SPIKES: the six-step protocol for breaking bad news
SPIKES is a six-step protocol for breaking bad news, published by Baile and colleagues in The Oncologist in 2000: Setting up the interview, assessing the patient's Perception, obtaining the patient's Invitation, giving Knowledge and information, addressing the patient's Emotions with empathic responses, and Strategy and summary. It is a structure for the conversation, not an official GMC or RCGP marking scheme, but each step maps onto the domains PLAB 2 and the SCA are marked on.
Last checked Nov 1, 2026 against the primary paper and the GMC and RCGP pages listed under Sources.
The short version
- SPIKES comes from Baile WF et al., "SPIKES—A six-step protocol for delivering bad news: application to the patient with cancer", The Oncologist 2000;5(4):302–311.
- The paper's goal is four things: gather information from the patient, give the medical information, support the patient, and work with them on a plan for what comes next.
- It was written for cancer care but is widely used for any bad news: a serious diagnosis, an abnormal result, a complication, a death.
- Neither the GMC nor the RCGP says you must use SPIKES. They mark the domains: in PLAB 2, data gathering, clinical management and interpersonal skills; in the SCA, data gathering and diagnosis, clinical management and medical complexity, and relating to others.
- The steps that most often go wrong under time pressure: checking what the patient already knows (P), asking how much they want to hear (I), and stopping to respond to emotion (E).
- Finish with a plan and a next contact, not just the news.
The six steps
| Step | What it means | What you might say (written by Confetto) |
|---|---|---|
| S: Setting up the interview | Private space, sit down, enough time, no interruptions, offer to have someone with them | "Would you like anyone to join us? I've made sure we won't be disturbed." |
| P: Assessing the patient's perception | Find out what they already know or suspect before you tell them anything | "What's your understanding of why we did the scan?" |
| I: Obtaining the patient's invitation | Ask how much they want to know and how | "Some people like all the details, others just the main points. What would you prefer?" |
| K: Giving knowledge and information | Signal that bad news is coming, then give it in plain words and small chunks | "I'm afraid the results aren't what we hoped. The biopsy shows a cancer in the bowel." |
| E: Addressing emotions with empathic responses | Notice the emotion, name it, give time | (silence) "This is a huge shock. Take all the time you need." |
| S: Strategy and summary | Agree next steps, summarize, check understanding, arrange support and follow-up | "Let me go over what happens next…" |
S: Setting up
Find a private room, sit at eye level, and hand your bleep or phone to a colleague if you can. Ask if they would like a relative or friend with them. In an exam, you show this in a sentence or two: "Is it OK to talk here? Would you like anyone with you?"
P: Perception
"Before I go through the results, can you tell me what you understand so far?" Their answer tells you where to start, what words they use, and whether they already suspect bad news.
I: Invitation
Not everyone wants every detail at once. Asking "How much would you like me to go into today?" respects that. If they don't want details now, offer to talk again, and check who they'd like you to talk to.
K: Knowledge
Give a short warning first ("I'm sorry, I have some difficult news"), then say it clearly. Avoid jargon ("neoplasm", "lesion", "metastatic"). Give information in small chunks and check after each one. NICE's shared decision making guideline (NG197) calls this "chunk and check".
E: Emotions
Stop talking. Let silence happen. Name what you see ("You look shocked"), and acknowledge it ("Anyone would find this hard to hear"). Don't rush on to treatment while the patient is still taking in the news.
S: Strategy and summary
When they are ready, explain what happens next, who they will see, and when. Summarize in two or three sentences, check understanding, offer written information and a named contact, and ask about support at home.
Worked example: breaking bad news (8-minute station)
Example written by Confetto for practice (not a real exam station). Clinical details are kept general; follow local pathways in real practice.
Candidate instructions: You are an F2 on a surgical ward. Mrs. Ruth Okafor, 58, had a colonoscopy last week for a change in bowel habit. The biopsy shows bowel cancer. A CT scan has been requested to see whether it has spread. Explain the result.
[S] Doctor: Hello Mrs. Okafor, I'm Dr. Ali, one of the junior doctors. Is it alright if we talk in here, where it's private? Would you like anyone to be with you?
Patient: No, it's fine. My husband's at work.
[P] Doctor: Can you tell me what you understand about why you had the camera test?
Patient: They said there was something they wanted to check. A polyp, maybe. I've been worried, to be honest.
[I] Doctor: Thank you. I have the results of the samples. Some people like all the details, others want the main points first. What would you prefer?
Patient: Just tell me straight.
[K] Doctor: I'm sorry, it isn't the news we were hoping for. The samples show that the area in your bowel is a cancer.
(pause)
[E] Patient: (quiet) Cancer. I… I knew something was wrong.
Doctor: (waits) This is a lot to take in. It's alright to take a moment.
Patient: Am I going to die?
