How to Break Bad News: The SPIKES Protocol With Scripts
Breaking bad news is a procedure. It has an indication, steps, a technique, and complications, and most residents perform it for the first time with no supervision, at night, in a hallway.
You will do this hundreds of times in a career: a new cancer, a stroke that will not recover, a death in the emergency department. Nobody grades it. The families grade it, and they remember the conversation word for word twenty years later when they cannot remember the name of the hospital. The words you choose are the intervention. So learn the actual words, the way you learned where to put the needle.
SPIKES came out of oncology, and it stuck because it works and it is easy to remember. Six steps: Setting, Perception, Invitation, Knowledge, Emotions, Strategy. Each one exists because skipping it produces a specific, predictable failure. This page gives you the sentences for each step, the sentences to ban, and what to do when the conversation stops going the way the mnemonic promised.
Bad news is a procedure The core idea
Bad news is any information that changes how a patient sees their future. That definition matters because it means you do not get to decide what counts. A hemoglobin A1c of 9 is routine to you and an earthquake to the patient who has watched a parent lose a leg to diabetes. The severity lives in the gap between what they expected and what you are about to say, which is why the protocol makes you measure that gap before you speak.
Talking too much. Under stress you will reach for pathophysiology, staging systems, and treatment options, because facts are the thing you have and grief is the thing you cannot fix. The patient stops absorbing information within seconds of the bad sentence. Everything you say after it, until you have dealt with the emotion, is for your comfort, not theirs.
One more framing point before the steps. Your job is not to make the news less bad. It cannot be done, and trying produces the hedged, mumbled, jargon-wrapped delivery that families describe as "nobody ever actually told us." Your job is to transfer true information clearly and then stay in the room while it lands.
S: Setting Before you say a word
Five minutes of logistics determine whether the conversation is possible at all.
- Sit down. Non-negotiable. Pull a chair to the bedside. If there is no chair, find one. Sitting signals that you are not leaving, and patients consistently perceive a seated conversation as longer and more caring than a standing one of the same length.
- Privacy. A private room if you can get one. If the roommate is behind a curtain, at minimum draw it and lower your voice, and consider moving the patient. A new metastatic diagnosis does not belong in a shared room with a game show on.
- The right people. Ask the patient who they want present. "Is there anyone you would like here when we talk about the results?" If family is driving in, and the news can wait two hours, wait.
- Your pager. Hand it to a colleague or silence it. Answering a page mid-sentence during this conversation is remembered forever.
- Know the data cold. Read the actual pathology report, the actual imaging read, and the oncologist's or consultant's note before you walk in. "I think it showed" is not acceptable here.
- Tissues within reach. Not as a prop. Because someone will cry, and leaving the room to find tissues breaks the moment you most need to hold.
If the results are life-altering and you have seven minutes between other obligations, do not start. Bad news badly delivered in seven minutes creates hours of repair work for the next team. Hand it off properly or come back.
P: Perception Before you tell, ask
Find out what the patient already knows and believes. This is the step everyone skips, and skipping it is how you end up delivering a terminal diagnosis to someone who thought they were here for pneumonia, with no warning shot, or explaining basics to a patient who read the portal result last night and has been waiting twelve hours for someone to say it out loud.
Sentences that open the door
"Before I go over the results, can you tell me what you understand so far about what is going on?"
"What have the other doctors told you about the scan?"
"When the symptoms started, what did you think might be causing them?"
Listen to the answer for two things: the facts they hold, and the words they use. If they say "spot on the lung," you can start from "spot on the lung." You are also screening for denial and for unrealistic expectations, because those change how you deliver the next step. A patient who says "I know it is probably cancer, I just want to know what we do about it" needs a different next sentence than one who says "they told me these things are almost always benign."
I: Invitation Ask permission
Ask how much they want to know, and ask permission to deliver it now. This feels unnatural, and it takes ten seconds, and it converts you from someone doing something to the patient into someone doing something with them.
What to say
"The results are back. Would it be all right if I go over them with you now?"
"Some people want all the details, and some people want the big picture and prefer that we go over details with their family. Which would you prefer?"
Most patients say yes, tell me everything. A minority, real and legitimate, want information routed through a daughter or want the headline only. Honoring that is not withholding, it is consent. If a patient declines information entirely, document it, offer again later, and identify who they do want informed.
