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SPIKES Protocol for Breaking Bad News: The 6 Steps With an Example
SPIKES is a six-step protocol for breaking bad news: Setting, Perception, Invitation, Knowledge, Empathy and Summary. The National Cancer Institute describes it as a framework for talking to patients about bad news, such as a cancer recurrence or a treatment failure (NCI PDQ). Walter Baile, Robert Buckman and colleagues published it in The Oncologist in 2000 (PubMed).
This guide gives each step in the NCI's words, with what to say and the usual slip, what patients have told researchers they want, words for the empathy step, a full example conversation and how to use SPIKES in an MMI role-play or an OSCE. Sources were read October 31, 2026. The example lines and conversation are ours.
The six steps of the SPIKES protocol
| Step | What the NCI says | What it sounds like | The usual slip |
|---|---|---|---|
| S: Setting | What the NCI says: Arrange for privacy and minimize interruptions. | What it sounds like: Sit down, silence your phone, ask who they would like in the room. | The usual slip: Giving the news standing in a hallway or with the door open. |
| P: Perception | What the NCI says: Find out what the patient understands is happening medically. | What it sounds like: "What have you been told about why we did the biopsy?" | The usual slip: Starting with the result before you know what they already think. |
| I: Invitation | What the NCI says: Discover how much information the patient wants. | What it sounds like: "Would you like me to go through the results in detail?" | The usual slip: Assuming everyone wants every number, or that no one does. |
| K: Knowledge | What the NCI says: Give information to the patient in small bites without jargon. | What it sounds like: A warning shot, then one plain sentence: "I'm sorry, the biopsy shows cancer." Then pause. | The usual slip: A long explanation full of medical terms before they have taken in the news. |
| E: Empathy | What the NCI says: Address the patient's emotions with empathy. | What it sounds like: Name the emotion and wait: "This is a lot to hear." | The usual slip: Rushing to treatment plans, or false reassurance like "It'll be fine." |
| S: Summary | What the NCI says: Sum up the clinical information and make a plan for the next step. | What it sounds like: Recap in two sentences, agree on the next appointment, check what they will tell family. | The usual slip: Ending without a plan, which leaves the patient alone with the news. |
The NCI shortens two of the names. In the original 2000 paper, step 5 is “Addressing the patient's emotions with empathic responses” and step 6 is “Strategy and summary,” which is why you will also see Emotions and Strategy for E and the last S (Baile et al., 2000). The paper also puts the warning that bad news is coming at the start of Knowledge, as in the table above.
Where the SPIKES protocol comes from
The protocol was published in 2000 as “SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer” in The Oncologist (volume 5, pages 302 to 311, full text). Its authors set four goals for a bad news conversation: gathering information from the patient, giving the medical information, supporting the patient, and working with the patient on a plan. They report that oncologists, oncology trainees and medical students taught the protocol felt more confident disclosing bad news.
It is used because the task is common. The NCI cites a study in which oncologists reported delivering bad news an average of 35 times a month, and notes that most communication training uses role-play with a standardized or simulated patient (NCI PDQ). It also says evidence linking tools like SPIKES to outcomes is extremely sparse, so treat it as a structure for the conversation, not a script.
What patients say they want
From the research the NCI summarizes (NCI PDQ):
- Patients with a new cancer diagnosis preferred to hear it in person rather than by phone, and in private.
- They wanted the physician to spend adequate time, more than 10 minutes, and to be ready to describe treatment options.
- In one study, patients consistently disliked hearing bad news that began with words such as “unfortunately.” The 2000 paper's own sample warning starts that way, so a plain “I'm afraid I have difficult news” may land better.
- Physicians may react to emotion with false hope or premature reassurance, which the Empathy step is there to prevent.
- Family members or friends should not be used to interpret (more in cultural competence in healthcare).
The empathy step: NURSE
When emotions are high, the NCI says, the ability to hear and understand information is impaired, so respond to the emotion before giving more facts. NURSE gives you five ways to do that, with the NCI's example lines:
- Name: “It sounds as if you are very worried.”
- Understand: “I cannot imagine how it feels to hear this.”
- Respect: “You are asking the right questions and being a strong advocate.”
- Support: “I will be here to care for you no matter what happens.”
- Explore: “Tell me more about how you are feeling.”
An example SPIKES conversation
A patient hearing a biopsy result, written by us to show all six steps in about two minutes. Notice how little is said after the news itself, and that the plan comes last.