Doctor: That's a very natural question. I can't answer it properly yet, because we don't know if it has spread. That's what the next scan will tell us. What I can tell you is that you won't be doing this alone.
[S] Doctor: Here's what happens next. You'll have a CT scan to look at the rest of your body. Then a team of specialists, called the multidisciplinary team, will meet to talk about the best treatment, and you'll see a specialist to go through the options. You'll also have a specialist nurse you can call with questions. Can you tell me in your own words what the next steps are?
Patient: A scan, then the specialists decide, and I'll have a nurse to call.
Doctor: Exactly. Would you like me to be here when you tell your husband, or to talk to him with you?
How each step earns marks (our reading of the published domains)
| Step in the example | PLAB 2 domain | SCA domain and toolkit item |
|---|---|---|
| S: privacy, offering a companion | Interpersonal skills | Relating to others: "Generates rapport" |
| P: "what do you understand?" | Data gathering, technical and assessment skills | Data gathering and diagnosis: "Discovers patient's ICE" |
| I: asking how much detail | Interpersonal skills | Relating to others: "Listens and shows curiosity" |
| K: warning, clear words, no jargon | Interpersonal skills; clinical management | Relating to others: "Verbalises diagnosis and/or analysis" |
| E: silence, naming the shock, honest answer about dying | Interpersonal skills | Relating to others; a feedback statement covers respect and sensitivity |
| S: next steps, MDT, specialist nurse, teach-back | Clinical management skills | Clinical management: "Offers a safe patient-centred management plan", "Provides follow-up / safety net" |
The GMC and RCGP don't publish station- or case-level checklists. The table shows where each behavior fits in the published domains, not an official mark sheet.
Timing guide (our advice, not an official rule)
| PLAB 2 (8 minutes) | SCA (12 minutes) | |
|---|---|---|
| S + P | 0:00–1:30 | 0:00–2:00 |
| I + K | 1:30–3:00 | 2:00–4:00 |
| E | 3:00–5:00 (let it take as long as it needs) | 4:00–7:00 |
| S | 5:00–7:30 | 7:00–11:00 |
| Close, summary, questions | 7:30–8:00 | 11:00–12:00 |
The SCA has 3 minutes' reading time before each 12-minute case (RCGP). The GMC says you read the instructions outside each PLAB 2 room before entering, but the GMC pages we read don't state how long that reading time is.
Common mistakes in breaking bad news stations
| Mistake | Better |
|---|---|
| Giving the news in the first sentence | Set up and check perception first, then give a warning shot |
| Jargon: "malignant lesion", "neoplasm" | "a cancer" |
| Filling every silence | Wait. Silence is part of the E step |
| Moving to treatment while the patient is crying | Respond to the emotion first, then ask if they're ready to go on |
| False reassurance: "You'll be fine" | Honest uncertainty: "We'll know more after the scan" |
| Guessing a prognosis | Explain what is known now and how the specialist team will answer the rest |
| No plan at the end | Next steps, a named contact, and follow-up |
Practice this with an AI patient
Confetto isn't affiliated with the GMC or RCGP.
Frequently asked questions
What does SPIKES stand for?
Setting up the interview, Perception (the patient's), Invitation, Knowledge, Emotions (addressed with empathic responses), and Strategy and summary. It comes from Baile et al., The Oncologist, 2000.
Who created the SPIKES protocol?
Walter Baile, Robert Buckman and colleagues, in a paper published in The Oncologist in 2000, originally for patients with cancer.
Do I have to use SPIKES in PLAB 2 or the SCA?
No. The GMC and RCGP mark domains, not a named model. SPIKES is a helpful structure because it covers what those domains look for: finding out what the patient knows, explaining clearly, responding to emotion and agreeing a plan.
What is a warning shot?
A short sentence that prepares the patient before the bad news, such as "I'm afraid the results aren't what we hoped." It gives them a second to brace themselves.
What if the patient asks "Am I going to die?"
Don't guess and don't give false reassurance. Acknowledge the question, say honestly what is and isn't known yet, and explain how and when they'll get more answers.
Can SPIKES be used on the phone?
Yes, with more care over setup (is it a good time, are they somewhere private, is anyone with them) and more spoken checking, since you can't see their reaction. The RCGP says some SCA cases are audio only.
Sources
Read on November 1, 2026.
- Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. "SPIKES—A six-step protocol for delivering bad news: application to the patient with cancer." The Oncologist 2000;5(4):302–311
- GMC. "How will you be tested in your PLAB 2 test?"
- GMC. "What is the PLAB 2 exam and how does it work?"
- RCGP. "Introducing the SCA."
- RCGP. "SCA toolkit: Relating to others."
- RCGP. "SCA toolkit: Clinical management."
- RCGP. "Feedback statements for the SCA."
- NICE. "Shared decision making (NG197)."