SPIKES

Short description: Protocol used in clinical medicine to break bad news to patients and families

The SPIKES protocol is a method used in clinical medicine to break bad news to patients and families.[1][2][3][4][5][6][7] As receiving emotionally distressing information can cause distress and anxiety,[7] clinicians need to deliver the news carefully.[8] Using the SPIKES method is an acronym for introducing and communicating information to patients and their families, can aid in the presentation of the material. The SPIKES method is helpful in providing an organized manner of communication during situations that are typically complex and difficult to communicate.

This method has received praises and criticism, while majorly influencing clinician-patient communication.[9] According to research related to the SPIKES method, important factors to consider when using this protocol involve empathy, acknowledgement, culture, and validation of feelings, providing information about intervention and treatment, and ensuring that the patient clearly understands the news being delivered.[1]

The protocol was first published in 2000 by Baile et al, in the context of oncology.[10][11]

## Steps

The name SPIKES is an acronym, where the letters stand for:[1][12][13][10]

* S: setting, i.e. setting up the consultation appropriately:

→ The patient should only be provided with the bad news when they are in a private setting that contains little to no distractions to ensure the message is being properly received. Examples of inappropriate settings are: via phone call or in an open area such as a hallway. Furthermore, the clinician should remember to be facing the patient and the family throughout the process and establish therapeutic alliance or connection through the use of eye contact and physical touch, i.e. holding a hand or touching an arm.[1][12][13][10]

* P: perception, i.e. assessing the patient's perception of the situation:

→ The clinician should initiate the process by asking the patient what they believe is going on. This can allow the clinician to find out to what extent the patient knows about the situation, and also engages the patient, acquiring their attention. It allows for them to realize that their thoughts matter and forms a starting point for how to proceed. Most importantly, the response of the patient can lead to any misconceptions to be corrected by the clinician immediately.[1][12][13][10]

* I: invitation, i.e. prompting the patient to invite the clinician to deliver the news:

→ Phrases such as "Shall I share the results of the scan with you now?" or "Is this a good time to share with you what I believe is going on?" allow for the patient to decide if they are ready to proceed and also allow for open discussion to follow. Phrasing is important because the fundamental purpose of this step is for the clinician to request permission to share unpleasant news with the patient. The way this is worded must show respect for the patient's feelings and inquire about their readiness to receive news.[1][12][13][10]

* K: knowledge, i.e. providing the knowledge to the patient:

→ The clinician should speak slowly, maintain eye contact, and use terms both parties can understand. The clinician should then explain what the bad news means for the patient while avoiding adding extra details initially as this is the place to be clear and concise about what is happening.[1][12][13][10]

* E: empathy, i.e. empathizing with the impact of the news on the patient:

→ Understanding the thoughts and feelings in the minds of the patient and their family can be difficult. It is often best for the clinician to remain silent instead of speaking out as everyone is processing emotions. When the clinician feels it is appropriate to speak, they should speak with empathy and acknowledge that the patient is feeling something. Tears or silence should never be discouraged, this may be a processing strategy that is necessary to fully acknowledge the situation. Support should be provided.[1][12][13][10]

* S: strategy, i.e. devising a strategy for what to do next:

→ The clinician then summarizes all thoughts and helps the patient decide where to go from here. Options to discuss may be treatment, setting another meeting, discussing hospice care, etc. Each situation is unique and it is best to do what is in the best interest of the patient's wants and needs.[1][12][13][10]

## Influence and Criticism of the SPIKES method

The SPIKES protocol has had an influence on medical communication training. Since its introduction, it has become one of the most widely taught methods for delivering difficult news in clinical practices.[14] Multiple studies[15][16] have found that physicians across multiple countries recognize the SPIKES protocol as a helpful structural guide for organizing emotionally complex and even difficult conversations. Researchers found that physicians and clinicians located in Oman were familiar with the steps of the SPIKES method and viewed the protocol as a valuable tool for improving confidence and professionalism when communicating difficult or distressing news.[15] Similarly, international uses are found in research from Nigeria, where many clinicians reported using the SPIKES protocol either formally or informally as a tool for structuring these difficult conversations.[16]

Researchers however, have observed that patient needs are often more nuanced than what the six-step SPIKES protocol can fully cover.[17] Researchers showed that patients differ widely in their preferences regarding information depth, pacing, emotional support, and involvement in the decision making process.[14] These variations revealed that following the SPIKES protocol in a very rigid manner may overlook individual patient preferences. In response, newer tools such as the MABBAN scale, specifically measure which elements of the SPIKES model that patients tend to value the most.[17] Their findings suggested that while many of the SPIKES components align with patient expectations, not all patients prioritize the same aspects.[14][17]

