SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer.
ABSTRACT We describe a protocol for disclosing unfavorable information-"breaking bad news"-to cancer patients about their illness. Straightforward and practical, the protocol meets the requirements defined by published research on this topic. The protocol (SPIKES) consists of six steps. The goal is to enable the clinician to fulfill the four most important objectives of the interview disclosing bad news: gathering information from the patient, transmitting the medical information, providing support to the patient, and eliciting the patient's collaboration in developing a strategy or treatment plan for the future. Oncologists, oncology trainees, and medical students who have been taught the protocol have reported increased confidence in their ability to disclose unfavorable medical information to patients. Directions for continuing assessment of the protocol are suggested.
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ABSTRACT: EinleitungZur ärztlichen Aufgabe gehört unter anderem das Überbringen von schlechten Nachrichten an Patienten und ihre Angehörigen. Schlechte Nachrichten werden definiert als „[Nachricht], welche in einem kognitiven, emotionalen oder sich auf das Verhalten auswirkenden Defizit in der Person, welche die Nachricht erhält, resultiert“. Dieses Defizit hält für einige Zeit an, nachdem die Nachricht überbracht wurde (, S. 496). Die Bewertung, ob eine Mitteilung in die Kategorie „schlechte Nachrichten“ gehört, ist für den Patienten subjektiv. Der Arzt kann versuchen, sich in den Patienten hineinzuversetzen, aber die abschließende Beurteilung der Nachricht liegt beim Patienten. Es gibt diverse Studien über die Ansichten von Ärzten über das Überbringen schlechter Nachrichten [2,4,9]. Viele Ärzte haben das Überbringen schlechter Nachrichten im Rahmen ihres Studiums oder ihrer Weiterbildung nicht gelernt  und empfänden eine Ausbildung in diesem Gebiet als hilfreich . Die Patienten wünsc ...Ethik in der Medizin 09/2012; 24(3):241-244. · 0.54 Impact Factor
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ABSTRACT: Abstract: Medical providers are trained to investigate, diagnose, and treat cancer. Their primary goal is to maximize the chances of curing the patient, with less training provided on palliative care concepts and the unique developmental needs inherent in this population. Early, systematic integration of palliative care into standard oncology practice represents a valuable, imperative approach to improving the overall cancer experience for adolescents and young adults (AYAs). The importance of competent, confident, and compassionate providers for AYAs warrants the development of effective educational strategies for teaching AYA palliative care. Just as palliative care should be integrated early in the disease trajectory of AYA patients, palliative care training should be integrated early in professional development of trainees. As the AYA age spectrum represents sequential transitions through developmental stages, trainees experience changes in their learning needs during their progression through sequential phases of training. This article reviews unique epidemiologic, developmental, and psychosocial factors that make the provision of palliative care especially challenging in AYAs. A conceptual framework is provided for AYA palliative care education. Critical instructional strategies including experiential learning, group didactic opportunity, shared learning among care disciplines, bereaved family members as educators, and online learning are reviewed. Educational issues for provider training are addressed from the perspective of the trainer, trainee, and AYA. Goals and objectives for an AYA palliative care cancer rotation are presented. Guidance is also provided on ways to support an AYA’s quality of life as end of life nears.Clinical Oncology in Adolescents and Young Adults. 01/2015; 5:1-18.
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ABSTRACT: Introduction: We investigated whether a communication skill training (CST) for physicians leads to improved satisfaction of patients with the disclosure procedure about lung cancer and whether the patient´s recall can be improved.Methods: In an observation study 101 patients, who were disclosed about their lung cancer diagnosis, were questioned about the recall and satisfaction regarding diagnosis, therapy and therapy goal. The contents of the physicians' structured questionnaire were then matched with the questions posed to patients in interviews regarding recall. A total of 37 physicians from the lung cancer center attended to a structured CST with simulated patients on basis of the SPIKES model. After this intervention, 100 diagnosed patients were interviewed accordingly. Results: Patients recall of diagnosis and therapy was very high in the observational study (correct recall of diagnosis 86%, correct recall of therapy 81%). The recall results of the physicians trained in communication were comparably high (80% and 82%). The recall of the therapeutic goal respectively, were initially low (42%) and could be raised significantly using the CST (61%; p=0.009). The level of satisfaction with the conversation about diagnosisand therapy was high in both studies. Patients` satisfaction with communication about the treatment goal improved significantly when disclosed by trained physicians (81% versus 53%; p<0.001). Conclusion: Lung cancer patients do understand the therapeutic goal and their prognosis better, if the disclosing physician took part in a CST. Moreover, patients are more satisfied with the conversation about their prognosis, when trained physicians explain the disease.J Palliat Care Med. 01/2015; 4:182-186.
