What is the SPIKES protocol?
SPIKES is a structure for breaking bad news, first published in 2000 by Baile and colleagues in the journal The Oncologist. It was designed for cancer care but is now used across healthcare, from emergency departments to maternity and physiotherapy.
Bad news is any information that seriously and negatively changes a person's view of their future. That might be a cancer diagnosis, but it could also be a miscarriage, a treatment that has not worked, a new long-term condition, or the news that someone cannot return home. Whether news is bad depends on the person hearing it, not on how serious it looks to you.
| Letter | Step | What you are trying to do |
|---|---|---|
| S | Setting up | Prepare the room, the facts, the people and yourself |
| P | Perception | Find out what the person already knows or suspects |
| I | Invitation | Find out how much they want to know, and how |
| K | Knowledge | Give a warning shot, then share information in small, plain chunks |
| E | Emotions and empathy | Notice the reaction and respond to it before moving on |
| S | Strategy and summary | Agree next steps, check understanding and arrange follow-up |
S: How do you set up a bad news conversation?
Preparation is the step most often skipped and the one that affects the conversation most. Know the facts first: the result, what it means and the likely next steps. If you cannot answer an obvious question, find out beforehand or be ready to say who will.
- Find a private room. Curtains round a bed are not private.
- Hand over your bleep or phone if you can, and allow enough time.
- Ask whether the person wants someone with them, and offer to wait.
- Bring the nurse or key worker who will support them afterwards.
- Book a professional interpreter if needed. Do not use family, and never children, to interpret bad news.
- Sit at the same level, without a desk between you, with tissues to hand.
Prepare yourself too. Decide on your first sentence. Feeling anxious is normal, and having a structure helps.
P and I: Finding out what they know and want to know
Before giving information, ask what the person already understands. This tells you where to start, whether there is a misunderstanding to correct, and how prepared they are.
Nurse practitioner: "Hi Ruth, your biopsy results are back. Unfortunately it's breast cancer."
Nurse practitioner: "Hello Ruth, I'm Hannah, one of the breast care team. Is it all right if I sit down? Before we go through the biopsy, can you tell me what you've been told so far about why it was done?" Ruth: "They said the lump needed checking. I've been dreading this appointment, to be honest."
In the stronger version Hannah learns that Ruth is already worried, which tells her Ruth is partly prepared. Now she asks how Ruth would like to receive the information. Most people want full information, but not everyone, and not always all at once.
- "How would you like me to go through the results? Some people want every detail, others prefer the main points first."
- "Would you like me to talk about what happens next as well, or focus on the result today?"
- "Is there anyone you would like to be here, or to hear the details instead of you?"
If someone says they do not want to know, respect it, explore it gently and ask who they would like you to speak to. Do not withhold information from a patient who wants it because a relative has asked you to.
K: How do you actually say the bad news?
Start with a warning shot, a short sentence that signals bad news is coming, then pause. Give the information in small pieces, in plain words, and stop after each one. Check understanding before going further.
"The histology shows a grade 2 invasive ductal carcinoma, ER positive, so we'll be looking at wide local excision and sentinel node biopsy, then the MDT will decide on adjuvant therapy."
"I'm afraid the results aren't what we were hoping for." [pause] "The biopsy shows that the lump is a breast cancer." [pause; Ruth's eyes fill] "I'm so sorry. That's a lot to hear." [silence] "Would you like a moment before we talk about anything else?"
Avoid false reassurance such as "don't worry" or "there's lots we can do" if that is not true. Do not volunteer a precise life expectancy. If asked, check what the person wants to know, then give an honest range with uncertainty, such as months rather than years, while explaining that everyone is different.
E: How do you respond to emotion?
People react in many ways: tears, silence, shock, anger, disbelief, or practical questions straight away. All are normal. Until the emotion has been acknowledged, the person is unlikely to take in more information.
- Observe: Notice the reaction: tears, silence, a change in posture, a raised voice.
- Identify: Think about what the emotion is and what caused it. If unsure, ask: "What's going through your mind right now?"
- Acknowledge: Name what you see: "I can see this is a real shock." "This isn't what you wanted to hear."
- Allow silence: Wait. Silence often feels harder for the professional than for the patient. Let them speak first.
Avoid saying "I know how you feel". You do not, and it can sound dismissive. Phrases that tend to help include "I'm so sorry this is the news", "It's understandable to feel like this" and "Tell me what worries you most".
When the person is angry
Anger is common, especially if someone feels there was a delay. Do not argue or become defensive. Acknowledge it: "I can hear how angry you are that this wasn't found sooner." If there are genuine concerns about earlier care, be honest, explain how they can raise them and make sure they are looked into. Do not speculate or criticise colleagues.
S: How do you end the conversation well?
Before you finish, the person should know what happens next. People cope with uncertainty better when they have a plan, even a short one.
- Explain the next step, such as a scan, a specialist appointment or a meeting with the consultant.
- Give a time frame if you can, and be honest if you cannot.
- Ask what matters most to them and what questions they have.
- Name their key contact, such as a clinical nurse specialist, and how to reach them.
- Offer written information and, with consent, to speak to family.
- Arrange a follow-up, because questions often come later.
Then check understanding: "So I know I've explained it properly, could you tell me in your own words what you've taken from today?"
After the conversation
- Document who was present, what was said and the words used, the person's understanding and reaction, the plan, and anything they asked not to be shared.
