Breaking bad news • SPIKES • Consent • Empathy • Family communication • Emergency settings

The Six-Step Protocol for Breaking Bad News in Palliative Care

A practical communication guide for emergency medicine, oncology and palliative-care teams

Learning objectives

• Explain what makes news “bad” and why communication quality affects safety and trust.
• Prepare a private, culturally respectful setting and the right people.
• Apply each step of SPIKES with example language, pauses and empathy.
• Respond to denial, anger, guilt, silence, family nondisclosure and unrealistic expectations.
• Adapt communication for emergencies, children, low literacy, disability, language difference and delirium.
• Document the discussion, decisions, uncertainty, follow-up and safety plan.

1. What is bad news?

Bad news is information that substantially changes a person’s view of the present or future in a negative way. It may be a new diagnosis, a serious scan result, treatment failure, recurrence, permanent disability, deterioration, need for urgent intervention, change to comfort-focused care or death.

The same information can be experienced differently by different people. Good delivery cannot remove grief, but it can reduce confusion, prevent false expectations, preserve dignity, support informed decisions and maintain the therapeutic relationship.

2. Why bad news is difficult

• Uncertainty, limited time, heavy workload, inadequate privacy or fear of emotional reactions.
• Clinician guilt, discomfort, language barriers, cultural differences and fear of destroying hope.
• Family requests for secrecy, disagreement about treatment, misinformation or spiritual explanations.
• The patient’s pain, breathlessness, shock, delirium, low literacy, disability or previous trauma.

Hope is not the same as cure. Hope can shift toward comfort, time, meaningful activities, reconciliation, symptom relief, family presence or a peaceful death. Truthful communication preserves realistic hope better than false reassurance.

3. Preparation before the conversation

Preparation area	Questions/actions
Clinical facts	What is confirmed? What remains uncertain? What is the likely next step? What options, burdens and alternatives exist?
Patient preference	How much does the patient want to know? Who may be present or informed? Is an advance decision recorded?
Capacity and safety	Can the patient understand, weigh and communicate a decision now? Is there delirium, hypoxia, shock, coercion, abuse or suicidal risk?
People and roles	Choose a lead communicator; invite the patient’s chosen support person, nurse, interpreter, counsellor, social worker or spiritual-care provider.
Setting	Private, quiet, accessible room; sit at eye level; tissues and water; phones silenced; enough time; plan for interruption.
Follow-up	Arrange a next meeting, written summary, referral, symptom plan and contact number before starting.

4. SPIKES: the six-step protocol

The supplied reference uses six steps: Setting, Perception, Invitation, Knowledge, Emotion/Empathy and Strategy/Subsequent summary. SPIKES is a flexible structure, not a script.

S — Setting up the interview

• Review the record, results and likely questions. Decide who should lead and what cannot yet be answered.
• Choose privacy; sit, maintain appropriate eye contact and keep the patient physically comfortable.
• Introduce yourself and confirm the patient’s name, preferred language and relationship to those present.
• Ask permission for a support person: “Would you like someone with you?”
• Manage interruptions and have a plan for urgent clinical deterioration.
• Begin with an agenda: “I would like to explain the results, hear what you understand and discuss what we do next.”

P — Assessing perception

• Ask, “What is your understanding of why these tests were done?” or “What have you noticed about your health?”
• Identify misinformation, denial, expectations and the words the patient uses.
• Listen without correcting every detail at once. Correct dangerous misunderstandings gently.
• Notice non-verbal signs: silence, gaze, posture, breathing, tears and agitation.

I — Obtaining invitation

• Ask, “How much information would you like today?” and “Would you prefer details now or in stages?”
• Respect a competent patient’s wish not to know, while asking who may receive information and how decisions will be made.
• Offer a future opportunity: “We can stop here and continue tomorrow; you can ask questions at any time.”
• Do not allow a family request for secrecy to automatically override the patient’s preference.

K — Giving knowledge

• Use a warning shot: “I am afraid the result is more serious than we hoped.”
• Use plain language, short sentences and small chunks. Avoid jargon, euphemisms such as “passed on” when death must be clear, and unexplained numbers.
• Name the diagnosis or situation directly but compassionately. Separate facts, possibilities and uncertainty.
• Pause after each key point. Check understanding: “What is your understanding so far?”
• Explain what can still be done, including symptom relief, support and the next decision.
• Provide written or pictorial information, a translated summary and contact details.

E — Addressing emotions with empathic responses

Emotion may appear as tears, anger, silence, disbelief, guilt, blame, laughter, agitation or withdrawal. Use the NURSE skills:

NURSE	Example
Name	“I can see how frightening this is.”
Understand	“I want to understand what this means to you.”
Respect	“You have been carrying a lot and have asked important questions.”
Support	“We will not leave you alone with this; we will plan the next step.”
Explore	“What worries you most right now?”

• Allow silence, tears and time. Offer tissues or water and ask before touching.
• Do not interrupt with premature advice, argue with denial, criticize coping or say “Everything will be fine.”
• Assess immediate safety if there is hopelessness, suicidal thinking, violence, severe agitation or inability to care for self.

S — Strategy, summary and subsequent plan

• Ask permission to discuss the plan: “Would it be okay if we talk about what happens next?”
• Summarize what is known, what remains uncertain, the patient’s goals and the options.
• Discuss benefits, burdens, alternatives, consequences of no treatment, time frame and who will help decide.
• Agree on immediate actions, symptom control, referrals, investigations, place of care and an emergency contact.
• Use teach-back and write a short plan. Arrange the next conversation; bad news rarely fits into one meeting.
• Document participants, consent/disclosure preference, capacity, information, emotion, decisions, uncertainty, referrals and follow-up.

