult for providers to empathetically deliver and for patients to emotionally receive, and the current pandemic poses additional challenges. Virtual technologies are increasingly being used to deliver care through telemedicine and can be extended to support breaking bad news virtually. These strategies should only be employed when a face-to-face meeting is unable to be scheduled due to transportation barriers or social distancing recommendations. Some educators may choose to allow trainees to practice using standardized patients, casebased discussions, and role plays. By creating high fidelity simulations, it will help to both reinforce the key concepts of delivering bad news and will help improve provider communication skills. The COVID-19 pandemic has presented challenges in our ability to deliver bad news. However, we have the ability to utilize virtual technology to help us deliver high value care to our patients and their loved ones. We have focused on ways to maintain empathy when having difficult conversations with patients and their family members. We believe these adaptations to the traditional SPIKES model can be easily Be sure to introduce yourself and inquire as to the names and relationship of those involved in the encounter. Ask who else the patient or family member would like to have present for the conversation. Confirm the patient or family member is somewhere they can focus and safely receive news. Ensure they are not driving or in a noisy environment. Ensure there is a way to contact the patient or family member in the event of technologic failure (phone, address, etc). Encourage the patient or family member to set up their camera so they are visible. Position the image of the person on the screen close to the camera on your device, in order to look into the camera and make eye contact with the other individual(s) as closely as possible. Avoid bright light directly behind you as this will cause a glow. Proper Positioning on Screen 1 Ask the patient or family member what they understand about the current situation. This will be the basis on how the information is delivered. For example: "I would like to give you an update, but first could you tell me what you understand about why your loved one was brought in?" Address and empathize with the fact that the family member may not have been allowed to see the patient since they entered the hospital, due to stricter isolation protocols than usual. Anticipate that the family member will know less of the hospital course and be ready to explain more to them than usual. Inquire as to their readiness for the conversation. Address concerns of the patient or family members. Telephone or Video conferencing may make it difficult to understand emotions. Explore the individual's readiness to receive the information by asking questions such as: "Tell me how you are feeling" or "How much of this information would you like to discuss today." Be clear, concise and unambiguous. Avoid vague statements or medical terminology. For example, if someone has died, clearly state "Your loved one has died" and avoid phrases such as "passed on" or "passed away" or "expired." When using body language in the conversation, ensure the motions are slower and more exaggerated than they would be in a face-to-face encounter. Acknowledge and allow for emotions. Allow for silence, but be sure to move slightly, since not moving can be interpreted as a frozen screen. Use phrases such as: "If I were in the room right now, I would offer you a tissue." "Please take a moment if you need one. I will be waiting here for you." This may be a good time to lean in closer to the camera, using body language to show empathy. Make extra effort to notice the patient or family member's body language, which will be more difficult with a limited window from the camera. implemented by others to provide virtual training in delivering bad news. Discuss next steps. An important conversation should not happen once. Create a way to follow-up. For example: "I would like to give you and your family a moment to discuss this and I will be back shortly." Offer to use video conferencing to allow the family member to interact with the hospitalized patient, if possible. Offer a daily phone call from the primary team members to update family. Encourage the family to call and check on the patient as often as needed. Delivering bad news to patients Breaking bad news to patients and relatives • LITFL • CCC Clinical Governance. Life in the Fast Lane • LITFL • Medical Blog Breaking bad news via telemedicine: a new challenge at times of an epidemic SPIKES-a six-step protocol for delivering bad news: application to the patient with cancer Breaking bad news education for emergency medicine residents: a novel training module using simulation with the SPIKES protocol Effectiveness of a multiprofessional, online and simulation-based difficult conversations training program on self-perceived competence of oncology healthcare provider trainees Assessing patients' preferences for breaking bad news according to the SPIKES-protocol: the MABBAN scale Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations