Review

The use of protocol in breaking

bad news: evidence and ethos
Antonia Dean and Susan Willis

H
ow to break bad news to patients has
been a subject of professional concern
Abstract
for many years, with interest growing
This article discusses health professionals use of protocol in the
alongside a culture of increasing medical
breaking of bad news, focusing particularly on the well-known SPIKES
disclosure of diagnosis and prognosis (Buckman,
framework. The evidence of impact on the patient experience is
1992). In many ways, ‘bad news’ is self-defining,
examined and recommendations are made for further outcome-based
but many publications refer to the description
research. Existing evidence suggests that the model as commonly
proposed by Buckman (1984): news that
interpreted may not fully meet the needs of patients or reflect the
negatively alters a person’s view of their future. It
clinical experience of breaking bad news for some professionals and
remains a topical issue. UK national guidance for
further guidance may be needed to support them in their practice.
professionals caring for people dying has stressed
The ethos of the step-wise protocol is debated, questioning whether it
the importance of sensitively communicating to
helps or hinders individualised care and the formation of a genuine
patients the recognition that they are dying:
re l a t i o n s h i p b e t we e n p a t i e n t a n d p ro fe s s i o n a l . F i n a l ly,
perhaps the ultimate ‘bad news’ (Leadership
recommendations for practice are offered.
Alliance for the Care of Dying People, 2014;
Key words: Breaking bad news l Protocol l Communication
National Institute for Health and Care
l Information l Support
Excellence, 2015). In acknowledgment that news
may be perceived differently by the giver and
This article has been subject to double-blind peer review.
receiver, some publications have started to refer
to ‘significant news’ (Mishelmovich et al, 2016),
but bad news remains the more common term
and will be used for ease of reference throughout ●●Preparation
this article. ●●Communication
Notwithstanding the psychological impact of ●●Planning
the news itself, breaking bad news insensitively ●●Follow-up.
can cause patients additional distress (Walsh et However, it has been identified that these
al, 1998) and anecdotal accounts abound of the strategies lack robust supporting evidence
impact of poor delivery (Diamond, 1998; (Fallowfield and Jenkins, 2004). This article will
Granger, 2012). Moreover, a metasynthesis of focus on the SPIKES protocol developed by Baile
evidence by Bousquet et al (2015) highlights the et al (2000) due to the frequency to which it is
emotional sequelae to the clinician, including: referred to in guidance (National Council for
●●Guilt Hospice and Palliative Care Services, 2003; RCN,
●●Anger 2013; Seifart et al, 2014), used in teaching
●●Anxiety programmes (Baer et al, 2008) and adopted by
●●Exhaustion. clinicians (Morgans and Schapira, 2015). The
It is therefore imperative to discover the best evidence base for this approach will be examined
way of breaking bad news for patient and and the utility and ethos of step-wise protocols Antonia Dean, Lecturer
professional alike. will be discussed, with the intention of providing Practitioner, Hospice of
St Francis, Berkhamsted,
A number of strategies have been developed to a fresh perspective on breaking bad news. UK; Susan Willis, Senior
support best practice in breaking bad news, such Implications for future practice will be identified. Lecturer, Department of
Allied Health
as the SPIKES protocol (Baile et al, 2000) and
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Professionals, Faculty of
Kayes 10 steps (1996). Royal College of Nursing Background: Health and Wellbeing,
(RCN, 2013) guidance for nurses breaking bad the SPIKES protocol Sheffield Hallam
University, Sheffield, UK
news to parents about their child’s diagnosis The SPIKES protocol, summarised in Table 1,
Correspondence to:
notes that most strategies share a was developed in response to the reported antonia.dean@stfrancis.
similar structure: discomfort of oncology doctors in breaking bad org.uk

