Supportive Care Marcelle Kaplan, RN, MS, AOCN®, CBCN®—Associate Editor

SPIKES: A Framework for Breaking Bad News

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to Patients With Cancer

Marcelle Kaplan, RN, MS, AOCN®, CBCN®

SPIKES is an acronym for presenting distressing information in an organized manner to patients and families. The SPIKES protocol
provides a step-wise framework for difficult discussions such as when cancer recurs or when palliative or hospice care is indicated.
Each letter represents a phase in the six-step sequence. S stands for setting, P for perception, I for invitation or information, K for
knowledge, E for empathy, and S for summarize or strategize. Breaking bad news is a complex communication task, but following the
SPIKES protocol can help ease the distress felt by the patient who is receiving the news and the healthcare professional who is breaking
the news. Key components of the SPIKES strategy include demonstrating empathy, acknowledging and validating the patient’s feelings,
exploring the patient’s understanding and acceptance of the bad news, and providing information about possible interventions. Having
a plan of action provides structure for this difficult discussion and helps support all involved.

M.J. is a 68-year-old woman who has The Intervention: vides a step-wise structure for difficult
been disease free since being treated for discussions, such as when cancer recurs,
stage IIA breast cancer 15 years ago with Breaking Bad News or when treatment options have been ex-
a right-side modified radical mastectomy This type of discussion usually is quite hausted and palliative or hospice care is
and adjuvant chemotherapy, followed by difficult and uncomfortable for health- indicated. Each letter represents a phase
five years of tamoxifen therapy. She has care professionals to participate in. Often in the six-step framework (Back, Arnold,
two adult children, four grandchildren, they have little preparation and experi- Baile, Tulsky, & Fryer-Edwards, 2005;
and is newly retired from her job as a ence in how to support the patient in a Baile et al., 2000; Buckman, 2005; Finlay
school secretary. She and her husband constructive, empathetic manner when & Casarett, 2009) (see Figure 1).
have been making plans to take a month- delivering bad news. Having a prepared
long cruise. However, M.J. recently had
a persistent cough that developed into
plan of action can help support all the
participants in this difficult discussion.
The SPIKES Protocol
pneumonia. A chest x-ray revealed sev- The oncology team has four goals in S = Setting
eral lesions in her right lung. Today she breaking the news to M.J.: (a) learn what
is returning with her husband to the Respect and empathy for the patient is
she already knows about the situation and
oncology clinic to learn the results of a shown by choosing a setting which pro-
determine her readiness to hear the news,
full-body positron-emission test (PET) vides quiet and privacy. Pagers are turned
(b) provide clear information tailored to
and computed tomography (CT) scan. to vibrate and calls are held. Significant
her needs and desire to know, (c) provide
The medical oncologist and the oncol- others are included in the discussion as
empathy and emotional support, and (d)
ogy nurse are aware that the PET/CT scan the patient wishes. The person delivering
develop a treatment plan that takes her
has revealed areas of increased activity in the bad news demonstrates good listening
wishes into account (Baile et al., 2000).
M.J.’s right lung and liver that most likely skills and focuses his or her attention on
A useful strategy for accomplishing
represent metastatic breast cancer. They the patient in a calm, engaged manner.
these goals employs a six-step protocol
know that this portends a poor prognosis for breaking bad news, known as SPIKES.
and that M.J. needs immediate definitive SPIKES is an acronym for presenting P = Perception
tissue diagnosis and treatment. M.J. had distressing information in an organized Before launching into a description
been anxious for several years about the manner to patients and families. It pro- of the plan of care with the patient and
possibility of disease recurrence but, in
recent years, she thought she “had beat it.”
The immediate problem for the oncology Marcelle Kaplan, RN, MS, AOCN®, CBCN®, formerly was a breast oncology clinical nurse specialist
team is how to break the bad news to M.J. at Weill Cornell Medical Center at New York Presbyterian Hospital in New York.
in the most gentle and therapeutic way. Digital Object Identifier: 10.1188/10.CJON.514-516

514 August 2010 • Volume 14, Number 4 • Clinical Journal of Oncology Nursing