Breaking bad news and serious-illness communication — formative SAQs

SAQ 1 (10 marks)

A 6-year-old is admitted with pallor and bruising; the blood film shows blasts. Both parents are present and waiting to hear the results. [1]

1. Name and define the six steps of the SPIKES protocol. (4) [1]
2. Describe how you would prepare the setting before sharing this news. (3) [1] [3]
3. Describe how you would respond to emotion once the news is shared, and name a structured tool for doing so. (3) [1] [2]

Model answer

SPIKES: Setting (private space, time, right people, interpreter); Perception (what they already know); Invitation (how much they want now); Knowledge (warning shot then plain-language headline in chunks); Empathy (respond to emotion); Strategy and summary (plan, written summary, follow-up). [1]

Prepare: a private room, both parents seated at eye level, enough uninterrupted time, phones away, tissues and water, and a trained interpreter if needed; confirm the facts and align the team beforehand. [1] [3]

Respond with NURSE (Naming, Understanding, Respecting, Supporting, Exploring); tolerate silence rather than filling it; do not continue information before acknowledging the emotion. [1] [2]

SAQ 2 (10 marks)

Later, the child relapses. A parent asks directly, "How long does she have?" and continues to demand further disease-directed treatment the team judges futile. [8] [11]

1. How should you approach answering a direct prognostic question honestly while preserving realistic hope? (4) [8] [11]
2. What is the likely underlying problem when families demand treatment the team judges futile, and how do you address it? (3) [8]
3. Describe the follow-up and team supports you would arrange after this conversation. (3) [3] [14]

Model answer

Answer honestly and with calibrated uncertainty; explore what the family already understands and what they hope for; give ranges or trajectories rather than false precision; move hope toward what is achievable (comfort, presence, meaning) without abandoning the family. [8] [11]

The likely problem is a goals-prognosis mismatch from inadequate prior prognostic communication, not parental unreasonableness. Address it by exploring values and goals, sharing prognosis honestly, and aligning the plan with what the family most wants for their child. [8]

Offer a written summary and a named next contact; arrange a follow-up meeting; involve palliative care early; use a trained interpreter; and plan a team debrief to address clinician moral distress. [3] [14]