Table 3:

The SPIKES protocol, which we have modified for discussion of the FVD diagnosis with the patient

S: SETTING up the interview	Clinician preparation: Clinician should be mentally prepared for the discussion, including as required mentally rehearsing the planned direction of discussion, possible questions and answers from the patient. Clinical setting Ideally private room Everyone should be sitting down to avoid feeling rushed Manage time constraints and interruptions Patient and family should be prepared for the discussion
P: PERCEPTION	Assess the patient’s perception of their vision capacity Assess insight, as well as expectations Identify what the patient already knows or suspects about their illness
I: INVITATION	Be aware that not all patients want to know all aspects of their condition – assess each situation individually to determine who much and which information is provided. If patients report not wanting to know about their condition, offer to discuss details in the future or with a friend / family member.
K: KNOWLEDGE	Give knowledge at the level of comprehension of the patient Emphasize that the symptoms are real and do not have any anatomic or physiologic basis Focus on good visual prognosis Avoid excessive bluntness Provide knowledge in small easy to understand ‘chunks’
E: EMOTIONS	Respond to patient’s emotions with empathic responses Observe the emotion Self-identify the emotion Identify the reason for the emotion After giving the patient time to connect with their emotion, make a comment that connects with the emotion.
S: STRATEGY and SUMMARY	Clarify if the patient wishes to discuss management at this time, or in the future Provide a clear plan for the future, including emphasizing good visual prognosis Depending on patient factors and individual situation, consider whether further psychology / psychiatry input would be beneficial.