Breaking Bad News (SPIKES)
Summary
Breaking bad news is one of the most challenging and important communication tasks in clinical medicine. It refers to the process of conveying information that adversely and seriously affects an individual's view of their future. This includes disclosing diagnoses of serious illness (cancer, degenerative diseases, terminal conditions), informing of treatment failure, communicating prognosis, or notifying family of death. Poor delivery of bad news can cause lasting psychological harm, damage the therapeutic relationship, and impair patient decision-making. The SPIKES protocol provides a structured, evidence-based approach to ensure information is delivered with clarity, compassion, and appropriate emotional support. Mastery of this skill is essential for all clinicians.
Key Facts
- Prevalence: Physicians deliver bad news an average of 20,000 times during their careers
- Core framework: SPIKES (Setting, Perception, Invitation, Knowledge, Empathy, Summary)
- Key principle: Patient autonomy — information should be tailored to what the patient wants to know
- Critical component: The "warning shot" prepares the patient emotionally
- Evidence basis: Baile et al. (2000) developed SPIKES specifically for oncology settings
- Common errors: Information overload, inadequate empathy, no follow-up plan
- Cultural competence: Preferences for information disclosure vary significantly across cultures
- Documentation: The conversation should be documented in clinical notes
- Who should deliver: The most senior/informed clinician available
- Support present: Offer the patient the option to have someone with them
Clinical Pearls
"Warning Shot First": Never deliver devastating news without a warning shot. "I'm afraid I have some serious news to tell you" allows the patient to prepare emotionally before hearing details.
"Silence is Golden": After delivering bad news, pause and allow silence. Resist the urge to fill the silence — this is processing time for the patient. Wait for them to speak first.
"Chunk and Check": Deliver information in small chunks (1-2 sentences) then check understanding before proceeding. Patients can only absorb limited information under stress.
"Fire a Shot Across the Bow": Before the main consultation, a brief phone call saying "We have your results and I need to discuss them with you in person" is a warning shot that allows the patient to prepare and bring support.
"Acknowledge the Emotion, Not Just the Information": Responding to emotion with more information is a common mistake. Stop, name the emotion, and empathise before continuing: "I can see this is devastating news..."
Why This Matters Clinically
Effective delivery of bad news affects patient psychological outcomes, trust in medical care, treatment adherence, and quality of life. Poor delivery is associated with patient anxiety, depression, and complaints. This skill is assessed in medical school OSCEs, specialty training, and is relevant throughout a clinical career. The SPIKES model has been validated internationally and adapted for various clinical contexts.[1,2]
Scope of the Problem
| Context | Statistics |
|---|---|
| Physician career | Average 20,000 bad news conversations over a career |
| Cancer diagnoses (UK) | ~375,000 new cases per year requiring disclosure |
| Hospital deaths (UK) | ~500,000 per year; many require end-of-life discussions |
| Medical complaints | Poor communication is the leading cause of patient complaints |
Impact on Patients
| Outcome | Impact of Poor Delivery | Impact of Good Delivery |
|---|---|---|
| Psychological | Anxiety, depression, PTSD | Better adjustment, less distress |
| Information recall | Poor; distorted by emotion | Improved; validated understanding |
| Decision-making | Impaired capacity | Supported autonomous choices |
| Therapeutic relationship | Damaged trust | Maintained/strengthened trust |
| Treatment adherence | Reduced | Improved |
Barriers to Effective Delivery
| Barrier | Notes |
|---|---|
| Lack of training | Many clinicians receive minimal formal training |
| Fear of causing distress | Concern about patient reactions |
| Fear of blame | Not wanting to be the "bearer of bad news" |
| Time pressure | Rushed consultations in busy clinical environments |
| Personal discomfort | Confronting mortality, own emotions |
| Uncertainty | Difficulty discussing prognosis when uncertain |
| Cultural differences | Differing expectations about truth-telling |
The Emotional Response to Bad News
Step 1: Shock and Denial
- Immediate response to devastating information
- "This can't be happening" — protective psychological mechanism
- Reduced information processing capacity
- May appear calm externally while internally processing
Step 2: Fight-or-Flight Activation
- Sympathetic nervous system activation
- Increased heart rate, blood pressure, sweating
- Cortisol and adrenaline surge
- Cognitive tunnelling — focus narrows
- Impaired memory formation
Step 3: Emotional Response
- Tears, anger, silence, or apparent numbness
- Individual responses vary greatly
- Cultural and personality influences
- May cycle through responses rapidly
Step 4: Cognitive Processing
- Begins once initial emotional wave subsides
- Questions about "what happens now?"