SPIKES—A Six-Step Protocol for Delivering Bad News:
Application to the Patient with Cancer
WALTER F. BAILE,aROBERT BUCKMAN,bRENATO LENZI,aGARY GLOBER,a
ESTELA A. BEALE,aANDRZEJ P. KUDELKAb
aThe University of Texas MD Anderson Cancer Center, Houston, Texas, USA;
bThe Toronto-Sunnybrook Regional Cancer Centre, Toronto, Ontario, Canada
Key Words. Neoplasms · Physician-patient relations · Truth disclosure · Educational models
We describe a protocol for disclosing unfavorable
information—“breaking bad news”—to cancer
patients about their illness. Straightforward and prac-
tical, the protocol meets the requirements defined by
published research on this topic. The protocol
(SPIKES) consists of six steps. The goal is to enable the
clinician to fulfill the four most important objectives
of the interview disclosing bad news: gathering infor-
mation from the patient, transmitting the medical
information, providing support to the patient, and elic-
iting the patient’s collaboration in developing a stra-
tegy or treatment plan for the future. Oncologists,
oncology trainees, and medical students who have been
taught the protocol have reported increased confidence
in their ability to disclose unfavorable medical infor-
mation to patients. Directions for continuing assess-
ment of the protocol are suggested. The Oncologist
The Oncologist 2000;5:302-311www.TheOncologist.com
Correspondence: Walter F. Baile, M.D., 1515 Holcombe St., Box 100, Houston, Texas 77030, USA. Telephone: 713-792-
7546; Fax: 713-794-4999; e-mail: email@example.com Received March 9, 2000; accepted for publication June 12,
2000. ©AlphaMed Press 1083-7159/2000/$5.00/0
Surveys conducted from 1950 to 1970, when treatment
prospects for cancer were bleak, revealed that most physicians
considered it inhumane and damaging to the patient to disclose
the bad news about the diagnosis [1, 2]. Ironically, while treat-
ment advances have changed the course of cancer so that it is
much easier now to offer patients hope at the time of diagno-
sis, they have also created a need for increased clinician skill
in discussing other bad news. These situations include disease
recurrence, spread of disease or failure of treatment to affect
disease progression, the presence of irreversible side effects,
revealing positive results of genetic tests, and raising the issue
of hospice care and resuscitation when no further treatment
options exist. This need can be illustrated by information col-
lected by an informal survey conducted at the 1998 Annual
Meeting of the American Society of Clinical Oncology
(ASCO), where we queried attendees at a symposium on com-
munication skills. For this symposium several experts in teach-
ing aspects of the doctor-patient relationship in oncology
formulated a series of questions to assess attendees’ attitudes
and practices regarding breaking bad news. Of the 700 persons
attending the symposium, which was repeated twice over a
two-day period, 500 received a transponder allowing them to
respond in “real time” to questions that were presented on a
screen. The results were immediately analyzed for discussion
and are presented in Table 1. We asked participants about
their experiences in breaking bad news and their opinions as
to its most difficult aspects. Approximately 60% of respon-
dents indicated that they broke bad news to patients from 5 to
20 times per month and another 14% more than 20 times per
month. These data suggest that, for many oncologists, break-
ing bad news should be an important communication skill.
However, breaking bad news is also a complex com-
munication task. In addition to the verbal component of
actually giving the bad news, it also requires other skills.
