Breaking bad news is something that every doctor will have to do many times during his or her career. It can be a tremendously difficult job for the doctor involved and is fraught with potential problems. Many experienced clinicians still find this task anxiety inducing and stressful.

Patients are frequently dissatisfied with the way in which they were told about their particular diagnosis and, as difficult as it is for the doctor involved, it is always hardest for the patient that is receiving the news. A good understanding of the communication skills required can make the process much smoother for both the clinician and the patient, and can help to alleviate some of the stress and emotional difficulty involved for both parties involved.

The interpretation of what ‘bad news’ is, is a very personal thing and can vary from a diagnosis of terminal cancer to being told about a less serious but potentially life altering chronic condition such as diabetes or asthma. What exactly ‘bad news’ is, is very much in the eye of the beholder.

Breaking bad news is something every doctor will have to do many times during his or her career

Because of the difficulties involved in breaking bad news it has become a prerequisite topic in most medical school curriculums and is now a very common exam topic, particularly in clinical exams and OSCEs.

Baile, W. et al. advocated that breaking bad news be broken down into a six-step technique that incorporates key communication techniques that facilitate the effective flow of information. This six-step strategy can be remembered by using the mnemonic SPIKES, which is a useful adjunct when approaching breaking bad news in any context.

The SPIKES mnemonic stands for:

• Setting
• Perception
• Invitation
• Knowledge
• Emotions
• Strategy & Summary

The six steps of SPIKES are as follows:

Setting

Ensure that the area that you use is private and appropriate for purpose. You should be able to discuss the news with the patient without interruptions. It is often a good idea to have someone else with you, such as a nurse, when you break the bad news. Make sure that the patient has the opportunity to have a friend or loved one with them also.

Perception

Try to determine what the patient knows about their condition or the situation being discussed. Try using a ‘warning shot’ to see if they are prepared to receive the news.

Invitation

Once you have ascertained the patient’s perception you should use a straightforward statement such as ‘I have some bad news for you’. Then ask the patient directly if they want to hear this bad news. Accept the patient’s right not to know if they do not want to receive the news at this point in time.

Knowledge

Avoid medical jargon and use language that is easily understood by the patient. Be direct and to the point but deliver the news in a sensitive and empathetic manner. Check whether the patient has understood what you have said and ask if they have any questions.

Emotions

Be prepared for the patient to be upset, tearful or angry and acknowledge their emotional response sympathetically. Give the patient time to express their feelings to you and try to be as supportive and empathetic as possible.  Offer reassurance but remain realistic and avoid giving false hope. Do not be afraid to show emotion yourself.

Strategy & Summary

Work together with the patient to develop a strategy for approaching the situation. Discuss management options and explore what the patient wants to do next. Check if they need anything clarified or any further questions answered before bringing the conversation to a close. Finally, set an agenda for the next time that you meet.

Above all treat the patient and their family with empathy and humanity; in a real life situation this may be the most challenging and difficult day of their lives and you will remembered as the centerpiece of it. You should try to behave the exact the same way in an exam situation. Be honest and open and be aware of your own limitations. It is very common to be asked questions that you won’t have the answer to, such as ‘how long do I have left?’, in these circumstances it is far better to explain that you don’t have the answer as opposed to giving the patient bad advice or false hope.

Breaking bad news will never be easy, no matter how many times you do it, and as well as thinking about your patient it is important to consider your own wellbeing too. Real-life breaking bad news scenarios can be very upsetting and emotionally draining. It is always a good idea to reflect on what happened and take time to discuss things with a suitable colleague in a debrief session afterwards. It may be worth mentioning this to an examiner at the end of a station if the opportunity arises.

Reference: Baile, WF, Buckman R et al. SPIKES – A Six-Step Protocol Delivering Bad News: Application to the Patient with Cancer. The Oncologist August 2000 vol.5 no 4 302-311.

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Thank you to the joint editorial team of MRCGP Exam Prep for this ‘Exam Tips’ blog post.