SAN FRANCISCO — Telling a patient they have cancer or another life-changing diagnosis is one of the most challenging aspects of being a healthcare provider, but preparing ahead of time can help clinicians make the most out of a difficult situation.

A six-point protocol for delivering difficult news, called SPIKES, is a straightforward and practical tool to make the process more manageable.

Anthony Brenneman, MPAS, PA-C, director of physician assistant studies and services at the University of Iowa Carver College of Medicine in Iowa City, and Emily Fenton, a PA student at the college, explained the protocol during a session at the American Academy of Physician Assistants 2015 meeting.

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The SPIKES protocol is a mnemonic device that can help providers achieve quality interactions with patients, Fenton told The Clinical Advisor. It stands for the following:

Setting. Make sure you have a quiet location with no distractions. Sit at eye level with the patient and make sure that they are comfortable. Think about potential distractions ahead of time. “Consider leaving your pager with the nurse if you are on call, or asking a colleague to fill in for you if you have an appointment scheduled that requires delivering bad news,” said Brenneman.  

Patient perception. Make sure you understand where the patient is coming from on that day. Be sure to ask them what they think the purpose of the visit is.

Invitation for Information. Find out how much information would the patient like to hear at that time, and what will need to be covered in a future appointment. “Often, when you deliver bad news it’s about as much as a patient can handle at that particular moment,” Fenton said. Make sure that you ask the patient if he or she is ready to hear more before moving on.

Knowledge. Talk to patients on a level that they will understand. Remember that they may not always be familiar with specific medical terms. Also, try to gauge how much a particular patient already knows about the diagnosis. “This will tell you how hard you’re going to have to work to get them to the point where they need to be,” Brenneman said.

Explore emotions and empathize. “This is one of the most critical components of delivering bad news,” Fenton said. It’s important to be aware of both patients’ verbal and nonverbal communication of emotions. Ask the patient, “How do you feel about this news?”

Also know your own comfort level, Brenneman suggested. “Are you comfortable with laying a hand on a patient and being present? Are you able to empathize with them? Be prepared for not only the patient’s emotional response, but your own.”

Strategy and summary. Summarizing the conversation is important to make sure that the patient walks away with a good understanding of the diagnosis. Ask the patient to repeat the information provided to make sure he or she understood what had been said. 

“By putting the patient at ease, you are going to be more at ease as well,” said Fenton. “That really lends itself to greater job satisfaction. You are helping patients through a difficult process, and having a good strategy in place to make that easier for them is really important.”


  1. Brenneman A, Fenton E. “Maximizing the Patient Encounter: Strategies to Provide Excellent Patient Education.” Presented at: AAPA 2015. May 23-27, 2015. San Francisco, California.