Scholars[18] have also criticized SPIKES for focusing too heavily on physicians behavior without fully addressing the interactive, relational, and evolving aspects of breaking bad news. They argue that the emotional and cognitive needs of patients are not static and therefore require a more dynamic, and patient centered approach than the SPIKES protocol had originally proposed.[18] Their revised SPw-ICE-S model emphasizes additional elements, like ongoing emotional attunement, checking patient understanding and comprehension throughout the conversation, and supporting the patient.[18] These are areas that the SPIKES method covers very minimally. This critique points to the broader concern, which is that SPIKES may be too rigid for real world clinical implications, which tend to require circling back, adjusting communication strategies, and responding flexibly to the patient's cues.[18]

Another recurring criticism among studies involves the gap between knowledge of the protocol and consistent, high quality execution. Multiple[15][16] studies found that although many clinicians understood the steps of the SPIKES protocol, actual execution during clinical practices varied considerably, often due to external factors like time constraints, emotional discomfort, or limited communication training. These critics argue that without continuous practice, constructive feedback, and support through the medical institution, the SPIKES protocol risks becoming a checklist rather than a meaningful tool for empathetic patient care.[15][16]

## References

1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Kaplan, Marcelle (2010-08-01). "SPIKES: A Framework for Breaking Bad News to Patients With Cancer". Clinical Journal of Oncology Nursing 14 (4): 514–516. doi:10.1188/10.CJON.514-516. ISSN 1092-1095. PMID 20682509. https://www.ons.org/publications-research/cjon/14/4/spikes-framework-breaking-bad-news-patients-cancer.
2. ↑ Dean, Antonia; Willis, Susan (2016-06-02). "The use of protocol in breaking bad news: evidence and ethos" (in en). International Journal of Palliative Nursing 22 (6): 265–271. doi:10.12968/ijpn.2016.22.6.265. ISSN 1357-6321. PMID 27349844. http://www.magonlinelibrary.com/doi/10.12968/ijpn.2016.22.6.265.
3. ↑ Seifart, C.; Hofmann, M.; Bär, T.; Riera Knorrenschild, J.; Seifart, U.; Rief, W. (March 2014). "Breaking bad news–what patients want and what they get: evaluating the SPIKES protocol in Germany" (in en). Annals of Oncology 25 (3): 707–711. doi:10.1093/annonc/mdt582. https://linkinghub.elsevier.com/retrieve/pii/S0923753419342747.
4. ↑ de Moura Villela, Edlaine Faria; Bastos, Luana Kronit; de Almeida, Wanderson Sant’ana; Pereira, Andressa Oliveira; de Paula Rocha, Matheus Silva; de Oliveira, Fábio Morato; Bollela, Valdes Roberto (June 2020). "Effects on Medical Students of Longitudinal Small-Group Learning about Breaking Bad News". The Permanente Journal 24 (2). doi:10.7812/tpp/19.157. ISSN 1552-5767. PMC 7039420. https://doi.org/10.7812/tpp/19.157.
5. ↑ Servotte, Jean-Christophe; Bragard, Isabelle; Szyld, Demian; Van Ngoc, Pauline; Scholtes, Beatrice; Van Cauwenberge, Isabelle; Dardenne, Nadia; Goosse, Manon et al. (2019-10-14). "Efficacy of a Short Role-Play Training on Breaking Bad News in the Emergency Department". Western Journal of Emergency Medicine 20 (6): 893–902. doi:10.5811//westjem.2019.8.43441. PMID 31738716. PMC 6860397. https://escholarship.org/uc/item/0xx0w6b9.
6. ↑ Alves, Carolina Guimarães Bonfim; Treister, Nathaniel Simon; Ribeiro, Ana Carolina Prado; Brandão, Thaís Bianca; Tonaki, Juliana Ono; Lopes, Marcio Ajudarte; Rivera, César; Santos-Silva, Alan Roger (April 2020). "Strategies for communicating oral and oropharyngeal cancer diagnosis: why talk about it?" (in en). Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology 129 (4): 347–356. doi:10.1016/j.oooo.2019.11.014. PMID 31928903. https://linkinghub.elsevier.com/retrieve/pii/S2212440319315998.