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 Review

Table 1.The SPIKES protocol for breaking bad news delivery of bad news is supported by patient
Setting preference (Sastre et al, 2011). And certainly, were
• Prepare for the invitation by reviewing the notes and inviting the patient to involve one to adopt the opposite of the
people important to them. Prepare the environment, ensure time and privacy. Take recommendations in SPIKES, it seems likely that
note of body language, be seated, not standing. the encounter would go very badly indeed. It is
difficult to argue that the advice is anything less
Perception than ‘sensible, worthy and helpful’ (Fallowfield
• Find out the patient’s perception of their illness. and Jenkins, 2004:312) and has contributed
Invitation hugely to the development of practice in this area.
• Find out how much information they would like, and to what level of detail. However, it may be helpful to re-examine this,
Knowledge now ‘classic’, model to see if current evidence or
• Impart the bad news clearly and simply, avoiding jargon, with frequent pauses to changes in the culture of care can offer
check for understanding. Use a ‘warning shot’ statement first so that patients are new insights.
prepared that bad news is coming. Baile et al (2000) reported positive feedback
from oncologists and changes in self-assessed
Emotions
confidence levels across skills such as detecting
• Allow the patient to express their emotions, using empathic responses to
sadness/anxiety and making empathic responses
acknowledge their feelings and show support.
following training in the SPIKES protocol.
Strategy and summary However, it is not clear at what point after
• Make a plan with the patient for the future and summarise the discussion, checking training the oncologists’ confidence levels were
the patient’s understanding. assessed, or how this was undertaken. A later
study (Baer et al, 2008) used the SPIKES protocol
Adapted from Baile et al (2000) as a model of good practice to teach breaking bad
news to medical students (alongside role play
news to their patients (Baile et al, 2000). It takes with cancer survivors) and again self-rated
the view that ‘disclosing unfavourable clinical confidence was found to increase post training
information to cancer patients can be likened to across domains that reflected the six steps of
other medical procedures that require the SPIKES, although it was not assessed if this
execution of a stepwise plan’, giving confidence was sustained over time.
cardiopulmonary resuscitation (CPR) or the Improving clinician confidence is without doubt
management of diabetic ketoacidosis as examples an important outcome: feelings such as anxiety
(Baile et al, 2000:305). It describes six steps, may impede the clinician’s ability to perform this
from preparation to information delivery, role (Bousquet et al, 2015). However, Fallowfield
ventilation of feelings, future plans and summary, and Jenkins (2004) note that there is very little
with the aims of increasing clinician confidence, evidence that guidelines such as SPIKES alter the
reducing stress and facilitating patient patient experience of receiving bad news.
involvement in decision-making. In addition to self-assessed clinician confidence
levels, cancer survivors in Baer et al’s (2008) study
Discussion rated the students on their behaviour during role
Evidence and effectiveness play following SPIKES training. This at least
At the time of publication, Baile et al (2000) provided a survivor’s perspective, albeit one that
reported that SPIKES incorporated the available would have had more validity had students been
evidence but was not wholly derived from rated before as well as after training. Further
empirical research, with the implication that it assessment of the students’ behaviour in their
also reflected the authors’ clinical experience. Its day-to-day practice would provide even more
structure is similar to the Calgary Cambridge useful data: a change in behaviour directly after
model of the medical interview (with a shared training does not necessarily translate to clinical
emphasis on preparation, rapport-building, reality (Kaushik and Pothier, 2007). Moreover, a
information and preference seeking, expression of sustained change in behaviour is only the first
emotion and future plans and summary), widely step in supporting the recommendation of a
adopted as a model of good practice (Kurtz et al, protocol such as SPIKES. Success that is measured
2003). And while it is beyond the scope of this purely against adherence to a preset process is
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article to examine the evidence basis for each effectively self-referential; the altered professional
individual recommendation, there are a number behaviour should also be demonstrated to
of studies that suggest that the advice given may improve patient experience, a challenge facing
be helpful. For example, the emphasis on palliative care research more generally (Sleeman
demonstrating high levels of empathy during the and Collis, 2013).