5. Do and do not

Do	Do not
Tell the truth in understandable words.	Lie, distort, conceal essential facts or offer a guarantee.
Ask what the patient knows and wants to know.	Assume the family’s preference is the patient’s preference.
Use privacy, dignity, empathy and time for questions.	Break news in a corridor, by hurried phone call or in front of strangers.
Allow silence and emotion.	Fill every pause, change the subject or rush to technical details.
Explain uncertainty and what can still be done.	Use false optimism or equate palliation with abandonment.
Check understanding and document.	Assume nodding means consent or comprehension.

6. Difficult responses

Denial

Do not force acceptance. Ask what the patient believes, provide one clear fact, acknowledge uncertainty and offer a return conversation. Assess whether denial protects coping or prevents urgent safe decisions.

Anger

Stay calm, listen for fear or pain, name the emotion and set a boundary against threats: “I want to help, and we must keep everyone safe.” Call senior/security help if there is violence risk.

Guilt or blame

Explore the meaning, correct inaccurate medical blame and offer psychological/spiritual support. Do not argue or shame.

Family asks for secrecy

Explore their concern, then ask the patient privately how information should be handled. Offer staged disclosure and a family meeting with consent. Share only necessary information.

Unrealistic cure expectation

Ask what cure means, acknowledge hope and explain the medical reality. State what remains possible—comfort, time, function, treatment of reversible problems and family support.

Conflicting relatives

Pause non-urgent decisions, establish one shared clinical update, return to the patient’s values and prior wishes, and involve senior, ethics, social-work or spiritual support.

7. Special situations

Emergency department or resuscitation

• Stabilize immediate threats and give a short update: “Your breathing is dangerously difficult; we are treating it now.”
• Use one spokesperson, avoid speculation and return for a fuller SPIKES conversation after stabilization.
• Clarify known goals/advance decisions without delaying lifesaving care; document emergency decisions and who was involved.

Children and adolescents

Include the child at an age-appropriate level, speak directly to them, check what they understand and avoid talking over them. Obtain guardian consent and seek assent where appropriate. Ask about siblings, school, play and fears.

Language, literacy and disability

• Use a trained interpreter; do not use children as interpreters for serious news.
• Use simple words, pictures, large print, audio or communication devices. Face the person and allow extra time.
• Do not assume hearing, speech, cognitive or physical disability equals lack of capacity.

Delirium or reduced consciousness

Treat reversible causes, assess decision-specific capacity and communicate in short repeated phrases. Involve a lawful surrogate or family appropriately while preserving dignity and previously expressed wishes.

Telephone or remote disclosure

Confirm identity, location, privacy, callback number and immediate safety. Give a clear headline, avoid complex news when the person is alone or driving, and arrange in-person follow-up.

8. Cultural and spiritual humility

• Ask what the illness means, who should be involved and which practices provide strength.
• Respect family-centred decision-making while protecting a competent patient’s confidentiality and autonomy.
• Offer a chosen spiritual or traditional support person with permission, provided urgent care is not delayed or harmed.
• Check whether silence, eye contact, touch, directness or disclosure have culturally different meanings.

9. After the conversation: action and continuity

• Write a one-page summary: diagnosis/uncertainty, goals, choices, medicines/symptoms, warning signs and contacts.
• Coordinate referrals, transport, home care, social support, spiritual care, mental-health support and family meeting.
• Check the patient’s immediate safety, pain, breathlessness, hydration and ability to leave the room.
• Contact the patient or caregiver according to the agreed plan; repeat information because shock reduces recall.
• Offer clinician debrief and supervision after especially distressing conversations.

10. Documentation template

11. Clinical cases

12. Quick self-test

1. What do the six SPIKES steps represent?
2. Why is a warning shot useful?
3. Give three patient rights relevant to disclosure.
4. How should a clinician respond to tears or anger?
5. What must be documented after breaking bad news?
6. Name two adaptations for language or disability.

Answers

1. Setting, Perception, Invitation, Knowledge, Emotion/Empathy and Strategy/Summary or subsequent plan.
2. It prepares the patient that difficult information is coming and reduces the shock of an abrupt headline.
3. Accurate information, privacy, choosing how much to know, choosing who is present/informed, participation in decisions and the right to accept or decline treatment.
4. Pause, listen, name and validate the emotion, allow silence, ask what it means, offer support and assess safety; do not argue or give false reassurance.
5. Participants/interpreter, consent and disclosure preference, capacity, understanding, facts/uncertainty, emotional response, goals, decisions, referrals and follow-up.
6. Trained interpreter, plain language, pictorial/large-print material, hearing/vision aids, communication device, extra time and direct conversation with the patient.

Key take-home points

• Breaking bad news is a process of preparation, truth, empathy, shared planning and follow-up.
• SPIKES provides structure, but the patient’s pace, culture, capacity and goals guide the conversation.
• Never confuse honesty with bluntness or hope with a cure guarantee.
• In emergencies, stabilize first, communicate a brief update and return for full discussion.
• Document what was said, who was present, what the patient wanted and what happens next.

Further study and references

• Breaking Bad News — supplied Slideshare reference
• WHO: Palliative care
• Related lesson: Counselling patients, caregivers and families
• Related lesson: Effective communication with patients and caregivers

Educational resource for supervised learning. Apply current Uganda consent, confidentiality, safeguarding and professional guidance.