What are the steps of the SPIKES protocol for delivering serious or bad news?

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Last updated: June 18, 2026 • View editorial policy

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SPIKES Protocol for Breaking Bad News

The SPIKES protocol is a six-step structured framework for delivering serious or bad news to patients, endorsed by ASCO guidelines and widely validated in oncology communication. 1

The Six Steps of SPIKES

S - Setting

  • Arrange a private, quiet location with adequate uninterrupted time 1
  • Sit down at eye level with the patient
  • Ensure appropriate family members or support persons are present (with patient permission)
  • Minimize physical barriers (desks, computers)
  • Turn off pagers/phones to avoid interruptions
  • Have tissues available
  • Mentally prepare yourself by reviewing the case and anticipating emotional reactions 1

P - Perception

  • Assess what the patient already knows before delivering news 1
  • Ask open-ended questions: "What have you been told about your test results?" or "What is your understanding of why you're here today?"
  • This prevents information overload and allows you to correct misconceptions 2
  • Identifies the patient's baseline knowledge and emotional state
  • Critical pitfall to avoid: Proceeding directly to bad news without assessing understanding leads to confusion and backtracking 2

I - Invitation

  • Determine how much information the patient wants to know 1
  • Ask: "Would you like me to explain the test results in detail?" or "How much information would you like me to share?"
  • Some patients want full details; others prefer general information
  • Respect cultural and individual preferences for information disclosure
  • For ambivalent patients, discuss pros and cons of knowing 1
  • Negotiate with family members if patient doesn't want information (with patient's permission)

K - Knowledge

  • Deliver the bad news clearly, succinctly, and in plain language 1
  • Use a warning shot: "I wish I had better news" or "Unfortunately, I have some serious news" 1
  • State the diagnosis directly without medical jargon: "Your cancer has spread to your liver" (not "metastatic disease to hepatic parenchyma") 1
  • Provide information in small chunks and check understanding frequently 1
  • Pause after delivering the news - use supportive silence to let information sink in 1
  • Critical pitfall: Using medical jargon causes patients to withdraw into polite silence rather than ask for clarification 2

E - Empathy

  • Wait for the patient to respond before saying anything more 1
  • If patient is silent, ask: "What's going through your mind?" or "What are you feeling right now?" 1
  • Acknowledge and name emotions explicitly: "You look overwhelmed" or "I can see this is very difficult news" 1
  • Use empathic responses that connect emotion to cause: "I can see you're shocked by this news" 1
  • Express partnership: "I want to make sure we do everything we can to help you" 1
  • Do NOT minimize the bad news or change the subject to reduce distress 1
  • Critical pitfall: Blocking emotional reactions by redirecting to objective topics leaves patients lost in their emotions 2
  • Critical pitfall: Talking while the patient is absorbing prevents emotional processing 2

S - Strategy and Summary

  • Titrate additional information to the patient's emotional state 1
  • Discuss the meaning of findings and next steps 1
  • Outline a clear treatment plan or next steps
  • Focus on what CAN be done to maintain hope 1
  • Affirm non-abandonment: "I'll continue to take care of you whatever happens" or "It's my job to help you get the best care possible" 1
  • Encourage questions: "What questions do you have?" (not "Do you have questions?") 1
  • Offer additional support resources (social work, chaplaincy, support groups) 1
  • Schedule follow-up visit
  • Document the conversation in the medical record 1

Key Communication Principles Throughout

  • Use silence strategically - it creates space for patients to process and express concerns 1
  • Avoid information overload when patients are highly emotional 1
  • Include other team members (nurses, social workers) when possible 2
  • Consider spreading difficult conversations over multiple visits 1
  • Respond to emotion cues in facial expressions, body language, and verbal statements 2

Common Pitfalls to Avoid

The evidence strongly emphasizes these critical errors 2:

  • Proceeding without assessing baseline knowledge - leads to gaps and confusion
  • Using medical jargon - causes patient withdrawal and misunderstanding
  • Blocking or overlooking emotional reactions - leaves patients emotionally abandoned
  • Talking while patient is absorbing - prevents processing
  • Not responding to emotion explicitly - signals that emotions aren't welcome
  • Redirecting away from sadness - gives message that negative feelings are not allowed

References

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.