- Attempts to integrate new information
- May take hours to days
Step 5: Adaptation
- Long-term adjustment process
- May involve grief stages (Kübler-Ross model)
- Varies from acceptance to prolonged grief
- Influenced by support systems and coping resources
Information Processing Under Stress
| Factor | Effect |
|---|---|
| Memory impairment | Only 40-50% of information recalled after bad news |
| Selective attention | Patient may fixate on single details (e.g., "cancer") |
| Distortion | Information may be misremembered or misinterpreted |
| Cognitive overload | Too much information overwhelms processing |
| Delayed processing | Full understanding may take hours to days |
When Bad News Must Be Delivered
| Category | Examples |
|---|---|
| Diagnosis | Cancer, MND, dementia, HIV, genetic conditions |
| Prognosis | Terminal illness, life-limiting condition, reduced life expectancy |
| Treatment | Treatment failure, recurrence, no curative options available |
| Adverse events | Complications, medical errors, unexpected outcomes |
| Family | Death of a patient, critical illness, poor prognosis |
| Screening | Positive screening tests (antenatal, genetic, cancer) |
| Disability | Permanent disability, loss of function |
Patient Response Patterns
| Response | Characteristics | Management |
|---|---|---|
| Shock/Silence | Appears stunned, minimal response | Allow silence, offer tissues, wait |
| Tears/Sadness | Crying, grief | Empathise, allow expression, offer support |
| Anger | Directed at doctor, system, or self | Don't take personally, acknowledge, explore |
| Denial | "This can't be right" | Don't argue, leave door open, offer second opinions |
| Bargaining | Seeking alternatives | Acknowledge hopes, be realistic |
| Questions | Many questions immediately | Answer carefully, don't overwhelm |
| No questions | Overwhelmed or processing | Offer to defer, arrange follow-up |
Red Flags During Disclosure
[!CAUTION] Warning Signs Requiring Immediate Attention:
- Expression of suicidal ideation or hopelessness
- Severe dissociation or panic
- Aggressive behaviour threatening safety
- Patient refuses to leave or make decisions impaired by acute distress
- Requests to withhold information from patient (legal/ethical issue)
- Patient has no support system
Pre-Consultation Preparation
Information Preparation:
- Review all relevant results and reports
- Know the diagnosis, stage, and treatment options
- Understand prognosis (ranges, not false precision)
- Anticipate questions
- Know patient's baseline (prior knowledge, expectations, values)
Setting Preparation:
- Private room with no interruptions
- Tissues available
- Comfortable seating (same level as patient)
- Turn off/silence all devices
- Ensure adequate time (minimum 30 minutes)
- Have water available
Personnel:
- Senior clinician who knows the case delivers news
- Nurse specialist or support worker if available
- Patient's choice of companion (partner, family, friend)
- Interpreter if needed (professional, not family)
Assessment During Conversation
| Assess | How |
|---|---|
| Information preferences | "Some people want to know everything, others prefer the headlines. What would you like?" |
| Emotional state | Observe verbal and non-verbal cues throughout |
| Understanding | Ask patient to summarise what they've understood |
| Support needs | "Who do you have at home who can support you?" |
| Immediate safety | Assess for suicidal ideation if concern |
Pre-Consultation Information Gathering
| Information | Purpose |
|---|---|
| Diagnosis details | Ensure accuracy and completeness |
| Histology/pathology | For cancer diagnoses |
| Staging | Determines treatment options and prognosis |
| MDT outcome | Team treatment recommendations |
| Previous correspondence | What has patient been told already? |
| Patient background | Social situation, dependants, occupation |
| Interpreter needs | Language, cognitive capacity |
| Cultural background | Any known preferences regarding information sharing |
Documentation Requirements
| Component | Details |
|---|---|
| Who was present | Patient, family members, clinical staff |
| Information shared | Diagnosis, prognosis, treatment plan |
| Patient understanding | How they summarised the information |
| Emotional response | How the patient reacted |
| Questions asked | And answers provided |
| Plan agreed | Next steps, follow-up |
| Support offered | Clinical nurse specialist, palliative care, counselling |
The SPIKES Protocol
BREAKING BAD NEWS — SPIKES PROTOCOL
↓
┌────────────────────────────────────────────────────────────┐
│ S — SETTING │
