Table 1

Communication models for discussing prognosis

Communication modelSerious Illness Conversation Guide28 ADAPT29 PREPARED30 SPIKES31 The four habits model32
ComponentsSet up the conversation
Assess understanding and preference
Share prognosis
Explore key topics
Close the conversation
Document your conversation
Communication with key clinicians
Ask what the patient knows,
Discover what information about the future would be useful
Anticipate ambivalence
Provide information
Track emotion
Prepare for the discussion
Relate to the person
Elicit patient and caregiver preferences
Provide information tailored to needs of patients and their families
Acknowledge emotions and concerns
(Foster) Realistic hope
Encourage questions
Invitation or Information
Summarize or Strategize
Invest in the beginning
Elicit the patient’s perspective
Demonstrate empathy
Invest in the end
Created/sponsored byAriadne Labs-MGH, National Advisory Group, United States, 2012VitalTalk
National Institutes of Health funding, 2012
Expert Advisory Panel, New Zealand, Australia, 2007MD Anderson physicians, 2000Kaiser Permanente, 1995
Introduction/environmentSet up the conversation
  • Introduce purpose

  • Prepare for future decisions

  • Ask permission

Prepare for the discussion
  • Confirm pathological diagnosis and investigation results before initiating discussion

  • Try to ensure privacy and uninterrupted time for discussion

  • Negotiate who should be present

Relate to the person
  • Develop rapport

Show empathy, care and compassion during the entire consultation
Setting up the Interview
  • Arrange for some privacy

  • Involve significant others

  • Sit down, make connection with the patient

Manage time constraints and interruptions
Invest in the Beginning
  • Create rapport quickly

  • Elicit the patient’s concerns

Plan the visit with the patient
“I understand that you're here for… Could you tell me more about that?”
– “What else?”
Patient’s understanding and preferenceAssess understanding and preferencesAsk what the patient knows, what they want to know
Discover what information about the future would be useful for the patient (statistics vs living to a particular date)
Anticipate ambivalence
Elicit patient and caregiver preferences
  • Identify reason for consultation and elicit patient’s expectation

  • Clarify understanding and establish how much detail they want to know

  • Consider cultural and contextual factors influencing information preferences

Assessing the patient’s perspective
  • ‘Before you tell, ask’

Obtaining the Patient’s Invitation
  • How much information and in what manner would you like it

Elicit the patient’s perspective
  • Ask for the patient’s ideas

  • Elicit specific request

Explore the impact on the patient’s life
PrognosisShare prognosis
  • Share prognosis tailored to information preferences

  • Frame as a ‘wish…worry’, ‘hope… worry’ statement

Provide information in the form the patient wantsProvide information tailored to individual needs of both patients and their families
  • What to expect

  • Use clear, jargon-free language

  • Explain uncertainty, limitations and unreliability of prognostic and end-of-life information

  • Consider caregiver’s distinct information needs

Giving Knowledge and Information to the Patient
  • Prepare that you are giving bad news

  • Start at the level of comprehension and vocabulary of the patient; use nontechnical words

  • Don’t use excessive bluntness

  • Give information in small chunks and check periodically as to the patient’s understanding

Invest in the end
  • Deliver diagnostic information frame in terms of patient’s original concerns

  • Provide education

Respond to patient’s emotionAllow silence, explore emotionTrack emotionAcknowledge emotions and concerns
  • Explore and acknowledge patient’s and caregiver’s fears and concerns and their emotional reaction to the discussion

  • Respond to distress

(Foster) Realistic hope
  • Be honest without being blunt

  • Do not give misleading or false information to try to positively influence patient’s hope

  • Reassure support, treatments and resources are available to control pain and other symptoms

Addressing the patient’s emotions with empathic responses
  • Observe for any emotion (tearfulness, sadness, silence, shock)

  • Identify the emotion (name it), use open ended questions

  • Identify the reason for the emotion

  • Let the patient know that you have connected the emotion with the reason for the emotion

Demonstrate empathy
  • Be open to the patient’s emotions

  • Make an empathic statement

Convey empathy nonverbally
GoalsExplore key topics
  • Goals

  • Fears and worries

  • Sources of strength

  • Critical abilities

  • Tradeoffs

  • Family

(Foster) Realistic hope
  • Explore and facilitate realistic goals and ways of coping on a day-to-day basis

  • Clear plan for the future

  • Shared decision making

Understand important specific goals
Elicit the patient’s perspective
  • Explore the impact on the patient’s life

Invest in the end
Involve the patient in making decisions
ConclusionClose the conversation
  • Summarise

  • Make a recommendation

  • Check in with patient

  • Affirm commitment

Encourage questions
  • Check understanding and if information meets patient’s and caregiver’s needs

  • Leave door open for topics to be discussed again in future

SummarizeComplete the visit
  • Summarise

  • Review next steps

  • Ask for additional questions

Assess satisfaction
After encounterDocumentation
  • Document your conversation

Future plans
  • Communicate with key clinicians

  • Write a summary of what has been discussed

  • Speak or write to other key healthcare clinicians involved in patient’s care

ValidationRCT34 35 RCT39 Not validatedObservational study40 RCT51
  • RCT, randomised controlled trial.