How to Break Bad News with the SPIKES Protocol

Healthcare 20 minute read

06 Jun 2022 20 minute read

Duncan Ritchie Media Team


Jun, 2022

Breaking bad news to patients is not always a skill that comes naturally to healthcare professionals. The SPIKES protocol provides a framework for doctors and nurses to follow in order to get the most out of meetings with patients, allowing them to communicate the seriousness of the news and agree treatment plans.


In this article, we’ll talk about the importance of delivering bad news in a structured and empathetic manner, and look at the various stages of the SPIKES protocol in more detail.


Let’s get started…



1. A Definition of “Bad News”


2. How to Break Bad News to Patients


3. The SPIKES Protocol for Delivering Bad News

          3.1. Setting

          3.2. Perception

          3.3. Invitation

          3.4. Knowledge

          3.5. Emotions

          3.6. Strategy and Summary

          3.7. Post-Meeting


4. The Analysis of the SPIKES Protocol


5. Try Codimg Free


Spikes Protocol Healthcare


A Definition of “Bad News”

In terms of healthcare, “bad news” can be defined as a diagnosis or prognosis which will negatively affect a patient’s quality of life in the present or future.


One obvious example of this comes in palliative care when a clinician has to break the news that treatment has been unsuccessful and that death is imminent. This is a difficult situation for any doctor to navigate and is one that requires care, tact, empathy and sensitivity from the practitioner.


Although the most extreme, an end-of-life prognosis is not the only example of “bad news” in the field of healthcare, and clinicians are not the only professionals that need to be adept in this skill.


Informing patients of new chronic illnesses, the treatment of which will drastically change how the patient lives their life, can also be considered “bad news”. Likewise, the worsening of a chronic condition and the subsequent changes to treatment plans can also have a severe, negative impact on a patient’s quality of life. 


And it’s not only clinicians who deliver this type of news, GPs, nurses and specialists may also need good communication skills to effectively convey the message, ensuring that the patient understands the treatment and that they face the future, not only with realism, but with a feeling of hopefulness

How to Break Bad News to Patients

Breaking bad news is not an easy process for healthcare professionals. They may be faced with grief, denial and despair from the patient. This is a skill that requires a great deal of patience and energy from the practitioner in order to get the message across to the patient.


The goal when meeting with patients and / or their family is:


  • To communicate the diagnosis in understandable language, free from medical jargon.
  • To communicate in a way which is kind and empathetic, but also realistic.
  • To assess the reactions of the patient and / or their family and manage the conversation accordingly.
  • To ensure the patient understands what they are being told and are aware of the treatment options open to them.
  • To establish a plan for the future and move forward with hopefulness, but, at the same time, with realism.


Obviously, juggling so many aspects of a conversation is not an easy task, especially in a busy medical environment where time is not usually at a premium. Doctors and nurses need training in the delivery of bad news, and it takes a lot of practice to become adept at it.


But there are some accepted methods of breaking bad news, and the SPIKES protocol is one of the most common standardised approaches. The protocol gives healthcare professionals a solid structure for delivering bad news and is an extremely useful tool for ensuring a patient’s understanding.

Spikes for doctors and nurses


The SPIKES Protocol for Delivering Bad News

SPIKES was developed in 2000 by Walter F. Baile et al at the University of Texas, Houston. Initially perceived as a way of breaking news to cancer patients, it soon spread to other areas of the healthcare industry.


SPIKES is an acronym which stands for Setting, Perception, Invitation, Knowledge, Emotions, and Strategy


When using this protocol, the person who is delivering the news needs to consider their responses. They should be empathetic, acknowledge the patient’s feelings and validate them, provide information about treatment plans, and ensure the patient understands what they are being told.


Now, let’s take a closer look at each part of the protocol.


In this stage of the protocol, the practitioner must think carefully about where they break the bad news.