├────────────────────────────────────────────────────────────┤
│ ➤ Private room, no interruptions │
│ ➤ Sit at same level as patient │
│ ➤ Adequate time (30+ minutes) │
│ ➤ Tissues, water available │
│ ➤ Invite patient to have support person present │
│ ➤ Introduce yourself and your role │
└────────────────────────────────────────────────────────────┘
↓
┌────────────────────────────────────────────────────────────┐
│ P — PERCEPTION │
├────────────────────────────────────────────────────────────┤
│ ➤ "What do you understand about your illness so far?" │
│ ➤ "What have you been told about your tests?" │
│ ➤ Assess: knowledge level, expectations, misconceptions │
│ ➤ Correct any serious misunderstandings gently │
└────────────────────────────────────────────────────────────┘
↓
┌────────────────────────────────────────────────────────────┐
│ I — INVITATION │
├────────────────────────────────────────────────────────────┤
│ ➤ "How much detail would you like to know?" │
│ ➤ "Some people want all the details, others prefer the │
│ headline. What works best for you?" │
│ ➤ Respects autonomy; some patients prefer less detail │
│ ➤ Offer to share with family if patient wishes │
└────────────────────────────────────────────────────────────┘
↓
┌────────────────────────────────────────────────────────────┐
│ K — KNOWLEDGE │
├────────────────────────────────────────────────────────────┤
│ ➤ WARNING SHOT: "I'm afraid I have some serious news" │
│ ➤ Deliver information in chunks (1-2 sentences) │
│ ➤ Use clear, simple language (avoid jargon) │
│ ➤ Check understanding: "What do you make of that?" │
│ ➤ Avoid false reassurance or prognosis predictions │
│ ➤ Allow pauses and silences │
└────────────────────────────────────────────────────────────┘
↓
┌────────────────────────────────────────────────────────────┐
│ E — EMOTIONS / EMPATHY │
├────────────────────────────────────────────────────────────┤
│ ➤ Acknowledge the emotion: "I can see this is a shock" │
│ ➤ Name the emotion: "You seem very angry/frightened..." │
│ ➤ Validate: "Anyone would feel that way" │
│ ➤ Allow silence and time for expression │
│ ➤ Offer tissues, a break if needed │
│ ➤ Don't rush to problem-solve or fill silence │
└────────────────────────────────────────────────────────────┘
↓
┌────────────────────────────────────────────────────────────┐
│ S — STRATEGY / SUMMARY │
├────────────────────────────────────────────────────────────┤
│ ➤ Summarise what has been discussed │
│ ➤ Outline next steps (appointments, tests, treatments) │
│ ➤ Check patient's priority concerns │
│ ➤ Arrange follow-up (usually within 1-2 weeks) │
│ ➤ Provide written information if available │
│ ➤ Give contact details (CNS, ward, helpline) │
│ ➤ "Is there anything else you need right now?" │
└────────────────────────────────────────────────────────────┘
Key Phrases
| Situation | Useful Phrases |
|---|---|
| Warning shot | "I'm afraid I have some difficult news to share..." |
| Diagnosis | "The tests have shown that this is cancer..." |
| Expressing empathy | "I can see this is very distressing news..." |
| Checking understanding | "What sense are you making of this?" |
| Acknowledging anger | "I can see you're angry, and that's completely understandable" |
| Uncertainty | "I wish I could give you a definite answer..." |
| Offering hope | "There are treatments we can offer..." |
| Closing | "What questions do you have right now?" |
Phrases to Avoid
| Avoid | Why | Alternative |
|---|---|---|
| "There's nothing more we can do" | Falsely hopeless | "We can't cure this, but there's a lot we can do to help you" |
| "You have 6 months to live" | False precision | "We're talking about months rather than years, but everyone is different" |
| "You're so brave" | Dismissive of genuine emotion | "It's okay to feel overwhelmed" |
| "I know how you feel" | You don't | "I can only imagine how difficult this is" |
| "Don't cry" | Suppresses emotion | Sit in silence, offer tissues |
Cultural Considerations
| Culture | Consideration | Approach |
|---|---|---|
| Some Asian cultures | Family receives news first; patient may not be told directly | Explore individual preferences; involve family |
| Some Middle Eastern cultures | Direct bad news considered harmful | Use gradual disclosure; involve family |
| Individualistic cultures | Patient autonomy paramount | Direct disclosure to patient |
| Religious frameworks | Fatalistic acceptance; spiritual meaning | Involve chaplaincy; respect beliefs |
Key Principle: Never make assumptions based on culture. Always ask the individual: "How would you like me to share information about your health?"