K: Knowledge The warning shot, then the news
Fire a warning shot, then deliver the news in one short, plain sentence, then stop talking.
The delivery, complete
"I'm afraid I have serious news. The biopsy showed cancer."
"This is not the result we were hoping for. The scan shows the cancer has spread to your liver."
"I wish I had better news. The heart muscle is severely weakened, and this is the reason you keep ending up in the hospital."
Anatomy of the good version: a warning phrase that gives the brain half a second to brace, then the fact in words a twelve year old could repeat, then silence. "Cancer," not "malignancy." "Spread," not "metastatic disease." "Died," not "passed" or "didn't make it," when that is the news. Vague language is not kindness. Families who were told a relative "did not survive the procedure" have asked, in real conversations, when they could see them awake.
What not to say, and why it fails
"So the biopsy came back and it showed a moderately differentiated adenocarcinoma with signet ring features, and we will need to get a PET and molecular markers before staging is complete." Why it fails: jargon as armor. The patient heard nothing after "biopsy" and now must ask "is it cancer?" out loud, doing your job for you.
"There's a little something on the scan we need to keep an eye on." Why it fails: minimizing to dodge the reaction. The truth arrives eventually, delivered by someone else, and the patient learns you knew.
"The results are concerning, but let's not get ahead of ourselves, there are a lot of treatment options these days, immunotherapy has really changed the landscape, and my aunt actually had something similar and did great." Why it fails: the escape into optimism and anecdote before the news has even been stated. Nothing was communicated except your own discomfort.
Give information after that in small pieces, checking as you go: "Does that make sense so far?" and "What questions do you have?" Not "Do you have any questions," which invites no. Expect to repeat the essentials at the next visit. Retention after the bad sentence is poor, which is also an argument for writing key facts down for them.
E: Emotions The step that is the whole skill
After the news lands there will be an emotional response: tears, silence, anger, a flat "okay, what's next." You must respond to the emotion before any planning, because a flooded brain cannot process a treatment plan, and because ignoring the emotion is experienced as coldness no matter how accurate your information was.
The move is the empathic statement: name what you see, or acknowledge it, and connect. The NURSE framework gives you five kinds, and you should be able to produce each without thinking.
"I can see this is a shock." "You seem angry, and that makes sense."
"I can't imagine what it is like to hear this. It makes sense that this feels overwhelming." Do not say "I understand how you feel." You do not, and someone will tell you so.
"You have been through a huge amount this year, and you have handled every step of it." "You are asking exactly the right questions."
"Whatever happens with the treatment, we are going to be with you through all of it." Then honor that sentence.
"Tell me more about what worries you most." The answer is frequently not what you assumed: not death but the mortgage, the daughter's wedding in June, who will take the dog.
One empathic statement is rarely enough. Emotion comes in waves. Respond to each wave, and do not move to Strategy until the patient signals readiness, usually by asking a cognitive question: "So what do we do now?" That question is your green light, and it is theirs to give, not yours to force.
S: Strategy and summary Never leave without a next step
End with a concrete plan and a concrete timeline, however provisional. Uncertainty about the disease is bearable. Uncertainty about what happens Tuesday is not.
Closing the conversation
"Here is what happens next. Oncology will see you tomorrow morning, here, before noon. The PET scan is scheduled for Thursday. You will not leave this hospital without a plan and a follow-up appointment in your hand. What questions can I answer right now?"
"We have covered a lot. Can you tell me, in your own words, what you are going to tell your husband tonight? I want to make sure I explained it clearly." Teach-back framed as your failure risk, not their comprehension test.
"I will be back this evening after my other patients, around six, and we can go over any of this again. Write down questions as they come to you."
If the news reshapes the goals of the whole admission, this conversation is the doorway to the next one. Prognosis, what matters to them, and code status get their own dedicated discussion, and there is a right way to run it: see goals of care and code status, and when the family is large or divided, how to run a family meeting.
Handling silence
After the bad sentence, many patients say nothing. Ten seconds of silence in that room feels like three minutes, and the junior instinct is to fill it with talk. Do not. The silence is the patient's mind rearranging their future, and it is work you cannot do for them.
- Count to ten slowly before you even consider speaking. Most patients break the silence themselves, and what they say first tells you exactly where to go next.
- If it holds, break it gently and openly. "What is going through your mind right now?" Not a repeat of the medical information.
