Delivering a cancer diagnosis, discussing prognosis and end-of-life issues and educating patients are all difficult conversations that occur routinely in the work of a health care provider. While difficult conversations may be commonplace in the health care environment, it doesn't make them any easier to deliver. I*CARE provides workshops designed to help providers prepare themselves, families and patients for what may not be the most positive prognosis.

The SPIKES protocol is a series of steps developed years ago by Robert Buckman, M.D., an oncologist at the Princess Margaret Hospital, in Toronto, Canada, and Walter Baile, M.D., professor of psychiatry at the University of Texas MD Anderson Cancer Center, in Houston, Texas, to deliver bad news to cancer patients.

"SPIKES" puts the task of breaking of bad news into steps, rather than making it one big procedure that can be confusing. Each step represents a part of a skill, learned and practiced one by one and then put together in a package to discuss unfavorable medical information for patients.

SPIKES stands for the following:
  • S: Setting. Pick a private location.
  • P: Perception. Find out how the patient views the medical situation.
  • I: Invitation. Ask whether and how much the patient wants to know.
  • K: Knowledge. Warn before disclosing bad news.
  • E: Emotions. Respond to the patient's emotions using empathy and validation.
  • S: Strategy/Summary. Once they know, include patients in treatment decisions and summarize the plan for the future.

SPIKES represents, more or less, a consensus of the literature and what experts feel should be the essential elements of giving bad news. We teach SPIKES workshops throughout the United States and worldwide, because everyone has the same challenge of giving bad news.

The last three parts of the SPIKES protocol are the most important in showing the patient support—a key element in the patient's healing and acceptance process.

Providing patients with the information is better than disguising it behind half-truths and euphemisms. Giving providers techniques to address the emotional reactions of patients and families by being empathic and validating these emotions helps them to support the patient in the process of giving them the bad news. In allowing patients to process their emotions, providers help the patients return—so to speak—to a more interactive state where they can begin to hear some of their treatment plan. Patients are often more receptive to a supportive health care provider than to one who may have all the clinical expertise but lack the interpersonal skills. It is important to recognize that some patients have a good prognosis and feel bad about their care because they don't have an empathic provider. Through their listening and their relationship with the patient, and through their encouragement and praising, an empathic provider can convey a hopeful spirit to their patients.

While much of the SPIKES protocol is aimed at physicians—who are traditionally the bearers of bad medical news, the steps can also be adjusted to suit nurses—SPIKES RN.

We surveyed 350 nurses at MD Anderson Cancer Center about what they would do in a situation when they were with a patient who was requesting information about their prognosis, but this information had not been disclosed to them by their doctor. The results showed that nurses felt awkward interacting with the patients because they were afraid they would say something they weren't supposed to. In fact, 48 percent of respondents said they couldn't speak to the patient about anything medical because they were afraid they'd slip up; 30 percent were afraid to even spend time with the patient because of this; and 7 percent admitted that they lied to their patients to avoid revealing something they shouldn't.

SPIKES RN allows nurses to apply the same SPIKES steps shown in our video for physicians to a conversation with the physician about the news that the patient needs to hear.

SSetting – Find an appropriate time to approach the physician
PPerception – Ask the doctor if he is aware of the patient's need for information and what the patient should know
IInvitation – Invite the physician to discuss the patient's needs
KKnowledge – Provide the doctor with knowledge about the nurse's interaction with the patient
EEmpathize - Handle the doctor's emotions
SStrategy – Devise a strategy for talking to the patient with the doctor

S, for setting, is to find a time to approach the physician to sit down and talk. P, for perception, is to find out if the doctor is aware of the patient's need for information and what the patient would like to know about. I is for the nurse's invitation to the physician to discuss the patient's needs and a plan for interaction. K is providing the doctor with knowledge about the nurse's interaction with the patient. E is the nurse handling the doctor's emotions—he may be insistent that he already told the patient—and being empathic with the physician's situation. Finally, S is the nurse devising a strategy for going in together and talking to the patient.

SPIKES RN is one way for nurses to support patients, without going beyond their comfort level, after bad news has been disclosed, when the patient needs additional information, or there are issues that the patient brings up. It provides clear, specific skills that a nurse can learn and can be taught to others through role playing with actors or colleagues taking on the role of patients. SPIKES is one way in which the messenger of bad news can also be the supporter of the patient. You can give patients hope no matter how bad the news is by providing them with the reassurance that you're going to give them the best care you possibly can. A pocket guide with these tips will be posted to this page soon. Stay tuned. To read more about workshops to train providers to deliver bad news view NurseZONE Nursing News.