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# Breaking bad news: the SPIKES protocol

- Procedure

SPIKES puts giving bad news into six steps: prepare, explore, ask, inform, respond to emotion and plan.

Updated Nov 5, 2026

## Key points

- S: prepare the place, privacy, time and whom to invite.
- P: ask what the patient knows before telling.
- I: ask how much they want to know and how.
- K: give a warning shot, then inform in small chunks without jargon.
- E: recognise and validate emotions with empathic responses.
- S: agree a plan and summarise; make the next contact clear.

## 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.

## Memory aid

SPIKES: Setting, Perception, Invitation, Knowledge, Emotions, Strategy and summary.

## 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.

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## Connections

## Related 1

- [Truthfulness: telling the patient the truth](https://durgical.com/en/medical-ethics/truthfulness-telling-the-patient-the-truth/)

[← All of medical ethics](https://durgical.com/en/medical-ethics/)

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.)](https://academic.oup.com/oncolo/article/5/4/302/6386191) (The Oncologist, Oxford University Press, 2000); [Breaking Bad News](https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/detail/55) (University of Washington, Department of Bioethics & Humanities, 2018); [Ley 23 de 1981, por la cual se dictan normas en materia de ética médica](https://www.funcionpublica.gov.co/eva/gestornormativo/norma.php?i=68760) (Función Pública, Gestor Normativo, 1981).

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Representative model, for educational purposes only.

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License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/medical-ethics/breaking-bad-news-the-spikes-protocol/