These include responding to patients’ emotional reactions,
involving the patient in decision-making, dealing with the
stress created by patients’ expectations for cure, the
involvement of multiple family members, and the dilemma
of how to give hope when the situation is bleak. The com-
plexity of the interaction can sometimes create serious
miscommunications [3-6] such as patient misunderstand-
ing about the prognosis of the illness or purpose of care [7-
12]. Poor communication may also thwart the goal of
Baile, Buckman, Lenzi et al.
Table 1. Results of survey of participants at Breaking Bad News Symposium, American Society of Clinical Oncology, 19981,2
1. In an average month, how often do you have to break bad news to a patient
(e.g., diagnosis, recurrence, progressive disease, etc.)?
Less than 5 times
5 to 10 times
10 to 20 times
More than 20
2. Which do you find the most difficult task?
Telling patient about recurrence
Talking about end of active treatment and beginning palliative treatment
Discussing end-of-life issues (e.g., do not resuscitate)
Involving family/friends of patient
3. Have you had any specific teaching or training for breaking bad news?
Sat in with clinicians in breaking bad news interviews
4. How do you feel about your own ability to break bad news?
5. What do you feel is the most difficult part of discussing bad news?
Being honest but not taking away hope
Dealing with the patient’s emotion (e.g., crying, anger)
Spending the right amount of time
Involving friends and family of the patient
Involving patient or family in decision-making
6. Have you had any training in the techniques of responding to patient’s emotions?
Sat in with practicing clinician
7. How would you rate your own comfort in dealing with patient’s emotions
(e.g., crying, anger, denial, etc.)?
Not very comfortable
8. Did you find that the SPIKES made sense to you?
9. Would a strategy or approach to breaking bad news interviews be helpful to you in your practice?
10. Do you feel that the SPIKES is practical and can be used in your clinical practice?
11. When you break bad news to your patients, do you have a consistent plan or strategy in mind?
Have a consistent plan or strategy
Several techniques/tactics but no overall plan
No consistent approach to task
12. Which element of the SPIKES protocol do you think you would find most easy?
13. Which element of the SPIKES protocol do you think you would find most difficult?
Day 1 (%)Day 2 (%) Average (%)
1Some questions asked on the first day were not included on day 2. Additional questions were added on day 2 based on response to questions of the previous
day. 2Presented in part at the Annual Meeting of the American Society of Clinical Oncology, New Orleans, LA, May 19-23, 2000.
Breaking Bad News
understanding patient expectations of treatment or involving
the patient in treatment planning.
The task of breaking bad news can be improved by under-
standing the process involved and approaching it as a step-
wise procedure, applying well-established principles of
communication and counseling. Below we describe a six-step
protocol, which incorporates these principles.
A DEFINITION OF BAD NEWS
Bad news may be defined as “any information which
adversely and seriously affects an individual’s view of his or
her future” . Bad news is always, however, in the “eye of
the beholder,” such that one cannot estimate the impact of the
bad news until one has first determined the recipient’s expec-
tations or understanding. For example, a patient who is told
that her back pain is caused by a recurrence of her breast can-
cer when she was expecting to be told it was a muscle strain is
likely to feel shocked.
BREAKING BAD NEWS: WHY IS IT IMPORTANT?
A Frequent but Stressful Task
Over the course of a career, a busy clinician may disclose
unfavorable medical information to patients and families many
thousands of times . Breaking bad news to cancer patients
is inherently aversive, described as “hitting the patient over the
head” or “dropping a bomb” . Breaking bad news can be
particularly stressful when the clinician is inexperienced, the
patient is young, or there are limited prospects for successful
Patients Want the Truth
By the late 1970s most physicians were open about telling
cancer patients their diagnosis . However, studies began
to indicate that patients also desired additional information.
For example, a survey published in 1982 of 1,251 Americans
 indicated that 96% wished to be told if they had a diag-
nosis of cancer, but also that 85% wished, in cases of a grave
prognosis, to be given a realistic estimate of how long they
had to live. Over many years a number of studies in the
United States have supported these findings [17-23], although
patient expectations have not always been met [24-27].