Follow-Up Actions
| Action | Timing |
|---|---|
| Document conversation | Same day |
| Inform GP | Same day (letter/call) |
| Clinical nurse specialist contact | Within 48 hours |
| Follow-up appointment | Within 1-2 weeks |
| Counselling/support services referral | As needed |
| Written information | Provide at consultation or post |
Immediate Complications
| Complication | Management |
|---|---|
| Severe distress | Stay with patient; involve crisis support if needed |
| Anger at clinician | Remain calm, don't be defensive, acknowledge feelings |
| Denial | Don't force acceptance; leave door open for further discussions |
| Physical symptoms (panic, fainting) | Basic first aid; reassurance |
| Suicidal ideation | Direct questioning; involve mental health services; safety planning |
Late Complications
| Complication | Prevention/Management |
|---|---|
| Adjustment disorder | Follow-up counselling, clinical psychologist |
| Depression/Anxiety | Screen at follow-up; refer to mental health |
| Poor treatment adherence | Ensure understanding; address concerns |
| Family conflict | Facilitate family meetings; social work input |
| Complaints | Ensure good documentation; open disclosure if errors |
Factors Associated with Better Patient Outcomes
| Factor | Impact |
|---|---|
| Adequate preparation | Reduced shock, better adjustment |
| Clear information | Better decision-making |
| Empathic delivery | Preserved therapeutic relationship |
| Written information | Improved recall |
| Follow-up arranged | Reduced abandonment feelings |
| Support offered | Better psychological adjustment |
Clinician Impact
| Area | Effect of Poor Delivery | Effect of Good Delivery |
|---|---|---|
| Complaints | Increased | Reduced |
| Burnout | Associated with avoidance | Confidence is protective |
| Litigation | Poor communication major factor | Strong communication mitigates |
| Professional satisfaction | Reduced | Improved |
Key Guidelines
| Guideline | Organisation | Year | Key Points |
|---|---|---|---|
| Talking with Your Patient About Cancer | Cancer Council Australia | 2014 | SPIKES adaptation for Australian context |
| Communication Skills Training | NICE | Various | Skills training for cancer professionals |
| Consensus Guidelines on Breaking Bad News | Buckman et al. | 2005 | Expert consensus; international applicability |
Landmark Studies
Baile et al. (2000) — SPIKES Protocol
- Developed structured 6-step protocol for oncology
- Validated through physician workshops
- Now international standard for bad news communication
- PMID: 10924459
Fallowfield et al. (2002) — Communication Skills Training
- RCT of communication skills training for oncologists (n=160)
- Training improved empathy and reduced patient distress
- Effect sustained at 15 months
- PMID: 11943783
Ptacek & Eberhardt (1996) — Literature Review
- Systematic review of bad news delivery literature
- Identified key elements: preparation, empathy, information, support
- PMID: 8676125
Fujimori & Uchitomi (2009) — International Perspectives
- Cross-cultural review of preferences for bad news
- Highlighted cultural variations in disclosure preferences
- PMID: 19396737
Evidence Strength
| Component | Level | Source |
|---|---|---|
| SPIKES protocol | 2a | Consensus, validation studies |
| Communication skills training | 1b | RCTs |
| Written information improves recall | 1b | RCTs |
| Empathy improves outcomes | 2a | Observational studies |
For Patients: Receiving Difficult News
What to expect
When doctors need to share difficult news, they will usually:
- Arrange a quiet, private space
- Ask if you'd like someone with you
- Ask what you already know and how much detail you want
- Give a "warning" before the main news
- Explain things in steps, checking you understand
- Give you time to react and ask questions
- Make a follow-up plan
Your rights
- You can ask questions — there are no "stupid" questions
- You can ask for time to process before making decisions
- You can ask for information in writing
- You can bring someone for support
- You can ask to stop and continue another time
- You can ask for a second opinion
After the conversation
- It's normal to forget details — write things down or record the conversation (with permission)
- It's normal to feel shock, anger, sadness, or numbness
- It's okay to call back with questions
- Support is available (counsellors, support groups, helplines)
For Families: Supporting Someone Receiving Bad News
- Be present without needing to fix things
- Listen more than you speak
- Don't minimise their feelings ("It could be worse")
- Offer practical help (driving, childcare, food)
- Respect their processing time
- Encourage them to seek professional support
Primary Framework
- Baile WF, Buckman R, Lenzi R, et al. SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. Oncologist. 2000;5(4):302-311. PMID: 10924459
Training Evidence
- Fallowfield L, Jenkins V, Farewell V, et al. Efficacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial. Lancet. 2002;359(9307):650-656. PMID: 11879860
Reviews
-
Ptacek JT, Eberhardt TL. Breaking bad news: a review of the literature. JAMA. 1996;276(6):496-502. PMID: 8676125
-
Buckman R. Breaking bad news: the SPIKES strategy. Community Oncol. 2005;2(2):138-142.