- Touch, if it fits. A hand on the forearm, if the relationship and culture allow it. When in doubt, sit still and stay.
- Do not mistake silence for acceptance. A quiet patient has not necessarily understood or agreed. Check before you leave: "I know this is a lot. Tell me what you are taking away from what I said."
Handling anger
Anger is grief with armor on. It will sometimes be aimed at you: the delay in diagnosis, the doctor who missed it, the hospital, the food, the parking. The instinct to defend yourself or the institution is the trap. You cannot win that argument, and winning it would not help.
What works
"You are right to be upset. You have been telling people something was wrong for six months." Acknowledge the legitimate core, without adjudicating blame on the spot.
"I hear you, and if I were in your position I would be asking the same questions. Right now I want to make sure we do everything correctly from today forward, and I will also make sure your concerns about the earlier care are heard through the right channel."
"This is a lot of anger, and it belongs to a terrible situation. I am not going anywhere."
What fails
"Well, actually, the earlier scan was read as normal, so nobody missed anything." Defensive, adjudicates a dispute you do not have the facts to settle, and converts a grieving family into an adversarial one in a single sentence.
"I need you to calm down." Has never once produced calm.
Two caveats. First, anger directed at real or possible error is a patient-safety and disclosure issue: loop in your attending and follow your institution's disclosure process rather than freelancing an apology or a denial. Second, anger that becomes threatening is a security issue, not a communication challenge. Position yourself near the door in any conversation you expect to be volatile, and leave and call for help if you feel unsafe. Empathy has limits and they are physical.
Phrases to ban
| Never say | Because | Say instead |
|---|---|---|
| "There's nothing more we can do." | False, and experienced as abandonment. There is always symptom control, comfort, and presence. | "There is no treatment that can cure this. There is a great deal we can do for how you feel and how you spend your time." |
| "I understand how you feel." | You do not, and it invites the correct reply: no, you don't. | "I can't imagine what this is like. Help me understand what is hardest right now." |
| "You have about six months." | A number that specific is a guess wearing a lab coat, and families set calendars by it. | "I think in terms of months, not years. Some people do better and some worse, and I will tell you as the picture changes." |
| "He passed" or "she didn't make it," to notify a death | Euphemism gets misunderstood at the exact moment clarity matters most. | "I am so sorry. Despite everything we did, he died." |
| "At least..." anything | "At least you caught it early," "at least you have other children." Comparison minimizes the loss in front of you. | Say nothing. Stay in the room. |
| "Everything happens for a reason." | Their theology is not yours to assign, especially now. | "This is unfair, and I am sorry it is happening to you." |
Documenting the conversation
The conversation is not finished until it is in the chart. The note protects the patient, the family, and every clinician who touches the chart after you, because the night float who gets called at 2 a.m. needs to know what the patient has actually been told. It also protects you: an undocumented disclosure conversation, legally and practically, did not happen.
Document five things: who was present, what was disclosed in plain terms, how the patient responded, what they understood, and the follow-up plan. Quote the important sentences, yours and theirs. Keep it factual and free of editorializing.
A documentation model
"Family and patient meeting at bedside, 1415. Present: patient, his wife, his son Marcus, myself, RN J. Okafor. Discussed biopsy results: I informed the patient that the lung biopsy showed cancer and that the CT shows spread to the liver. Patient tearful, then asked about treatment. I explained that oncology will evaluate tomorrow to discuss options, and that the goal of this admission is to complete staging and control his pain. Patient stated understanding: 'It's cancer and it has spread, and we find out about treatment tomorrow.' Wife asked about prognosis; I stated that it is too early to give a timeframe before staging and oncology input, and that we will revisit this within days. Questions answered. Patient declined chaplain today, may revisit. Oncology consult in place, PET ordered for Thursday. Will return this evening to readdress questions."
Note what that note does not contain: "family is difficult," "patient in denial," speculation about prognosis you did not state aloud. If the conversation happens because the patient died, the same discipline applies to the death pronouncement and family notification, which get their own documentation: see the death note guide. For the broader rules on charting sensitive conversations, see medical-legal charting.
The note is necessary and not sufficient. Tell the nurse before you leave the floor, and put what was disclosed into the written signout, so nobody walks in at midnight and cheerfully asks how he is feeling about going home. Continuity of the story is part of the treatment.
Related: goals of care and code status, running a family meeting, and the death note.