European patients’ wishes have been found to be similar to
those of American patients. For example, a study of 250
patients at an oncology center in Scotland showed that 91%
and 94% of patients, respectively, wanted to know the chances
of cure for their cancer and the side effects of therapy .
Ethical and Legal Imperatives
In North America, principles of informed consent, patient
autonomy, and case law have created clear ethical and legal
obligations to provide patients with as much information as
they desire about their illness and its treatment [29, 30].
Physicians may not withhold medical information even if they
suspect it will have a negative effect on the patient. Yet a man-
date to disclose the truth, without regard or concern for the sen-
sitivity with which it is done or the obligation to support the
patients and assist them in decision-making, can result in the
patients being as upset as if they were lied to . As has been
aptly suggested, the practice of deception cannot instantly be
remedied by a new routine of insensitive truth telling .
How bad news is discussed can affect the patient’s
comprehension of information , satisfaction with med-
ical care [33, 34], level of hopefulness , and subsequent
psychological adjustment [36-38]. Physicians who find it
difficult to give bad news may subject patients to harsh
treatments beyond the point where treatment may be
expected to be helpful . The idea that receiving unfa-
vorable medical information will invariably cause psycho-
logical harm is unsubstantiated [40, 41]. Many patients
desire accurate information to assist them in making impor-
tant quality-of-life decisions. However, others who find it
too threatening may employ forms of denial, shunning or
minimizing the significance of the information, while still
participating in treatment.
WHAT ARE THE BARRIERS TO BREAKING BAD NEWS?
Tesser  and others conducted psychological exper-
iments that showed that the bearer of bad news often expe-
riences strong emotions such as anxiety, a burden of
responsibility for the news, and fear of negative evaluation.
This stress creates a reluctance to deliver bad news, which
he named the “MUM” effect. The MUM effect is particu-
larly strong when the recipient of the bad news is already
perceived as being distressed . It is not hard to imagine
that these factors may operate when bad news must be
given to cancer patients [44, 45].
The participants in our previously mentioned ASCO sur-
vey identified several additional stresses in giving bad news.
Fifty-five percent ranked “how to be honest with the patient
and not destroy hope” as most important, whereas “dealing
with the patient’s emotions” was endorsed by 25%. Finding
the right amount of time was a problem for only 10%.
Despite these identified challenges, less than 10% of
survey respondents had any formal training in breaking bad
news and only 32% had the opportunity during training to
regularly observe interviews where bad news was deliv-
ered. While 53% of respondents indicated that their ability
to break bad news was good to very good, 39% thought that
it was only fair, and 8% thought it was poor.
Baile, Buckman, Lenzi et al.
From this information and other studies we may con-
clude that for many clinicians additional training in disclos-
ing unfavorable information to the patient could be useful
and increase their confidence in accomplishing this task.
Moreover, techniques for disclosing information in a way
that addresses the expectations and emotions of the patients
also seem to be strongly desired, but rarely taught.
HOW CAN A STRATEGY FOR BREAKING BAD NEWS
HELP THE CLINICIAN AND THE PATIENT?
When physicians are uncomfortable in giving bad news
they may avoid discussing distressing information, such as a
poor prognosis, or convey unwarranted optimism to the
patient . A plan for determining the patient’s values,
wishes for participation in decision-making, and a strategy
for addressing their distress when the bad news is disclosed
can increase physician confidence in the task of disclosing
unfavorable medical information [47, 48]. It may also
encourage patients to participate in difficult treatment deci-
sions, such as when there is a low probability that direct
anticancer treatment will be efficacious. Finally, physicians
who are comfortable in breaking bad news may be subject to
less stress and burnout .
A SIX-STEP STRATEGY FOR BREAKING BAD NEWS
The authors of several recent papers have advised that
interviews about breaking bad news should include a num-
ber of key communication techniques that facilitate the
flow of information [3, 13, 50-54]. We have incorporated
these into a step-by-step technique, which additionally pro-
vides several strategies for addressing the patient’s distress.
