Breaking bad news: the SPIKES protocol
- Technique
SPIKES is a six-step guide for giving bad news clearly and respectfully, with room for the patient's emotions.
What it is
SPIKES was published by Baile, Buckman and colleagues in 2000, in oncology, and is now used across medicine. Its six steps serve four goals: gathering information from the patient, giving the medical information, offering support and agreeing a plan with the patient. Bad news is any information that changes the patient's view of their future for the worse. This page goes deeper into the aim, phrases and pitfalls of each step.
How it is done
- Setting: arrange a private room, sit down, silence the phone, have tissues ready, say if time is limited.
- Perception: ‘What have you been told so far about the biopsy?’ This uncovers mistakes or denial.
- Invitation: ‘Would you like me to go through all the details, or the main points?’
- Knowledge: a warning shot (‘I am sorry, I do not have good news’), then short sentences, no jargon.
- Pause and check: ‘Have I explained that clearly so far?’ Leave room for silence.
- Emotions: observe, then name the emotion and its cause: ‘I can see this came as a shock’.
- Strategy: ask whether they are ready to talk about the plan and offer realistic options.
- Summary: sum up, agree the next meeting and make clear how to reach the team.
Common pitfalls at each step
| Step | Common pitfall | Alternative |
|---|---|---|
| Setting | Telling the news standing up, in a corridor, or by phone without preparation | Private space, seated, protected time |
| Perception | Starting to explain without knowing what the patient understands | Ask first and start from their words |
| Invitation | Giving every detail to someone who did not ask | Ask how much they want to know and respect it |
| Knowledge | Jargon, too many numbers, or blunt delivery | Warning shot, short sentences, check understanding |
| Emotions | Carrying on with facts while the patient cries or is angry | Pause, name the emotion, respond with empathy |
| Strategy/Summary | Ending without a plan, or with false promises | Realistic plan, next step and clear contact |
Clinical notes
- Patients benefit more from honesty, clear and simple language and support than from false reassurance or avoidance.
- Language is matched to the health literacy of patient and family; hope is offered without misleading.
- With children, families or an interpreter the order is adapted, but perception, invitation and emotion are kept.
- Breaking bad news wears on the clinician; acknowledging it and talking it over in the team protects against burnout.
Test yourself
Think of the answer, then tap the question to see it.
Why does the perception step come before the news?
It shows what the patient understands, lets you correct mistakes, detect denial and fit the explanation to their starting point.
What does the clinician do in the invitation step?
Asks how much information and detail the patient wants, and respects a wish for the main points only or for someone else to be told.
What is advised if the patient cries during the emotions step?
Stop, allow silence, name the emotion and its cause with an empathic statement, and only then go on.
What four goals does SPIKES serve?
Gathering information from the patient, giving the medical information, providing support and gaining the patient's collaboration on a plan.
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Connections
Educational content on behavior and the clinical relationship; not a diagnostic or treatment guide and no substitute for assessment by a health professional. If you or someone near you is at risk, seek help now from an emergency service or a mental-health helpline.
Sources: Communication in Cancer Care (PDQ®)–Health Professional Version (National Cancer Institute (US), 2025); Giving Bad News (The Oncologist (PubMed Central), 2015).
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Representative model, for educational purposes only.