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 Review

Outcome and experience data reported by conditions often carry an uncertain disease ❛Improving
patients where possible, or their proxies, is trajectory, which may add complexity to clinician
important because their preferences may not the news. confidence is
always fully support current ‘best-practice’ Fallowfield and Jenkins (2004) describe ethical
guidance. For example, although broadly and practical difficulties in obtaining patient
without doubt
validating most recommendations, Australian outcome evidence: researchers are understandably an important
melanoma patients reported some differences wary of burdening patients at an already difficult outcome ... ❜
when asked to rate bad news guidance by Girgis time. Paul et al (2009) commented that there are
and Sanson-Fisher (1995). They felt there needed further difficulties in selecting which outcomes
to be greater emphasis on being offered the best one should measure, such as anxiety, depression
treatment but there was less support for other or satisfaction (although some may view
recommendations, such as signposting to cancer ‘satisfaction’ as a curious term in this context),
support services (Schofield et al, 2001). but the authors propose that these challenges are
Research on the patient experience following not insurmountable. Including patients in the
any breaking bad news intervention has been design of research, a key and current concern
called for by a series of authors over almost two within palliative care (Daveson et al, 2015), may
decades (Girgis and Sanson-Fisher, 1995; Arber validate the selection of these outcome measures
and Gallagher, 2003; Fallowfield and Jenkins, which, even so, could appear a ‘blunt instrument’
2004; Paul et al, 2009). However, a review of to capture such a complex interaction. Difficulties
available studies over a 15-year period found that notwithstanding, it seems vital to attempt a more
fewer than 2% were well-designed intervention rigorous examination of the impact of these
studies that provided patient outcome data (Paul discussions: as previously discussed, SPIKES is a
et al, 2009). recommended model of good practice in many
One such example of an intervention study areas. It exists as a national guideline in Germany
looks at a UK communication programme rolled despite a lack of proper evaluation (Seifart et al,
out to multidisciplinary team members working 2014). A sample of German cancer patients, half
in cancer care in the NHS. While the programme of whom had been diagnosed within the previous
does not focus specifically on breaking bad news, year, were given a survey using the SPIKES
it includes the topic in its curriculum and records protocol as a basis for questions around how
students role-playing difficult situations with news of their diagnosis was broken. Fewer than
actors then provides the opportunity to watch the half of patients (46.2%) were satisfied with how
footage with supportive, constructive criticism the encounter had gone. While this may reflect the
provided. In Wilkinson et al’s (2008) randomised skills of the oncologist rather than the protocol
control trial of the intervention, researchers rated itself, the study makes a rare attempt to reflect the
nurses performing patient assessments before and views of patients. Interestingly, most reported
3 months after the training and improvements receiving the news in a single encounter (and
were detected in comparison to the control group. SPIKES describes delivering bad news, decision-
Crucially, in addition, patients were assessed for making and planning in a single interview) but
anxiety, depression and satisfaction following more than half of the study’s participants stated
their assessments. Patients of nurses in the that they preferred to have a second consultation,
intervention group displayed less anxiety in as they were unable to make decisions
addition to various other positive outcomes. immediately after hearing distressing news (Seifart
Adapting a research model such as this one for et al, 2014). Indeed, there is much research to
bad news interventions could considerably add to suggest that memory and other cognitive
the knowledge-base. processes are hindered by anxiety and distress
However it is not simply the intervention itself (Kessels, 2003). It may be wiser, unless the patient
that requires additional research. It is important would prefer, to save making plans for another
to note that the majority of studies focus on the consultation. This does not negate the model, but
‘bad news’ experiences of those who have cancer. the ‘strategy’ element may be limited to giving the
Given the sheer volume of people who are patient another appointment and providing them
diagnosed with long-term conditions, including with details for where they can access further help
respiratory, cardiac and neurological disorders, it if they have questions or emotional support is
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should be ascertained if there are differences to needed. For some patients with an incurable
how bad news should be managed; for example, disease, this next appointment could see the
Milby et al (2015) suggest that both professionals beginnings of the process of advance care
and patients experience avoidance surrounding a planning as well as considering a strategy for the
dementia diagnosis. Long-term nonmalignant immediate future.