Complex Clinical Tasks May Be Considered as a Series
The process of disclosing unfavorable clinical informa-
tion to cancer patients can be likened to other medical proce-
dures that require the execution of a stepwise plan. In
medical protocols, for example, cardiopulmonary resuscita-
tion or management of diabetic ketoacidosis, each step must
be carried out and, to a great extent, the successful comple-
tion of each task is dependent upon the completion of the step
Goals of the Bad News Interview
The process of disclosing bad news can be viewed as an
attempt to achieve four essential goals. The first is gathering
information from the patient. This allows the physician to
determine the patient’s knowledge and expectations and
readiness to hear the bad news. The second goal is to provide
intelligible information in accordance with the patient’s
needs and desires. The third goal is to support the patient by
employing skills to reduce the emotional impact and isola-
tion experienced by the recipient of bad news. The final goal
is to develop a strategy in the form of a treatment plan with
the input and cooperation of the patient.
Meeting these goals is accomplished by completing six
tasks or steps, each of which is associated with specific
skills. Not every episode of breaking bad news will require
all of the steps of SPIKES, but when they do they are meant
to follow each other in sequence.
THE SIX STEPS OF SPIKES
STEP 1: S—SETTING UP the Interview
Mental rehearsal is a useful way for preparing for
stressful tasks. This can be accomplished by reviewing the
plan for telling the patient and how one will respond to
patients’ emotional reactions or difficult questions. As the
messenger of bad news, one should expect to have negative
feelings and to feel frustration or responsibility . It is
helpful to be reminded that, although bad news may be very
sad for the patients, the information may be important in
allowing them to plan for the future.
Sometimes the physical setting causes interviews about
sensitive topics to flounder. Unless there is a semblance of
privacy and the setting is conducive to undistracted and
focused discussion, the goals of the interview may not be
met. Some helpful guidelines:
• Arrange for some privacy. An interview room is ideal,
but, if one is not available, draw the curtains around the
patient’s bed. Have tissues ready in case the patient
• Involve significant others. Most patients want to have
someone else with them but this should be the patient’s
choice. When there are many family members, ask the
patient to choose one or two family representatives.
• Sit down. Sitting down relaxes the patient and is also a
sign that you will not rush. When you sit, try not to
have barriers between you and the patient. If you have
recently examined the patient, allow them to dress
before the discussion.
• Make connection with the patient. Maintaining eye con-
tact may be uncomfortable but it is an important way of
establishing rapport. Touching the patient on the arm or
holding a hand (if the patient is comfortable with this)
is another way to accomplish this.
• Manage time constraints and interruptions. Inform the
patient of any time constraints you may have or inter-
ruptions you expect. Set your pager on silent or ask a
colleague to respond to your pages.
Breaking Bad News
STEP 2: P—ASSESSING THE PATIENT’S
Steps 2 and 3 of SPIKES are points in the interview
where you implement the axiom “before you tell, ask.” That
is, before discussing the medical findings, the clinician uses
open-ended questions to create a reasonably accurate pic-
ture of how the patient perceives the medical situation—
what it is and whether it is serious or not. For example,
“What have you been told about your medical situation so
far?” or “What is your understanding of the reasons we did
the MRI?”. Based on this information you can correct mis-
information and tailor the bad news to what the patient
understands. It can also accomplish the important task of
determining if the patient is engaging in any variation of ill-
ness denial: wishful thinking, omission of essential but
unfavorable medical details of the illness, or unrealistic
expectations of treatment .
STEP 3: I—OBTAINING THE PATIENT’S
While a majority of patients express a desire for full
information about their diagnosis, prognosis, and details of
their illness, some patients do not. When a clinician hears a
patient express explicitly a desire for information, it may
lessen the anxiety associated with divulging the bad news
. However, shunning information is a valid psycholog-
ical coping mechanism [58, 59] and may be more likely to
be manifested as the illness becomes more severe .
Discussing information disclosure at the time of ordering
tests can cue the physician to plan the next discussion with
the patient. Examples of questions asked the patient would
be, “How would you like me to give the information about
the test results? Would you like me to give you all the infor-
mation or sketch out the results and spend more time dis-
cussing the treatment plan?”. If patients do not want to
know details, offer to answer any questions they may have
in the future or to talk to a relative or friend.
