Breaking bad news: the SPIKES protocol
- Procedure
SPIKES puts giving bad news into six steps: prepare, explore, ask, inform, respond to emotion and plan.
What it is
Bad news is any information that seriously and negatively changes the patient's view of their future. Many patients remember for ever how a diagnosis was given to them. Communicating well is a skill that can be learned and trained. The SPIKES protocol, published by Baile, Buckman and colleagues in 2000 from Buckman's six-step method, is the one most used in teaching and exams: Setting, Perception, Invitation, Knowledge, Emotions, and Strategy and summary.
How it is done
- Setting: review the case, find a private place, sit down, silence interruptions and ask whom the patient wants present.
- Perception: ask what they know or have been told about their illness.
- Invitation: ask how much information they want now and in what detail.
- Knowledge: say that you have bad news, then give the information in small chunks, in plain words.
- Knowledge: pause often to check understanding and answer questions.
- Emotions: notice the emotion, name it and respond with empathy; allow silence.
- Strategy and summary: when they are ready, agree a plan, summarise and set the next contact.
In clinical practice
- If the patient cries, pause, offer a tissue and wait; do not fill the silence with data.
- A short agenda (one or two topics) works better than a complete explanation all at once.
- Give the patient a way to make contact before the next appointment.
- The same steps work for disclosing an error, a poor prognosis or the death of a relative.
Common mistakes
- Giving the news standing up, in the corridor or by phone without need.
- Starting to inform without knowing what the patient understands.
- Using jargon or explaining pathophysiology instead of answering what the patient asks.
- Ignoring the emotion and jumping straight to treatment.
- Ending without a plan or a next contact.
Test yourself
Think of the answer, then tap the question to see it.
What does each letter of SPIKES stand for?
Setting, Perception (the patient's), Invitation, Knowledge, Emotions, and Strategy and summary.
Why ask what the patient knows before informing?
To start from what they understand, correct mistaken ideas and fit the news to their level and emotional state.
What happens in the Emotions step?
The emotion is noticed, named and met with empathy, allowing silence before going on with information.
How should information be given in the Knowledge step?
First with a warning that bad news is coming, then in small chunks, without jargon, checking understanding often.
Connections
Educational content on ethics and health law; not legal advice. Laws and case law change: each page links the official text and says when it was last checked. For a real case, read the text in force and ask a lawyer or the medical ethics tribunal.
Sources: SPIKES: a six-step protocol for delivering bad news: application to the patient with cancer (Baile WF, Buckman R, et al.) (The Oncologist, Oxford University Press, 2000); Breaking Bad News (University of Washington, Department of Bioethics & Humanities, 2018); Ley 23 de 1981, por la cual se dictan normas en materia de ética médica (Función Pública, Gestor Normativo, 1981).
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Representative model, for educational purposes only.