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 Review

❛Indeed, there Breaking bad news as more than discovering the agenda of all present, encouraging
is much a single event each person to take part and avoiding ‘taking
research to The bad news process may be broader even than sides’ in situations of conflict. A study evaluating
a two-stage consultation: Warnock et al (2010) a ‘triadic’ communication skills training
suggest that criticise frameworks such as SPIKES for implying programme for doctors (with the aim of
memory and that breaking bad news occurs in a single, discrete incorporating both patient and relative in the
other cognitive interview instead of a series of interactions before discussion) found that relatives spoke more often
processes are and after the ‘news’ is imparted. A metasynthesis and earlier in the consultation and doctors
of evidence revealed that the views of oncologists addressed emotional concerns in patient and
hindered by reflect this concept of bad news communication relative more often in comparison with a control
anxiety and as a wider process (Bousquet et al, 2015) and group who received no training (Merckaert et
distress.❜ patient accounts demonstrate that events (e.g. al, 2013).
diagnostic tests) leading up to bad news affect
their perceptions of the news itself (Shaepe, Ethos
2011). This suggests that future guidance should As previously discussed, the SPIKES protocol
incorporate the notion of breaking bad news as a works on the assumption that breaking bad news
wider episode of care, looking beyond the is a clinical task, similar to other medical
moment when the news is imparted. procedures, which can be broken down into a
series of steps. The aim of this dissection of the
Nursing perspective encounter, in addition to increasing their
Looking beyond the single, planned consultation confidence, is to prompt the clinician to involve
might also better echo the clinical reality for other the patient in each step, helping them feel
professionals. It is of note that SPIKES was supported, well-informed and able to participate
designed for doctors by doctors, and most easily in decision-making (Baile et al, 2000). It is
translates to the outpatient setting with structured interesting to consider whether framing the
appointments. However, other professionals such sharing of bad news as an unpleasant task that
as nurses and allied health professionals are can be made more manageable has any impact on
frequently involved in bad news discussions the clinician-patient relationship. Do protocols
(Warnock et al, 2010; Griffiths et al, 2015) and encourage a focus on the process involved rather
despite SPIKES being recommended to nurses as a than the person themselves and improve
model of good practice (RCN, 2013) there has confidence as a result of increased detachment?
been little attempt to evaluate its clinical utility When a professional uses a mnemonic to
outside of medicine. Warnock et al (2010) remark structure their interaction, does it remove the
that, contrary to SPIKES guidance, nurses are likelihood of spontaneously experiencing and
frequently unable to prepare for bad news responding to that patient as they are? A doctor
discussions. They may be helping a patient with a reflecting recently on the death of his father in the
wash or performing another activity when a Lancet describes how ‘formulaic’ communication
question about diagnosis or prognosis comes ‘out strategies may obscure a more real human-to-
of the blue’. They may be pushing a wheelchair, human connection (Gardner, 2016). Greenwood
changing a dressing, or standing in the middle of (2007) frames a similar idea using concepts from
a corridor, far from the controlled ideal. It is not philosophy. He suggests that preconceptions or
clear how useful nurses find existing protocols: a expectations of a person or encounter (in this
study of clinical nurse specialists found they were case, the expectation of following a stepwise
aware of guidelines but relied more heavily on procedure) diminish the possibility of the I-Thou
their experience when shaping their practice relationship described by the philosopher Buber
(Mishelmovich et al, 2016). (2000), where both truly experience each other
and are transformed by the encounter. Likewise,
Involving significant others preconceptions increase the possibility of an I-It
Just as bad news may be broken by professionals relationship, where the patient becomes reduced
other than doctors, it is often received by to an object.
significant others such as relatives in addition to Put more simply, strategies may encourage a
the patient. Eggly et al (2006) suggest that difference in perspective between clinician and
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protocols such as SPIKES should involve guidance patient: for the clinician the aim of the
on how to break bad news when there are several consultation may be to transmit the information,
people present. There are various sources of albeit as sensitively as possible (Salander, 2002).
information on how to do this effectively. Lang et This is reflected in some of the language used in
al (2002) make recommendations such as the description of SPIKES:

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 Review

‘Until an emotion is cleared it will be difficult to Table 2. Implications for practice

go on to discuss other issues.’ (Baile et al, • Breaking bad news occurs over more than an isolated interview
2000:307) (Warnock et al, 2010)