STEP 4: K—GIVING KNOWLEDGE AND
INFORMATION TO THE PATIENT
Warning the patient that bad news is coming may lessen
the shock that can follow the disclosure of bad news 
and may facilitate information processing . Examples of
phrases that can be used include, “Unfortunately I’ve got
some bad news to tell you” or “I’m sorry to tell you that…”.
Giving medical facts, the one-way part of the physician-
patient dialogue, may be improved by a few simple guide-
lines. First, start at the level of comprehension and vocabulary
of the patient. Second, try to use nontechnical words such as
“spread” instead of “metastasized” and “sample of tissue”
instead of “biopsy.” Third, avoid excessive bluntness (e.g.,
“You have very bad cancer and unless you get treatment
immediately you are going to die.”) as it is likely to leave
the patient isolated and later angry, with a tendency to
blame the messenger of the bad news [4, 32, 61]. Fourth,
give information in small chunks and check periodically as
to the patient’s understanding. Fifth, when the prognosis is
poor, avoid using phrases such as “There is nothing more we
can do for you.” This attitude is inconsistent with the fact
that patients often have other important therapeutic goals
such as good pain control and symptom relief [35, 62].
STEP 5: E—ADDRESSING THE PATIENT’S
EMOTIONS WITH EMPATHIC RESPONSES
Responding to the patient’s emotions is one of the most
difficult challenges of breaking bad news [3, 13]. Patients’
emotional reactions may vary from silence to disbelief,
crying, denial, or anger.
When patients get bad news their emotional reaction is
often an expression of shock, isolation, and grief. In this sit-
uation the physician can offer support and solidarity to the
patient by making an empathic response. An empathic
response consists of four steps :
• First, observe for any emotion on the part of the patient.
This may be tearfulness, a look of sadness, silence,
• Second, identify the emotion experienced by the
patient by naming it to oneself. If a patient appears sad
but is silent, use open questions to query the patient as
to what they are thinking or feeling.
• Third, identify the reason for the emotion. This is usu-
ally connected to the bad news. However, if you are
not sure, again, ask the patient.
• Fourth, after you have given the patient a brief period
of time to express his or her feelings, let the patient
know that you have connected the emotion with the
reason for the emotion by making a connecting state-
ment. An example:
Doctor: I’m sorry to say that the x-ray shows that the
chemotherapy doesn’t seem to be working
[pause]. Unfortunately, the tumor has grown
Patient: I’ve been afraid of this! [Cries]
Doctor: [Moves his chair closer, offers the patient a
tissue, and pauses.] I know that this isn’t what you
wanted to hear. I wish the news were better.
In the above dialogue, the physician observed the
patient crying and realized that the patient was tearful
because of the bad news. He moved closer to the patient. At
Baile, Buckman, Lenzi et al.
this point he might have also touched the patient’s arm or
hand if they were both comfortable and paused a moment to
allow her to get her composure. He let the patient know that
he understood why she was upset by making a statement
that reflected his understanding. Other examples of
empathic responses can be seen in Table 2.
Until an emotion is cleared, it will be difficult to go on
to discuss other issues. If the emotion does not diminish
shortly, it is helpful to continue to make empathic responses
until the patient becomes calm. Clinicians can also use
empathic responses to acknowledge their own sadness or
other emotions (“I also wish the news were better”). It can
be a show of support to follow the empathic response with
a validating statement, which lets the patient know that
their feelings are legitimate (Table 3).
Again, when emotions are not clearly expressed, such
as when the patient is silent, the physician should ask an
exploratory question before he makes an empathic
response. When emotions are subtle or indirectly expressed
or disguised as in thinly veiled disappointment or anger
(“I guess this means I’ll have to suffer through chemother-
apy again”) you can still use an empathic response (“I can
see that this is upsetting news for you”). Patients regard
their oncologist as one of their most important sources of
psychological support , and combining empathic,
exploratory, and validating statements is one of the most
powerful ways of providing that support [64-66] (Table 2).