7. ↑ 7.0 7.1 Zheng, Ying; Lei, Fang; Liu, Bao (2019-12-14). "Cancer Diagnosis Disclosure and Quality of Life in Elderly Cancer Patients" (in en). Healthcare 7 (4): 163. doi:10.3390/healthcare7040163. ISSN 2227-9032.
8. ↑ Hausdorff, John (2017). "Ask the Hematologist: SPIKES Protocol For Delivering Bad News to Patients". The Hematologist 14 (4). doi:10.1182/hem.v14.4.7475. ISSN 1551-8779. https://doi.org/10.1182/hem.v14.4.7475.
9. ↑ Al Omrani, Sahar; Al Omrani, Noor; Al Kindi, Rahma; Al Farsi, Badriya; Al Mahrezi, Buthaina (2025-03-31). "Evaluating Physicians' Experiences and Compliance with the SPIKES Protocol for Communicating Adverse News: A Cross-sectional Study Conducted in Muscat, Oman". Oman Medical Journal 40 (2): e733. doi:10.5001/omj.2025.62. ISSN 1999-768X. PMID 40949501. https://doi.org/10.5001/omj.2025.62.
10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 Baile, Walter F.; Buckman, Robert; Lenzi, Renato; Glober, Gary; Beale, Estela A.; Kudelka, Andrzej P. (2000-08-01). "SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer" (in en). The Oncologist 5 (4): 302–311. doi:10.1634/theoncologist.5-4-302. ISSN 1083-7159. PMID 10964998. https://academic.oup.com/oncolo/article/5/4/302/6386019.
11. ↑ Sehouli, h.c. Jalid (2019-09-04), "Breaking Bad News Well", The Art of Breaking Bad News Well (CRC Press): pp. 11–55, doi:10.1201/9780429341083-2, ISBN 978-0-429-34108-3, https://doi.org/10.1201/9780429341083-2, retrieved 2025-12-04
12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 Baile, Walter F.; Buckman, Robert; Lenzi, Renato; Glober, Gary; Beale, Estela A.; Kudelka, Andrzej P. (August 2000). "SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer". The Oncologist 5 (4): 302–311. doi:10.1634/theoncologist.5-4-302. PMID 10964998.
13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 13.6 Kaplan, Marcelle (1 August 2010). "SPIKES: A Framework for Breaking Bad News to Patients With Cancer". Clinical Journal of Oncology Nursing 14 (4): 514–516. doi:10.1188/10.CJON.514-516. PMID 20682509.
14. ↑ 14.0 14.1 14.2 Parker, P. A.; Baile, W. F.; de Moor, C.; Lenzi, R.; Kudelka, A. P.; Cohen, L. (2001-04-01). "Breaking bad news about cancer: patients' preferences for communication". Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology 19 (7): 2049–2056. doi:10.1200/JCO.2001.19.7.2049. ISSN 0732-183X. PMID 11283138.
15. ↑ 15.0 15.1 15.2 15.3 Al Omrani, Sahar; Al Omrani, Noor; Al Kindi, Rahma; Al Farsi, Badriya; Al Mahrezi, Buthaina (2025-03-31). "Evaluating Physicians' Experiences and Compliance with the SPIKES Protocol for Communicating Adverse News: A Cross-sectional Study Conducted in Muscat, Oman". Oman Medical Journal 40 (2): e733. doi:10.5001/omj.2025.62. ISSN 1999-768X. PMID 40949501. https://doi.org/10.5001/omj.2025.62.
16. ↑ 16.0 16.1 16.2 16.3 Ipinnimo, Tope Michael; Asake, Olumide Temitope; Olowoselu, Oluwafemi Oreoluwa; Sanni, Taofeek Adedayo; Adekeye, Abolaji Paul; Adepoju, Rasheed Adeyemi; Akinlua, Gbenga Damilola; Ajayi, Paul Oladapo et al. (2025-04-28). "Breaking bad news: a cross-sectional study assessing SPIKES protocol adherence and other methods employed among medical doctors in Nigeria" (in en). BMC Primary Care 26 (1). doi:10.1186/s12875-025-02832-y. ISSN 2731-4553. PMID 40295981.
17. ↑ 17.0 17.1 17.2 von Blanckenburg, Pia; Hofmann, Mareike; Rief, Winfried; Seifart, Ulf; Seifart, Carola (August 2020). "Assessing patients´ preferences for breaking Bad News according to the SPIKES-Protocol: the MABBAN scale". Patient Education and Counseling 103 (8): 1623–1629. doi:10.1016/j.pec.2020.02.036. ISSN 0738-3991. PMID 32151521. https://doi.org/10.1016/j.pec.2020.02.036.
18. ↑ 18.0 18.1 18.2 18.3 Meitar, Dafna; Karnieli-Miller, Orit (2021-05-30). "Twelve tips to manage a breaking bad news process: Using S-P-w-ICE-S – A revised version of the SPIKES protocol". Medical Teacher 44 (10): 1087–1091. doi:10.1080/0142159x.2021.1928618. ISSN 0142-159X. PMID 34057007. https://doi.org/10.1080/0142159x.2021.1928618.

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