Introduction
The Death/Dying process (DDP) has profound repercussions on the mental health of patients,
family members and friends submitted to it. These consequences bring fear, sadness,
feeling of loneliness, abandonment and anguish (1). The representations of this process
depend on social, economic, political and historical factors in which that community
is inserted. Tools such as the humanization of care based on active listening, assertive
communication and a good doctor-patient relationship are essential to face the difficulties
inherent in terminality (2). However, several studies have already demonstrated difficulties
on the part of health professionals in dealing with issues related to terminality.
Therefore, these professionals have difficulty in the realization of effective communication
(3).
Since the start of Pandemic by the COVID-19, to date, more than 761,779 deaths have
occurred and more than 20 million people have been infected (4). Due to the high infectivity
of the virus, patients are separated from family and friends (5). Professionals are
forced to transmit news, including bad news, impersonally and without prior training
via mobile telephony. Thus, conversations using online communication systems have
an increasing role in palliative care. These online telecommunications-based services
challenge effective communication and communicating bad news (CBN). Tools such as
the SPIKES protocol (6) are essential to operationalize care and prepare professionals
for a more welcoming, effective and less impactful approach.
Robert Buckman (1992) created the SPIKES Protocol in order to guide health professionals
in communicating bad news to patients and their families. The protocol is divide in
steps: (a). This procedure consists of a six-step mnemonic: S - Setting up; P - Perception;
I - Invitation; K - Knowledge; E - Emotions; S - Strategy and Summary (6). However,
with the advent of the COVID-19 pandemic there was an overload of the health system.
The health team's ability to perform welcoming work, active listening and care were
harmed.
In this context, strategies and protocols designed to establish professional security
in terminal situations, such as the SPIKES Protocol, are difficult to implement. Thus,
health professionals worldwide face an unprecedented challenge (7, 8)—how to establish
care without touching, without eye contact, without physical presence? How to mourn
without seeing the bodies? How do you bond with people you don't know without being
there? Therefore, health teams have been adapting and incorporating the use of social
media in practice making the implementation of protocols such as SPIKES challenging
(3, 6, 9, 10).
Therefore, the aim of this article was to suggest an adaptation of the SPIKES protocol
for CBN in the management of patients hospitalized with COVID-19 when the therapeutic
interventions are limited. In particular, we will use scientific literature on the
COVID-19 related challenges to highlight key points of adaptation to the SPIKES protocol.
A Proposal for The Adaptation of The Spikes Protocol for Remote Communication in The
COVID-19 Pandemic
(S): Setting Up
Preparing for communication. At this step, the physician thinks about how to speak,
the possible reactions of family members and how to deal with them and prepares the
place for the conversation (6).
Some health professionals, who previously had no direct contact with DDP, are having
to deal with this situation daily and intensely during the pandemic. The DDP in Western
culture it is still taboo (3) and a representation goes back to the conception of
death adopted from the eighteenth century (5). It is synonymous with failure/fallibility,
impotence, sadness, suffering and abandonment (3). Besides that, the uncertainties
about the natural history of COVID-19, the lack of scientific information and the
experimental protocols cause psychological distress in the team, compromising care
and the realization of protocols such as SPIKES. Steps like “S” (Setting Up), “P”
(Perception), and “I” (Information), for example, are impaired in the protocol. How
will I prepare the environment well if family members are sometimes in a distant neighborhood
or even in a different city? Interactions through social media? How to provide information
safely if the knowledge produced so far is scarce? (6, 10). So in the step “S” (Setting
Up), in the context of the pandemic, we advise that:
There is a suitable place where the professional can make the calls and/or video calls,
if possible even outside the COVID-19 unit so that he can remove the PPE, eat beforehand
and go to the bathroom, if necessary. It is advisable to use video calls at CBN due
to the possibility of identifying, on the part of the professional, non-verbal signals
coming from the receiver in order to direct the conversation (10);
Prepare a script listing the main topics of the patient's evolution, his name and
the name of the companion who usually answers the phone. It is important to emphasize
that, in search of success in communication, it is necessary to have a deep knowledge
about the clinic and the patient's demand (11, 12);
Organize, according to the demand, the main priorities for the discussion (those he
perceives will be more delicate information should be prioritized) (6, 10).
(P): Perception
It is necessary to perceive the physical and psychological state, the expectations
and understanding of the companion/family member. At this step, the professional tries
to realize how much the patient/family understood the disease and corrects misinformation
(6). Thus, at this step, perhaps the most challenging for professionals, due to social
distance, there is a difficulty in capturing signals and expressions from the recipients
of information:
Call the companion by name, as well as the patient by name. This action helps to consolidate
the doctor-patient/family relationship (11–14);
Always ask if there is someone close to the companion who is receiving the information
and advice that, if the companion is unable to keep it going, pass it on (12, 14);
Notice variations in the companion's tone of voice (tones of doubt, sadness, pauses)
(6, 13);
In the case of a video call, attention to non-verbal language such as crossing arms,
frequent deviations in the look. Research has shown that 84.3% of professionals are
aware of the role of non-verbal communication and use these cues when they are communicating
(13).