It reduces the patient’s isolation, expresses solidarity, and
validates the patient’s feelings or thoughts as normal and to
be expected .
Table 2. Examples of empathic, exploratory, and validating responses
“I can see how upsetting this is to you.”
“I can tell you weren’t expecting to hear this.”
“I know this is not good news for you.”
“I’m sorry to have to tell you this.”
“How do you mean?”
“Tell me more about it.”
“Could you explain what you mean?”
“You said it frightened you?”
“I can understand how you felt that way.”
“I guess anyone might have that same reaction.”
“You were perfectly correct to think that way.”
“Yes, your understanding of the reason for the
“tests is very good.”
“It appears that you’ve thought things through
“Many other patients have had a similar
“This is very difficult for me also.”“Could you tell me what you’re
“Now, you said you were concerned about
“your children. Tell me more.”
“I was also hoping for a better result.”
Table 3. Changes in confidence levels among participants in workshops on communicating bad news
Breaking bad news Fellows Faculty
Plan the discussion in advance
Create a comfortable setting
Encourage family/friend presence
Assess patient’s ability to discuss bad news
Confirm patient’s understanding of cancer
Assess how much patient wants to know
Organize a strategy for disclosing information
Include family/caregiver in discussion
Provide information in small increments
Avoid medical jargon
Check to see if information was correctly received by patient
Reinforce and clarify information
Handle the patient’s emotional reactions
Breaking Bad News
STEP 6: S—STRATEGY AND SUMMARY
Patients who have a clear plan for the future are less
likely to feel anxious and uncertain. Before discussing a
treatment plan, it is important to ask patients if they are ready
at that time for such a discussion. Presenting treatment
options to patients when they are available is not only a legal
mandate in some cases , but it will establish the percep-
tion that the physician regards their wishes as important.
Sharing responsibility for decision-making with the patient
may also reduce any sense of failure on the part of the physi-
cian when treatment is not successful. Checking the patient’s
misunderstanding of the discussion can prevent the docu-
mented tendency of patients to overestimate the efficacy or
misunderstand the purpose of treatment [7-9, 57].
Clinicians are often very uncomfortable when they
must discuss prognosis and treatment options with the
patient, if the information is unfavorable. Based on our own
observations and those of others [1, 5, 6, 10, 44-46], we
believe that the discomfort is based on a number of con-
cerns that physicians experience. These include uncertainty
about the patient’s expectations, fear of destroying the
patient’s hope, fear of their own inadequacy in the face of
uncontrollable disease, not feeling prepared to manage the
patient’s anticipated emotional reactions, and sometimes
embarrassment at having previously painted too optimistic
a picture for the patient.
These difficult discussions can be greatly facilitated by
using several strategies. First, many patients already have
some idea of the seriousness of their illness and of the limi-
tations of treatment but are afraid to bring it up or ask about
outcomes. Exploring the patient’s knowledge, expectations,
and hopes (step 2 of SPIKES) will allow the physician to
understand where the patient is and to start the discussion
from that point. When patients have unrealistic expectations
(e.g., “They told me that you work miracles.”), asking the
patient to describe the history of the illness will usually
reveal fears, concerns, and emotions that lie behind the
expectation. Patients may see cure as a global solution to sev-
eral different problems that are significant for them. These
may include loss of a job, inability to care for the family, pain
and suffering, hardship on others, or impaired mobility.
Expressing these fears and concerns will often allow the
patient to acknowledge the seriousness of their condition. If
patients become emotionally upset in discussing their con-
cerns, it would be appropriate to use the strategies outlined in
step 5 of SPIKES. Second, understanding the important spe-
cific goals that many patients have, such as symptom control,
and making sure that they receive the best possible treatment
and continuity of care will allow the physician to frame hope
in terms of what it is possible to accomplish. This can be very
reassuring to patients.
EXPERIENCE WITH THE SPIKES PROTOCOL
Oncologists’ Assessment of SPIKES
In the ASCO survey mentioned previously, we asked
participants if they felt the SPIKES protocol would be use-
ful in their practice. Ninety-nine percent of those responding
found that the SPIKES protocol was practical and easy to
understand. They reported, however, that using empathic,
validating, and exploring statements to respond to patient
emotions would be the greatest challenge of the protocol
(52% of respondents).