- Hand over to the nurse in charge, the medical team and, with consent, the GP, so everyone gives the same message.
- Go back later, or ask a colleague to, to see how they are.
- Look after yourself. Take a moment, talk to a colleague and use debriefs or supervision.
Using SPIKES in other situations
When a family asks you not to tell the patient
Relatives sometimes ask this out of love or for cultural reasons. Acknowledge their concern, explain you will be guided by the patient, and ask the patient how much they want to know. GMC guidance allows information to be withheld from a patient only in very limited circumstances, and the fact that it may upset them is not enough. If the patient may lack capacity for a decision, follow the Mental Capacity Act 2005.
Over the telephone
Bad news should usually be given face to face. When it cannot be, for example after an unexpected death, confirm who you are speaking to, ask whether they are somewhere safe and whether anyone is with them, give a warning shot, use plain words such as died, and agree what happens next.
Who breaks bad news?
Not only senior doctors. Nurses and midwives often answer the first questions. Physiotherapists may tell someone they will not regain function. Paramedics may tell a family that resuscitation has not worked. Work within your role, and if a question is outside it, say so honestly and arrange for the right person to answer.
Kwame told a patient in a busy bay that she was unlikely to walk independently again, then moved straight on to a wheelchair referral. She became very distressed and her son later complained. Reflecting in supervision with SPIKES, Kwame saw that he had not checked her understanding of her recovery, gave no warning shot, did not respond to her distress, and jumped to a plan too early. He arranged a meeting in a side room with the patient, her son and the ward nurse, apologised for how he had shared the news, and went through her progress again at her pace.
Building confidence with breaking bad news
You cannot make bad news good. You can make sure it is heard in private, at a manageable pace, in clear words, from someone who notices how the person feels and explains what comes next. Rehearsing your opening line, your warning shot and two or three empathic phrases with a colleague makes them far easier to use under pressure. Many organisations also offer simulation-based communication training.
If you want structured learning, our course Breaking Bad News Training (SPIKES) works through each step with worked dialogue, covers culture, language, families and self-care, and includes reflective prompts linked to your professional standards. If you are completing learning because of a complaint or investigation, take advice from your defence organisation or union about how you use it.
Frequently asked questions
What does SPIKES stand for?
SPIKES stands for Setting up, Perception, Invitation, Knowledge, Emotions and empathy, and Strategy and summary. It is a six-step framework for breaking bad news, first published in 2000, which helps professionals prepare, share information at the person's pace, respond to emotion and agree a plan.
What is a warning shot when breaking bad news?
A warning shot is a short sentence that signals bad news is coming, such as "I'm afraid the results are not what we hoped". It is followed by a pause. It gives the person a moment to prepare before hearing the main news, which can make the information easier to take in.
What should you not say when breaking bad news?
Avoid jargon and euphemisms, false reassurance such as "don't worry", and "I know how you feel". Do not give a precise life expectancy unless asked, and then give an honest range. Do not rush to treatment plans before the person has had time to react.
Can nurses break bad news to patients?
Yes, within their role and competence. Nurses and midwives often share or reinforce difficult news, answer first questions and stay with people afterwards. Some diagnoses are usually given by the responsible clinician, so follow local practice, and if a question is beyond your role, say so honestly and arrange for the right person.
What if the family asks me not to tell the patient?
Acknowledge the family's concern, explain that you will be guided by the patient, and ask the patient how much they want to know. A patient with capacity is entitled to information about their condition. If capacity is in doubt, follow the Mental Capacity Act 2005 and local policy.
How do you respond when a patient cries after bad news?
Pause and allow silence. Acknowledge what you see, for example "I can see this is a real shock", offer tissues and wait until they are ready to continue. Do not rush to fill the silence with more information, because they are unlikely to take it in.
What should you document after breaking bad news?
Record who was present, what was said and the actual words used, the person's understanding and reaction, questions asked, the agreed plan, the key contact and anything they asked not to be shared. Hand over to the team so everyone gives a consistent message.
Related courses
Breaking Bad News Training (SPIKES)
This course teaches a structured, compassionate approach to breaking bad news using the six-step SPIKES framework. Each step is explained with worked…
Difficult Conversations with Patients and Families
This course gives you practical, published approaches for conversations that involve anger, disagreement, complaints or expectations that cannot be…
SBAR Handover Training
This course teaches you to use SBAR (Situation, Background, Assessment, Recommendation) for clear, structured handover and escalation. It shows how…
Sources and further reading
- SPIKES: a six-step protocol for delivering bad news (2000). The Oncologist.
- Good Medical Practice (2024). General Medical Council.
- Decision making and consent. General Medical Council.
- The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Nursing and Midwifery Council.
- Standards of conduct, performance and ethics. Health and Care Professions Council.
- Mental Capacity Act 2005 Code of Practice. Office of the Public Guardian.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
More guides
How to Handle Difficult Conversations With Patients and Families
How to handle difficult conversations with patients and families: calming anger, the NURSE approach, apologising, complaints, disagreement and safe boundaries.
SBAR Handover: Examples and Template for Nurses and Doctors
SBAR handover explained with a simple template and worked examples for nurses, doctors, physiotherapists, paramedics and community staff, plus read-back tips.
How to Escalate a Patient Over the Phone: A Clear Structure That Works
How to escalate a deteriorating patient over the phone: preparing, SBAR, phrases that get a response, read-back, what to do if the doctor won't come, and notes.