(I): Invitation
Inviting companions to understand the disease. Sometimes, patient's/family members
do not want to know details about the disease. At this time, the professional must
be available to answer any future questions (6). So, in this step, two elements are
fundamental:
Ask the companions how far they know about the patient's illness, diagnosis, health
status and prognosis. This step is analogous to what is seen in face-to-face clinical
practice (2, 14–16);
Make yourself available to answer questions (14, 16).
Try to create an intimate atmosphere even on the smartphone screen, A safe and welcoming
environment, showing willing to help (14).
(K): Knowledge
Providing information. At this stage it is essential to provide information in a simple
way, with accessible language and to be interested in patients' doubts about technical
terms.
Conversations using online communication systems have an increasing role in palliative
care, as families are faced with so many changes, including reduced face-to-face contact
and even abandonment of traditional funeral services. These online telecommunications-based
services challenge effective communication and CBN (2, 7, 17). This impersonal process
makes it difficult to understand the DDP and the palliative approach because it promotes
a reality break—family members deliver a person with shortness of breath to the hospital
and find themselves collecting a dead body in a very short period of time (2). In
association with that, the potential psychological impact on loved ones and patients
can vary from mourning to depression or from feeling of loss to immense guilt for
not being physically present at the moment of death (17, 18). In the context of the
SPIKES protocol, the steps “E” (Emotions) and “K” (Knowledge) (6) are especially harmed.
Thus, at the “K” (Knowledge) step, it is essential that the health professional mention
the medical needs that need to be discussed:
Offer information about the patient's evolution, diagnosis, prognosis respecting the
family's social, economic and cultural limitations (13, 14, 16, 19);
Avoid using medical jargon (e.g., sedoanalgesia) to the detriment of terms such as
“she/he are sleeping under medication” (13, 14, 19);
Always ask, at the end of each orientation, if the message was heard and understood
(2, 6);
(E): Emotions
Expressing emotions. The professional must offer support and solidarity through a
gesture or a phrase of affection. At this step, professional attention is essential:
One must perceive and become sympathetic to the manifestations of sadness and/or joy,
depending on the news, the family members/companions (2);
Show available and empathetic posture—demonstrate that you understand suffering and
difficulties; Given that in many cases after passing on difficult information, people
do not actively pay attention to what is said later (12, 14);
Getting emotional is allowed, it just can't be more than the companions themselves.
A survey carried out in 2017 showed that about 40% of doctors feel sad when they had
to give bad news (13, 14).
(S): Strategy and Summary
Before discussing therapeutic plans, it is important to ask the patient if he is ready
for this moment. Before discussing therapeutic plans, it is important to ask the patient
if he is ready for this moment. It is important to always make it clear that the patient
will not be abandoned. And there is a treatment plan thinking about the best that
can be offered to him at that moment (6).
Two factors directly affect step “S” (Strategy and Summary). The first is the little
time spent on communication. This factor also affects not only step “S” (Strategy
and Summary), but also the “S” (Setting Up) and “P” (Perception) (6). This fact rests
on two prerogatives: (I) the work overload due to the exhaustive routines of the care
units for COVID-19 and (II) the lack of training in palliative care, which is usually
reflected in some professional discourse rich in automatic, impersonal and technical
information (10). Therefore, the COVID-19 pandemic has led to growing concerns not
only about limited medical and hospital resources (e.g.,: ventilators, medications,
gauze, and intensive care beds), but concern about the professionals' interpersonal
limitations (20).
The second element to be considered is the lack of communication between professionals
in the sector. It is not uncommon for the doctor/nurse who gives the news in the daily
bulletin to not be the same person who is daily assessing the patient. This lack of
consistency causes dissonance in information and suffering to family members due to
a feeling of insecurity, because the hospital's restriction on families, per se, already
contributes to high levels of psychological suffering in the general population and
also made it difficult for overworked teams to establish trusting relationships through
digital means (21, 22). Thus, the implementation of telemedicine can be a facilitating
agent in these meetings with inpatients (19). However, the lack of skills and attitudes
about the use of technologies and social media (6, 10) in a stressful environment
such as the COVID-19 units can also be a factor that impairs care.
Therefore, at this step, two elements must be taken into account:
Summarize the information given, preferably repeating it in the same way as it was
presented (13–16);
Announce that the call is coming to an end (3, 6, 14);
Inform the date of the next call, as well as, if possible, the name of the professional
who will be responsible for it. Here, the need to be the same professional is highlighted,
in order to maintain continuity of care and relationship (6, 15).
Final Considerations
In the terminal environment the effective communication is a valuable and powerful
care weapon. There is a need to reinvent, research and, above all, reflect practices
based on scientific rigor. The protocol to CBN suggested in this opinion paper aims
to reduce the psychological distress of the health professional and foster discussion
and improvement of assertive communication in the terminal environment due to the
in the pandemic of COVID- 19. For, although the way in which palliative and end-of-life
care is approached has changed dramatically with the pandemic, effective and honest
communication must remain (3).
Author Contributions
All authors prepared the review, developed the inclusion criteria, selected titles
and abstracts, evaluated the quality of the articles included, and wrote the manuscript.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.