In teaching, the SPIKES protocol has been incorporated
into filmed scenarios, which appear as part of a CD-ROM
on physician-patient communication . These scenarios
have proven useful in teaching the protocol and in initiating
discussion of the various aspects of breaking bad news.
Does the SPIKES Protocol Reflect the Consensus of Experts?
Very few studies have sampled patient opinion as to their
preferences for disclosure of unfavorable medical informa-
tion . However, of the scarce information available, the
content of the SPIKES protocol closely reflects the consen-
sus of cancer patients and professionals as to the essential
elements in breaking bad news [3, 13, 50-54]. In particular,
SPIKES emphasizes the techniques useful in responding to
the patient’s emotional reactions and supporting the patient
during this time.
Can Students and Clinicians Learn to Use the Protocol?
Most medical undergraduate and postgraduate programs
do not usually offer specific training in breaking bad news
 and most oncologists learn to break bad news by observ-
ing more experienced colleagues in clinical situations . At
the University of Texas M.D. Anderson Cancer Center we
used the SPIKES protocol in interactive workshops for
oncologists and oncology fellows. As an outcome, before and
after the workshop we used a paper and pencil test to measure
physician confidence in carrying out the various skills associ-
ated with SPIKES. We found that the SPIKES protocol in
combination with experiential techniques such as role play
can increase the confidence of faculty and fellows in applying
the SPIKES protocol  (Table 3). Undergraduate teaching
experience also showed that the protocol increased medical
students’ confidence in formulating a plan for breaking bad
In clinical oncology the ability to communicate effec-
tively with patients and families can no longer be thought of
as an optional skill . Current ASCO guidelines for cur-
riculum development do not yet include recommendations
Baile, Buckman, Lenzi et al.
for training in essential communication skills . However,
a study by Shea of 2,516 oncologists showed interest in addi-
tional training in this area . Shea’s findings regarding
communication skills were echoed by our ASCO survey par-
ticipants, many of whom reported a lack of confidence in
ability to break bad news. A specific lack of training oppor-
tunities appeared to play a major role in leading to this prob-
lem, as almost 40% of respondents not only had no didactic
training but also did not have an opportunity to gain experi-
ence from observing other clinicians breaking bad news.
Several papers have clearly demonstrated that communi-
cation skills can be taught and are retained [47, 48, 71, 75,
76]. The SPIKES protocol for breaking bad news is a spe-
cialized form of skill training in physician-patient communi-
cation, which is employed in teaching communication skills
in other medical settings . These key skills are an impor-
tant basis for effective communication . Employing
verbal skills for supporting and advocating for the patient rep-
resents an expanded view of the role of the oncologist, which
is consistent with the important objective of medical care of
reducing patient suffering. They form the basis for patient
support, an essential psychological intervention for distress.
We recognize that the SPIKES protocol is not com-
pletely derived from empirical data, and whether patients
will find the approach recommended as useful is still an
important question. However, its implementation presup-
poses a dynamic interaction between physician and patient
in which the clinician is guided by patient understanding,
preferences, and behavior. This flexible approach is more
likely to address the inevitable differences among patients
than a rigid recipe that is applied to everyone.
We are currently in the process of determining how the
bearer of bad news is affected psychophysiologically during
the process of disclosure. We plan to determine empirically
whether the SPIKES protocol can reduce the stress of break-
ing bad news for the physician, and also improve the inter-
view and the support as experienced by the patient. We are
further investigating patient preferences for bad news dis-
closure, using many of the steps recommended in SPIKES,
across a variety of disease sites and by age, gender, and
stage of disease. Preliminary data indicate that, as recom-
mended in SPIKES, patients wish the amount of information
they receive to be tailored to their preferences. We are also
conducting long-term follow-up of workshops in which the
protocol has been taught to oncologists and oncology
trainees to determine empirically how it is implemented.
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