-
Fujimori M, Uchitomi Y. Preferences of cancer patients regarding communication of bad news: a systematic literature review. Jpn J Clin Oncol. 2009;39(4):201-216. PMID: 19396737
Further Resources
-
Macmillan Cancer Support. Talking about cancer. macmillan.org.uk
-
Cancer Council Australia. Talking with your patient about cancer. cancer.org.au
-
Cruse Bereavement Care. Supporting bereaved people. cruse.org.uk
High-Yield OSCE/Exam Topics
| Topic | Key Points |
|---|---|
| SPIKES acronym | Setting, Perception, Invitation, Knowledge, Empathy, Summary |
| Warning shot | "I'm afraid I have some difficult news..." — essential before disclosure |
| Chunk and check | Small pieces of information; verify understanding |
| Silence | Allow processing time; don't rush to fill |
| Empathy statements | Name the emotion, validate the feeling |
| Cultural competence | Ask individual preferences; don't assume |
| Documentation | Full record of discussion and patient response |
Sample OSCE Scenario
Task: You are an FY2 doctor. Mr Smith, 54, has had a CT scan which shows metastatic lung cancer. Break this news to him. You have 10 minutes.
Mark Scheme Components:
- Appropriate setting and introduction
- Checks what patient knows (Perception)
- Asks how much detail patient wants (Invitation)
- Warning shot before diagnosis
- Clear, jargon-free explanation
- Pauses appropriately
- Responds to emotion with empathy
- Checks understanding
- Discusses next steps (Strategy/Summary)
- Offers support and follow-up
Sample Viva Questions
Q1: What is the SPIKES protocol and why is it used?
Model Answer: SPIKES is a six-step structured protocol for delivering bad news, developed by Baile et al. in 2000. It stands for Setting (prepare the environment), Perception (assess what the patient knows), Invitation (determine how much the patient wants to know), Knowledge (deliver the information with a warning shot), Empathy (respond to emotions), and Summary (plan next steps). It provides a framework that ensures patient-centred communication, respects autonomy, and supports emotional processing. Evidence shows structured approaches improve patient satisfaction and psychological outcomes.
Q2: A patient becomes angry when you tell them they have cancer. How do you respond?
Model Answer: I would not take the anger personally — it is a normal response to devastating news. I would stay calm, maintain eye contact, and acknowledge the emotion: "I can see you're very angry, and that's completely understandable given what you've just heard." I would resist becoming defensive or trying to explain away the anger. I would allow silence for the patient to express themselves, and only continue when they are ready. If the anger escalates to threatening behaviour, I would ensure my own safety and involve security if needed. After the initial anger subsides, I would gently explore whether they have questions and offer follow-up support.
Q3: How do you handle a situation where the family asks you not to tell the patient their diagnosis?
Model Answer: This requires balancing respect for cultural preferences with patient autonomy. I would first explore why the family wants this — often it comes from a desire to protect. I would explain that in the UK, patient autonomy is paramount, and patients have a right to know their diagnosis if they wish. I would suggest involving the patient in deciding how much they want to know by asking: "How much would you like to know about your condition?" If the patient genuinely indicates they prefer family to receive information, I can respect this. However, I cannot deceive a patient who asks directly about their diagnosis. I would document the discussion carefully and involve senior colleagues if the conflict cannot be resolved.
Common Exam Errors
| Error | Correct Approach |
|---|---|
| Launching into diagnosis without warning shot | Always use a warning shot first |
| Filling silences immediately | Allow silence for processing |
| Responding to emotion with more information | Stop, acknowledge the emotion, then proceed |
| Too much information at once | Chunk and check |
| Forgetting to arrange follow-up | Always end with a plan |
| Making assumptions about cultural preferences | Ask the individual |
Last Reviewed: 2025-12-24 | MedVellum Editorial Team
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.