Example conversation: telling a patient her biopsy shows cancer (written by Confetto, the patient is invented)
Doctor: Thanks for coming in, Ms. Rivera. Is it all right if we talk here? I've asked not to be interrupted. Would you like anyone else with you?
Patient: No, my husband's parking. Let's just start.
Doctor: Before I go through the results, can you tell me what you understand about why we did the biopsy?
Patient: You found a lump and wanted to make sure it wasn't anything bad.
Doctor: That's right. Would you like me to go through the results in detail, or would you rather I give you the main point and we go from there?
Patient: Just tell me.
Doctor: I'm afraid the results aren't what we hoped for. The biopsy shows breast cancer.
Patient: (silence) I thought you were going to say it was nothing.
Doctor: I know. It's a lot to take in. (pause) What's going through your mind right now?
Patient: My kids. How do I tell my kids?
Doctor: That's one of the most important questions, and we'll help you with it. You don't have to work it out today.
Doctor: Here's where we are. The biopsy shows cancer, and the next step is a scan to see whether it has spread, which tells us the best treatment. I'd like to book that this week and see you again right after with your husband. What questions do you have for now?
Setting and Perception take the first two exchanges, Invitation the third. The news is one sentence. The doctor then names the emotion and asks an open question before moving to the Summary and a dated next step.
How to use SPIKES in an MMI role-play or OSCE
MMI acting stations often hide a bad news task in a non-clinical setting: a cancelled trip, a failed project, an injured child at camp. You do not need to say “SPIKES” out loud. Use the order:
- Read the prompt for who the person is and what they already know.
- Start by asking, not telling. Perception and Invitation take under a minute.
- Give the news in one plain sentence, then stop talking.
- Respond to the reaction with a NURSE line before any explanation.
- Finish with a concrete plan and an offer of support, before the bell.
Our MMI role-play guide has 24 scenarios to try this on. If the person in the room is angry rather than sad, see how to handle a difficult patient. If the conversation turns to resuscitation, see DNR vs DNI vs full code.
Practice question: a non-clinical bad news station
“MMI role-play: You are a volunteer coordinator. Tell a student volunteer that the hospital has ended the program she spent a year building. The actor is waiting inside.”
A non-clinical bad news station that rewards the same moves as SPIKES. A strong answer sets the scene, finds out what she knows, gives the news plainly, stays with her reaction and ends with a plan.
Example answer written by Confetto (the applicant is invented)
"Hi Maya, thanks for making time. Can we sit down? I've got the room for the next while, so we won't be rushed."
"Before I start, have you heard anything about the hospital's review of the volunteer programs?" (She has heard rumors.) "I wanted you to hear it from me. I'm afraid I have difficult news. The hospital has decided to end the reading program at the end of this month."
(Pause and let her react.) "I can see how much this hurts. You built this from nothing, and the kids in the ward looked forward to it every week. It makes sense to be upset."
"It wasn't about the program's quality. The review cut several programs because of a funding change. I asked whether we could keep it, and they couldn't make an exception."
"Here's what I'd like to do. I'll write you a reference that says exactly what you built. The children's ward has asked whether you'd help plan a final session. And I'd like to talk next week about another role, if you want one. What would be most useful to you right now?"
Sources: the National Cancer Institute's PDQ summary on communication in cancer care, the SPIKES paper's PubMed record and its full text, checked October 31, 2026.
Frequently asked questions
What does SPIKES stand for?
Setting, Perception, Invitation, Knowledge, Empathy and Summary. The National Cancer Institute describes it as a framework for talking to patients about bad news, such as a cancer recurrence or a treatment failure. See the NCI summary.
Who developed the SPIKES protocol?
Walter Baile, Robert Buckman and colleagues published it in The Oncologist in 2000, as a six-step protocol for delivering bad news to patients with cancer. See the paper on PubMed.
Does SPIKES actually help?
The original paper reports that oncologists, trainees and medical students taught the protocol felt more confident disclosing bad news. The NCI notes that evidence linking tools like this to patient outcomes is limited, so treat it as a structure, not a script. See the NCI on communication tools.
Is SPIKES only for cancer?
It was written for cancer care, but the steps fit any bad news conversation, which is why medical students use it in OSCEs and applicants use it in MMI role-play stations. See how MMI role-play stations work.
What is NURSE, and how does it fit with SPIKES?
NURSE is a set of five ways to respond to emotion: Name, Understand, Respect, Support and Explore. It gives you words for the empathy step. See NURSE in the NCI summary.