Ethics, communication and palliative care

Breaking bad news (SPIKES)

Reviewed Nov 2026·3 references
New· views rounded down, updated weekly

A six-step structure for giving serious news to patients and families in the ICU, with language that works in Indian settings.

Definition
SPIKES: Setting, Perception, Invitation, Knowledge, Emotions (Empathy), Strategy and Summary. It structures the conversation so that information is given at the family's pace and emotions are acknowledged before plans are discussed.

At the bedside

  1. 1

    Setting

    Private room, sit down, phones silenced, nurse present, key family decision-makers invited; interpreter if needed (not a child relative).

  2. 2

    Perception

    Ask what they already understand: 'What have the doctors told you so far?'

  3. 3

    Invitation

    Ask how much detail they want and who should receive information.

  4. 4

    Knowledge

    Warning shot ('I am afraid I have serious news'), then plain language in short chunks; avoid jargon and euphemisms; pause.

  5. 5

    Emotions

    Name and acknowledge emotion ('I can see this is a shock'); allow silence; respond with empathy before giving more facts.

  6. 6

    Strategy and summary

    Summarise, check understanding, agree the next step and time of the next update; document the conversation.

Useful phrases

Instead ofTry
'There is nothing more we can do.''We will always care for him; the question is which treatments will help.'
'Do you want us to do everything?''What would she say about these treatments if she could speak to us?'
'Withdrawal of care''Stopping treatments that are not helping, while continuing comfort care'
'He is critical.''He is very sick and could die in the next few days despite everything we are doing.'
Red flag · call your senior now
Serious news delivered by phone or in a corridor by a junior doctor without preparation - arrange a structured meeting as soon as possible.
Pitfall
Giving statistics and options before checking understanding and emotion.
Pitfall
Using medical jargon ('multi-organ dysfunction', 'poor prognosis') without explanation.
Pearl
Silence after the news is a tool, not a failure - wait for the family to speak.

References

  1. 1

    Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES - a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5:302-11.

  2. 2

    Davidson JE, Aslakson RA, Long AC, et al. Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Crit Care Med 2017;45:103-28.

  3. 3

    Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med 2014;370:2506-14.

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Family meetings and shared decision-making

Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.