The aim of addressing the emotion is to calm • Breaking bad news guidance needs to reflect the clinical reality for professions other
the patient to allow for further discussion or than medicine (Warnock, 2010)
decision-making. However, for the patient the
• Professionals may need additional education on the best way to break bad news
relationship between clinician and patient during
when significant others such as family are present (Merckaert et al, 2013)
the process of discovering bad news is perceived
as crucial, an end in itself, and more than just a
• Breaking bad news guidance should include reference to care and support of the
device to allow for information-sharing
health care professional (Arber and Gallagher, 2003; Bousquet et al, 2015)
(Salander, 2002).
Arber and Gallagher (2003) allude to the
• Care must be taken to emphasise a focus on the patient and the patient-professional
professional’s role in breaking bad news as a
relationship, rather than on the ‘task’ alone (Salander, 2002)
kind of expert companionship, while Papadatou
(2009) draws an analogy to being alongside • Guidance on breaking bad news may need to reflect cultural differences (Rollins and
suffering with the Greek myth Theseus and the Hauck, 2015)
Minotaur. She likens the professional-patient
relationship to Ariadne providing Theseus with a • Well-designed research is needed to elucidate patient outcomes (Paul et al, 2009),
ball of string when he entered the labyrinth to including for those living with non-malignant disease
face the Minotaur: we cannot live the horror of
bad news for each patient but we can stay linked
to them, providing reassurance and continuity as that professionals do not always perceive
they navigate the twists and turns. This is breaking bad news in a negative light. Nurses
acknowledged to some extent by SPIKES authors have described how being involved in breaking
in later works. Buckman (2010), when preceding bad news has strengthened their relationship
a description of SPIKES, provides a less evocative with patients (Warnock et al, 2010).
but pithier equation to this end: Ultimately, it is not clear whether protocols
help or hinder a focus on the individual and the
‘Treatment = medication + health care relationship they hold with the professional. As
professional.’ (Buckman, 2010:1) with any tool, it is only as useful as the person
who wields it. It depends on how it is interpreted
How this relationship is built and developed is and translated into real care. As Kate Granger, a
less clear and various approaches have been doctor living with incurable disease, describes in
proposed, for example, the approach of narrative a recent interview, one of the aims of any ‘bad
medicine emphasises making contact through a news’ intervention should involve:
genuine attention to listening to patients’ stories
(Charon, 2008). ‘ … how you think about the impact of bad
A focus on the relationship between news on an individual more than just viewing
professional and patient may not only benefit “telling Mrs Smith that she’s got lung cancer”
patient care, but also encourage investment in the as a task.’ (Giles, 2015)
support of the professional (Beach et al, 2006).
Research demonstrates that breaking bad news
has significant negative emotional effects on the Implications for practice and future
professional (Bousquet et al, 2015) and although direction of research
SPIKES was designed with the intention of There is no doubt that protocols such as SPIKES
reducing professional burnout (Baile et al, 2000), have contributed hugely towards professional
this has never been demonstrated and addressing practice but evidence accumulated over the past
the emotional needs of the practitioner does not 15 years suggests that certain adaptations could
form part of the six steps. British Medical potentially better reflect clinical reality, patient
Association (2010) online guidance for junior preference and professional need. These
doctors in breaking bad news issues the implications for practice, discussed throughout
© 2016 MA Healthcare Ltd

imperative: ‘do not forget you’. To this end this article, have been summarised in Table 2.
Bousquet et al (2015) recommend supervision for More outcome data is required to provide a
professionals to discuss the emotional impact of robust evidence base for the practice of breaking
undertaking this kind of work and to encourage bad news. As previously discussed, this will
reflective practice. It is also important to note require a careful selection of which outcomes to

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 Review

❛The aim measure to allow comparison between changes in the context of care indicate several
of addressing interventions. Moreover, guides such as SPIKES additions to the six steps of SPIKES, notably
the emotion provide a series of recommendations, which add looking beyond breaking bad news as a single
a further level of complexity. While it is quite interview, focusing on professions other than
is to calm possible to focus on researching individual medicine and supporting the health professional
the patient recommendations it is also important to reflect in their emotional labour. While the difficulties
to allow the ‘lived experience’ of receiving bad news have been acknowledged, the urgent need for
for further interventions such as SPIKES as a whole patient outcome research to guide future practice
(Bousquet et al, 2015). This may be difficult but has been identified, as so much ‘best practice’ is
discussion certainly not impossible: protocol of a recent based primarily on expert opinion. The potential
or decision- randomised control trial to evaluate an advance consequences of using a step-wise protocol to the
making.❜ care planning communication intervention is of development of a therapeutic relationship have
great interest when considering appropriate been discussed, with the recommendation that
methodology. This is because it measures attention is paid to not losing the person within
clinician confidence and satisfaction in addition the structure of the process.
to regular, self-reported patient (and patient-
proxy) data and various outcome measures Conflicts of interest
including peacefulness, anxiety, depression and The authors have no conflicts of interest to declare
quality of life and death (Bernacki et al, 2015).  

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Book reviews
International Journal of Palliative Nursing welcomes
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to palliative nurses and students. We are also keen to hear from
clinicians or educators who would be interested in reviewing
books. Guidelines are available.

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