Guest Author: Megha Shah Fitzpatrick, MD, pediatric intensivist, MGUH
Breaking bad news is a core competency in clinical communication and a skill physicians must repeatedly employ throughout their careers. This task carries a significant emotional burden, with clinicians often feeling anxious, fearing negative judgment, worrying about saying the wrong thing, and feeling a strong sense of responsibility for patient outcomes. Despite its importance, fewer than 10% of clinicians say they receive formal training in delivering bad news, and only 32% have regular chances to observe these conversations during training. Lack of preparation may lead to avoiding discussions about prognosis or medical errors, or accidentally conveying unwarranted optimism. These gaps emphasize the need for intentional, continuous, skills-based communication training in undergraduate and graduate medical education.
In 2000, Baile et al. introduced the SPIKES protocol, a widely adopted six-step framework (Setting, Perception, Invitation, Knowledge, Empathy, and Summary) to help learners deliver serious news. Since then, this model has evolved into the S-P-w-ICE-S framework, which builds on SPIKES by providing twelve practical strategies for navigating difficult conversations. Links to both references are included below. Additionally, the Vital Talk Tips app offers concise, evidence-based guidance for high-stakes clinical communication, including delivering serious news, facilitating goals-of-care discussions, and managing emotionally charged situations. Summaries of the SPIKES and S-P-w-ICE-S frameworks are provided below.
Setting Up the Conversation
Start by preparing yourself: reflect on your emotions, assumptions, information gaps, and possible challenges, then decide on a strategy before entering the room. Learn about the patient’s preferences and communication style so you can adapt how you deliver the news. Arrange the space by ensuring privacy, reducing interruptions, sitting down, involving support persons if desired, and being fully present.
Assess the Patient’s Perception (“Before you tell, ask”)
Before sharing medical findings, ask open-ended questions to understand what the patient already knows and believes about their situation, such as, “What have you been told so far?” or “What is your understanding of what’s happening?” This helps identify misconceptions and gaps in information, allowing you to adjust the amount of detail, language, tone, and pace. Ask how much information they want, knowing that some patients prefer full details while others prefer broad strokes.
Warning Shot and Pause
Signal that difficult news is coming with a brief, clear statement such as, “I’m afraid I have some hard news.” Follow this with a short pause to allow the patient time to emotionally prepare before continuing.
Provide Information and Check Understanding
Share information in simple, clear language, avoiding medical jargon. Deliver the news in small steps, pausing frequently to allow questions, silence, and emotional responses. Adjust your pace based on the patient’s reactions, and check understanding throughout to ensure the information is being absorbed.
Respond with Empathy
Acknowledge and name emotions as they arise. Patients may respond with silence, disbelief, tears, denial, or anger. Allow space for these reactions and resist the urge to fill quiet moments. Your calm presence and validation of feelings often matter more than finding the perfect words.
Strategy and Summary
Before proceeding, ask if the patient feels ready to discuss a plan. Explore their goals and priorities, then develop a collaborative strategy and highlight what remains possible. Summarize the main points, confirm understanding, provide written information when possible, and schedule follow-up. Finally, address whether the patient would like support in sharing the news with family members, as this is often a major source of distress.
Key Principles
Breaking bad news is a process, not a single moment. Emotions come before information. Empathy is a clinical skill. Patients should be active partners in decisions, and clinicians benefit from structure during emotionally challenging conversations. Throughout the encounter, strive to be fully present by minimizing distractions, setting aside competing demands, and acknowledging uncertainty honestly when it exists. Simple presence, attentiveness, and humility can be as therapeutic as any words.
To learn more, check out these great resources:
Vital Talk Tips App