Some aspects which should be considered include:


  • Privacy. Bad news should always be delivered in a private setting, as opposed to bedside in the ward, or standing in a busy hospital corridor.
  • Mode of delivery. As far as possible, bad news should always be given face-to-face, not by telephone or email. If it is not possible to meet the patient in person, a video call could be an alternative, as long as it is done in a quiet place.
  • Attention. The focus of the practitioner should always be on the patient. Mobile phones and other electronic devices should be switched off for the duration of the meeting.
  • Significant others. Careful consideration should be given to allowing family members to be present at the meeting, with the patient’s consent. They can provide additional emotional support. If appropriate, and always with the consent of the patient, GPs, specialists or other professionals may be helpful to have at hand.
  • Seating arrangements. Generally speaking, it is better to sit side-by-side with the patient rather than opposite from them, as this is less intimidating and more conducive to a supportive environment.
  • Time management. Despite being in one of the busiest working environments in the world, the healthcare professional should ensure that they have cordoned off sufficient time in order to conduct the meeting successfully. They should also make colleagues aware of the situation so that there are no interruptions during the meeting.


Spikes delivering bad prognosis



This stage is all about gauging the patient’s state of mind and finding out how much they already know about their illness and how it will affect them in the future. This stage is extremely important as it will allow the person breaking the news to judge the patient’s understanding and how much information they are going to take in and retain for the remainder of the conversation.


In order to do this, the healthcare professional must pay attention to what the patient says, how they say it, and their body language. Perhaps the patient is in denial, perhaps they are extremely agitated or over emotional, or it could be that they have absolute awareness of what they are about to go through.


Whatever the case, the practitioner must tailor the conversation around the patient’s understanding, and do so in a non-judgmental manner. Bad news affects everyone differently and there are any responses from the patient that may hinder their understanding. Doctors and nurses must tread carefully and check understanding at regular intervals.


In this stage, the medical practitioner must determine how much information the patient actually wants to hear. Obviously, the bad news must be delivered, but there are different levels of information about a diagnosis or prognosis that can be shared. This can differ from patient to patient. 


Not everyone wants to know every single detail about their illness, preferring instead to concentrate on the treatment plan. This must be respected. As long as the patient understands the seriousness of their illness, they don’t need to know everything that’s happening to their body.


On the other hand, the patient might get a certain degree of comfort from knowing all the little details. Again, the doctor cannot be judgemental and reply with “you don’t really need to know that”. If the patient wants to know everything about their diagnosis, they have every right to be told about it.


The person breaking the news must be prepared for both extremes and anywhere in between, but they must first must receive the patient’s permission to pass on the information they want.


How is this established? By asking direct, non-leading questions.


  • Would you like more details about your diagnosis?
  • How much do you want to know?
  • Would you prefer to concentrate on the treatment plan?


It should also be made clear to the patient that any questions can be answered at a later date if they don’t want the information at that particular moment.


Spikes delivering bad news


This is the stage where the medical practitioner breaks the bad news and passes on their knowledge of the illness. This must be done in a sympathetic way which takes into account the needs of the patient on an intellectual and cultural level, while avoiding excessive bluntness on the part of the person conveying the news.

Somethings to consider include:


  • Use of language. News must be given in plain language, avoiding the use of medical jargon. It’s also important to consider the level of education of the patient, their social background and emotional state. Always remember, there’s a thin line between simplifying language and condescension.
  • No information dumps. It’s better to break the news into small, digestible chunks and check the patient’s understanding periodically.
  • “The good news is…”. If possible, give the patient some hope by telling them any good news about their diagnosis / prognosis. This may lessen the blow of the bad news that’s still to come.
  • Avoid absolutes. In the case of end-of-life discussions, do not say things like “There’s nothing more we can do for you”. Even in cases where death is inevitable, there will still be discussions to be had on topics such as pain alleviation and palliative care.
  • Be patient, but be honest. The patient may have many questions, interrupting constantly to clarify. The practitioner must be patient in these cases and give an honest answer to every question. Remember that the patient is probably not a medical professional and no point of clarification can be considered irrelevant.
  • “I’m sorry to say that…”. Polite, sympathetic phrases such as these should be used in order to lessen the shock for the patient. Again, we repeat, bluntness will seldom be appreciated.




