Giving Bad News
 Is an important communication skill
 Is a complex communication task which
includes: responding to patients’ emotional reactions
 Involving the patient in decision making
 Dealing with the stress created
 Involvement of multiple family members
 How to give hope when situation is bleak
Giving Bad News
It is a difficult task because: It is frequent and stressful
 Most patients want to know the truth
 We are required to tell them what they desire
 The truth is unpleasant and will upset them
 We are anxious and fear negative evaluation
Giving Bad News
We feel a burden of responsibility for the
The recipient is already distressed
We don’t want to make things worse
We want to be honest but not destroy
We are therefore reluctant to deliver bad
Giving Bad News
The Good News!
Using a plan for determining the patient’s
values, their wishes for participation in
decision making, and a strategy for
addressing their distress when the bad
news is disclosed can increase our
confidence in the task.
Giving Bad News
The Good News (continued)
It may also encourage patients to
participate in difficult treatment decisions
Those who do so have a better quality of
Clinicians who are comfortable with giving
bad news are subject to less stress and
Giving Bad News
What do we want to achieve?
To gather information from the patient
To provide intelligible information in
accordance with their needs and desires
To support them to reduce the emotional
impact and isolation experienced
To develop a plan for management with
the input and cooperation of the patient
The SPIKES Protocol
SETTING UP the interview
Assessing patient’s PERCEPTION
Obtaining the patient’s INVITATION
Giving KNOWLEDGE and information
Addressing the patient’s EMOTIONS
Step 1: S - SETTING UP the interview
Preparation Preparation Preparation
Plan, Privacy, Significant others
Sitting, Non Verbal Behaviour
 Step 2: P - Assessing
 Gather before you Give
 Patient’s knowledge, expectations and hopes
 What do they understand about the situation?
Unrealistic expectations?
 What is their state of mind?
 Opportunity to correct misinformation and tailor
your information
Step 3: I – Obtaining
the patient’s INVITATION
Gather before you give
How much does the patient want to know?
Coping strategy?
Answer questions, offer to speak to
Step 4: K – Giving KNOWLEDGE and
information to the patient
Warning shot
Use simple language, no jargon,
Vocabulary and comprehension of patient
Small chunks, avoid detail unless requested
Pause, allow information to sink in
Wait for response before continuing
Check understanding
Check impact
Step 5: E – Addressing the patient’s
EMOTIONS with empathic responses
Shock, isolation, grief
Silence, disbelief, crying, denial, anger
Observe patient’s responses and identify
Offer empathic responses
What is Empathy?
The capacity to recognise emotions that
are being felt by another person.
Empathic Responses
An indication to the patient that you
recognise what they are feeling (and why)
Verbal and Non verbal
Often associated with the impact of the
news rather than the understanding.
I see that…. I appreciate …..
Wait for response
Are they ready?
Involve the patient in the decision making
Check understanding
Clarify patient’s goals
Contract for future
SPIKES – A Six-Step Protocol for
Delivering Bad News: Application to the
Patient with Cancer.
WF Baile, R Buckman et al.
The Oncologist 2000;5:302-311