Delivering difficult and life-altering news to a patient or their family is one of the most challenging conversations in medicine. Whether it’s a diagnosis of cancer, chronic illness, or a poor prognosis, how bad news is delivered has a profound impact on how patients process and cope. Bad news may need to be delivered in various contexts, such as unexpected tests or scan results, poor prognosis or treatment failure, medical errors, unexpected findings at surgery, or intra-operative or post-operative complications. The SPIKES protocol is widely model which can help to navigate these conversations with empathy, clarity, and structure. Whilst scenarios will differ, but the SPIKES model can be easily applied to each The SPIKES Protocol SPIKES stands for: Setting, Perception, Invitation, Knowledge, Emotions, Summary, and provides a guide delivering bad news in a structured, empathetic way. As a clinician, it can help share information clearly and sensitively, allowing you to understand and respond to patient’s or family’s emotions while supporting them as they consider what comes next. Moreover, SPIKES can help you tailor the level of detail, understand what the patient knows and maintain empathy. Adobe Stock, licensed to TeachMeSeries LtdFigure 1Learning how to break bad news is an essential skill for any doctor The Six Steps of SPIKES Setting Ensure the environment planned to break any bad news is appropriate. Find a private, comfortable space where interruptions are minimised – this can often be challenging on a busy ward or A&E, however always take the time to find the right environment for the conversation. Let colleagues know you are about to speak to the patient or their family so you are not disturbed, and silence any phones, pagers, or bleeps. Introduce yourself and con confirm the identity of the patient or family. Make sure to be sat with the patient or family, such that everyone is comfortable and present. Encourage the patient to have someone with them that they trust (family, friend, clinician) if they wish. Establishing the right setting allows for greater control, reduces anxiety, and is especially useful for a difficult conversation. Perception Before delivering any news, it is vital to understand what the patient or family already knows or believes, as this can help you avoid repetition causing undue frustration. Actively listening at this stage can identify any misunderstandings or overly optimistic expectations. At this stage listening is more important than talking. This is the opportunity to gauge how much further information to give or if you need to explain any key aspects of the situation. “What do you understand about your condition so far?” “Has anyone come to speak to you about any of your tests so far?” Invitation Not all patients want every detail. This step explores how much information the patient or family wants and whether they want support present. The patient may provide you with their own cue that you can proceed with providing more information. However, certain question can provide hints to the patient that further information may be coming: “Sometimes patients find it easier to have a family member or friend help them take in some of the information, is there anyone you would like with you?” Some patients do not want to know everything, or they want a brief explanation. You can always make it clear to the patient that you can speak to them again later or provide leaflets to help them understand their condition. Knowledge This is where you deliver the news. It has to be clear and direct, honest and compassionate. It is important to provide a warning shot to signal bad news “I’m afraid I have some difficult news” Warning shots help put you at the same level, so it is clear where the conversation is headed. They allow for some expectation and prepare the patient emotionally and cognitively. When giving the news, make sure to use plain non-jargon language, being direct but compassionate. Being clear in delivering the diagnosis is key, avoiding any chance of misinterpretation. After stating the diagnosis, ensure to pause and allow the patient to absorb the information. Give the patient or family as long as they need, it can feel like a long period of time has passed but speak only when they are ready to. This requires a balance between truthfulness and sensitivity. Emotions Strong emotional reactions are expected. This stage is about responding with empathy and pacing the conversation. Ensure not to minimise the patient’s feelings – if the patient tells you they are shocked, avoid use of words such as ‘quite’ or ‘little’, as this can minimise their feelings and lose the rapport. Make sure to remain empathetic throughout and acknowledge emotions “I can see this is a huge shock” “I can see this is really upsetting for you” Give the patient time and space to respond, and remember that long pauses are okay. Demonstrating empathy helps the patient feel heard, supported and less isolated in their distress. Strategy & Summary After acknowledging the patient’s emotions, gently move toward what comes next. This is where you work with the patient to develop a plan, ensuring their preferences and values guide their care. If they are not ready to discuss next steps, acknowledge this and offer to revisit the conversation later without pressure. Outline a plan for next steps, whether this is regarding referrals, further tests, or treatment options, and both in short-term and long-term planning. “What would you like to happen next?” “Do you have any concerns?” Ensure to offer follow-up support, which may be through written information like leaflets or directing them to online resources. If appropriate, discuss how the patient might tell family or friends, offer help with breaking that news for them. This ensures the patient is not left alone in confusion or despair, there is a plan, and you will work together. Conclusion Breaking bad news is emotionally challenging for the patient and the clinician. The SPIKES protocol provides a structure and flexibility to ensure the patient comes first whilst supporting clinicians in navigating highly emotional conversations. Rate This Article