This stage of the protocol is concerned with exploring the emotions of the patient and providing a sympathetic response. This is also one of the most difficult parts for practitioners to get right.


In general, doctors and nurses should give the patient the freedom to explore their feelings and express themselves accordingly after the news has been delivered. There may be a lot of shocked silence, disbelief, or even anger.


It’s easy to believe that the emotional response is connected to bad news that has just been given, but this may not always be the case. It’s possible that the patient is thinking more about their family than themselves, for example. Identify the cause of the emotion by asking the patient directly.


The bearer of bad news must allow for all these emotions and avoid arguments or confrontations with the patient. They should allow silence and not try to fill it with platitudes, but, at the same time, they should also be honest, display empathy, and always monitor the patient’s understanding of the situation.


Body language is also important at this stage. Practitioners should sit openly, not with crossed arms and legs, inviting the patient to express themselves openly. Physical contact, a touch on the arm, for example, may also be appropriate at this stage.


Allowing the stage to get through the initial emotional response will make it easier to discuss subsequent treatment plans later.

Strategy and Summary

This is the final stage in the SPIKES protocol. This is where the patient and doctor plan the next step and summarise the meeting.


Before discussing the next step, it’s important to double check the patient’s understanding of the situation and to ask whether they are capable of making this decision at the moment. It may be necessary to schedule a meeting further down the line if the patient is emotionally overwhelmed.


Things that should be discussed include:


  • Treatment options.
  • Best / worst case scenarios.
  • Coping strategies.
  • Support mechanism
  • Lingering questions that the patient may have.


As the meeting comes to a close, the practitioner should summarise everything that has been discussed, check the emotional state of the patient, and offer any additional support that might be needed, such as contacting family members on behalf of the patient.

Spikes Healthcare



Even with the SPIKES protocol in place, breaking bad news can be extremely emotionally draining on the practitioner. After the meeting, the doctor or nurse should check their own feelings and ensure they are emotionally fit to move on to the next patient. This is especially true if the next patient has similar issues.


A period of self-reflection should follow. Some questions that can be asked include:


  • Was the meeting successful?
  • Did the patient leave with a full understanding of their illness?
  • Was sufficient emotional support provided?
  • Was the SPIKES protocol followed?


When it comes to self-reflection, having a video record of interactions can be helpful, and analysis software can help you improve your communication skills.

The Analysis of the Spikes Protocol

Codimg is a software tool specifically designed for monitoring performance in the workplace. It has been used successfully for many years for analysing student doctors and nurses in medical simulation scenarios, and other healthcare situations.


The basic premise is that a simulated or real event is filmed. The trainer or observer has a premade interactive template which can be used to mark moments of interest during the event. This can either be done live, or retrospectively through video. If done live, the collected information will be synched with the video at a later time. When these moments are marked, an interactive database of video clips is created. These clips can then be accessed quickly and easily at any time.


Example of SPIKES protocol digital checklist template. To get this template free, contact us.



At the same time, the collected data can be used to create a dashboard with insightful statistics about the event. The dashboard is also interactive and linked to video clips.


Example of SPIKES protocol dashboard. To get this dashboard free, contact us.



Analysis of this type has been proven to give valuable insights into working practice which allows professionals to improve in all aspects of their post.


Try Codimg Free

So, there you have an overview of the SPIKES protocol. If you have any questions about anything you have read in this article, please don’t hesitate to get in contact with us and we’ll be happy to point you in the right direction.


In addition, we’d be happy to offer you a completely free, no-obligation trial of the Codimg software. The best way to get an idea of how Codimg can help you improve your practice is to try it for yourself. Again, get in contact with us and we’ll talk through your needs, and we’ll set you up with a trial.


Until then, thanks for reading.




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