Breaking Bad News (SPIKES model)
The four habits model provides an adequate structure for this consultation.
However, SPIKES is often used to teach ‘breaking the news of terminal illness so I have, included the model
and summarised key advice. It is important to remember that breaking the bad news of terminal illness is not
a task for medical students; you will have the opportunity to observe a consultant conducting the
consultation.
Remember that for a patient, many diagnoses can be ‘bad news’, leading to lost relationships or abandoned
goals. Take the opportunity to practice the skills of the best clinicians with your ‘routine’ patients.
The SPIKES approach (Baile, Buckman, Lenzi, Glober, Beale, & Kudelka (2000) was developed to assist health
professionals to disclose a terminal illness. I included the model because it is so often used in Ireland, U. K. and
North America
Breaking Bad News - Key Points
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Ensure that you have all the necessary information to hand before the interview
Ensure that you have fully reviewed the information
Ensure the information relates to the patient with whom you are speaking
Ensure that you will have sufficient undisturbed time in a suitable room
o Ensure that you will not be interrupted by bleeps or phones
o Ensure that the room is not double booked
o Ensure that everyone has a seat
o Ensure the patient and family can remain in the room if distressed
o Ensure the family has access to tissues if distressed
Invite a nurse especially if they have a pre-existing relationship with the patient or if
they will be supporting the patient or family
The consultation is for the patients benefit so establish they are comfortable with who
is in the room before you begin
Ask the patient what they know or suspect about their condition
Explain the tests and diagnosis invite the patient to ask questions and move at the
patients speed towards the condition and its implications
Use clear terms and language the patient and relatives will understand
The impact of the information is such that many patients require a second
appointment to fully comprehend that they have a life shortening condition
Ensure the patient and family understand that you (and the wider team) will actively
provide treatment, care and enhance their quality of life ‘we are your team; I assure
you we will work with you in the coming months and assist you to the best of our
ability.’
Some patients are more concerned about their relatives’ reaction rather than their
condition. They may welcome the opportunity to discuss their fears in private.
Always document the consultation, noting those present, the patients questions and
your replies
S. D. Smith 27/01/2011
SPIKES
The SPIKES approach (Baile,
Buckman, Lenzi, Glober, Beale, &
Kudelka (2000)
http://theoncologist.alphamedpr
ess.org/cgi/reprint/5/4/302
Setting up the
interview
Assessing the
patient’s perception
Obtaining the
patient’s invitation
Giving knowledge &
information
Newspaper article discussing the
medical dilemma of discussing
cancer survival times
http://www.washingtonpost.com/
wpdyn/content/article/2007/03/31/
AR2007033101090_pf.html
Addressing the
patient’s emotions
with empathic
responses
Strategy & summary
S. D. Smith 27/01/2011
Setting up the interview
Privacy
Try to use a private room or office
If you have no alternative, draw the curtains around the patient’s bed
Your conversation & the patient’s distress is likely to be overheard by
others on the ward
Try to anticipate the patient’s likely needs for a quiet
place to consider the future, make a telephone call, or
become distressed.
Remember to organise: Tissues, social support (when
you leave), a hot drink
Invite relatives
At the patient’s request
Try to restrict the numbers, especially for the first interview
Ask the patient to nominate one or two adults.
Uninterrupted time
Let the patient know how long you anticipate the interview will last
Try to persuade a colleague to cover your pager
Try to make an empathic connection with the patient
Use eye contact, tone of voice, proximity, stance
etc.
Although the interview will be distressing to you all, try to avoid
sitting behind a desk or not giving your opinion with sensitive
candour.
S. D. Smith 27/01/2011
Assessing the patients perception
What has the patient been told?
What are the patients goals or expectations?
Does the patient want to know?
Excessive optimism
Avoidance
Obtaining the patients invitation
How much information does the
patient want?
S. D. Smith 27/01/2011
Giving knowledge & information
In small chunks
Comprehensive patient/relative booklet discussing the experience of
terminal illness. (USA)
http://www.nia.nih.gov/NR/rdonlyres/D2709A8E-0818-467E86D9DD3254571481/0/End_of_Life_booklet_final.pdf
Check for understanding
Avoid medical jargon
S. D. Smith 27/01/2011
Addressing the patient’s emotions with empathic responses
Empathise
Explore patient’s emotions
Strategy & summary
Outline treatment options
Negotiate care with the patient
S. D. Smith 27/01/2011
Avoid the misleading belief that breaking bad news is only associated with terminal illness.
Many students are anxious about witnessing a Consultant breaking bad news. It may be helpful to
remember that sending a patient for tests or a specialist opinion can be bad news for the patient and their
family, unlocking medically unfounded fear.
Most clinical practice has opportunities for good news ‘all your tests are fine Mr Spring’; but for many
(most?) patients, fear propels them through your consulting room door.
The discussion of terminal illness obviously has a special significance for all participants. However, if you
learn, use and practice the 4 habits model you will be familiar with the constituent parts of the process.
Many doctors are able to recall their witnessing first birth and terminal illness interview.
Bear in mind
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Patients and relatives may already have acknowledged the condition as untreatable,
Some patients and relatives are so affected by the news that they seem unable to process the
information returning to seek clarification
Patient’s greatest fears may not be confined only to the shortening of life, but also incorporate,
fears of escalating pain, discomfort and indignity. Medical and health professionals are able to
address many of these concerns. The initial interview may not be the appropriate occasion;
however, it may be an important topic in follow up consultations.
Additional resources
Breaking the news of terminal illness; Guidelines for Doctors (PDF)
http://www.dhsspsni.gov.uk/breaking_bad_news.pdf
Comprehensive patient/relative booklet discussing the experience of terminal illness.
http://www.nia.nih.gov/NR/rdonlyres/D2709A8E-0818-467E-86D9DD3254571481/0/End_of_Life_booklet_final.pdf
Informing families of their child’s disability (guidelines)
http://www.fedvol.ie/
Kirk etal Breaking Bad News, video role plays (Canadian)
http://video.google.com/videoplay?docid=4503479808065742542
The SPIKES paper provides greater detail about each stage of the model.
http://theoncologist.alphamedpress.org/cgi/reprint/5/4/302
Always ensure that the GP is aware of the patient’s condition and your contact details the same
day, use fax or phone, remember, the letter takes days to arrive, but the patient can get a GP appointment
tomorrow.
S. D. Smith 27/01/2011