Breaking Bad News – SPIKES and NURSE mnemonic

spikes mnemonic


Mnemonic: IPC

  • Introduce yourself
  • Identify patient with 2 pieces of information like name and DOB
  • Infection control measures (wash hands or sanitize hands)
  • Involve significant others (establish whether the patient would like someone to be in the consultation with them)
  • Privacy must be arranged
  • Pager must be silenced
  • Consent must be taken

Perception of condition/seriousness

  • Take a brief history to identify important symptoms
  • Elicit “ICE” history (Ideas, Concerns and Expectations)
    • Accept denial but do not confront at this stage

Invitation from the patient to give information

  • Ask patient if s/he wishes to know the details of the medical condition and/or treatment
    • Accept patient’s right to not know
    • Offer to answer questions later if s/he wishes
  • To find out what your patient wants, simply ask questions like:
    • Would it be helpful for you to know what to expect from here on out with your illness?
    • Would it be OK if we talk about some serious issues with your care?
    • We have these lab tests back. Can we talk about them?

Knowledge – giving medical facts

  • Fire a warning shot, e.g. “I’m afraid the results are worrying”, “This may be serious than we originally hoped”.
  • Keep the terms simple and direct, e.g. use “cancer” instead of “growth” or “malignancy”
  • Break the news in small chunks
  • Give any positive aspects first, e.g. “cancer has not spread to lymph nodes”, “treatment is available locally”, “it is highly responsive to therapy”, etc.
  • Avoid giving false hopes, despite the need for confirmatory test
  • Give facts accurately about treatment options, prognosis, costs, etc.

Explore Emotions and Empathize

  • Identify emotions expressed, give them time to respond and allow them to express their emotions.
    • Silence – avoid the temptation to fill it, give them a few moments to respond
    • Cries – offer them tissue and allow them to express their emotions
  • Use the mnemonic “NURSE“:
    • Name: “It sounds like you are distressed”, “I wonder if you are feeling angry”
    • Understand: “If I understand what you are saying, you are worried how your treatment will affect your work”, “People going through your situation often report experiencing….. is that how you feel?”
    • Respect: “I’m impressed with how well you have handled this”
    • Support: “I’ll be with you during the treatments”, “Please let me know what I can do to help you”
    • Explore: “Can you tell me more about this?”

Strategy and Summary

  • Strategy – Give a clear plan but avoid too much technical information
    • Advise CT scan or biopsy if needed
    • Mention about treatment options
  • Ask whether they want to clarify something
    • If the patient asks how long they have to live, never give a precise answer. Ask for specific reason why they would like to know.
  • Arrange a follow-up appointment as appropriate. Offer agenda for the next meeting.
  • Leave contact details, e.g. bleep number as appropriate
  • Close consultation and thank the patient

SPIKES protocol in application



  1. DrExam Part B MRCS OSCE Revision Guide Book 2
  2. SPIKES: A Strategy for Delivering Bad News (
  3. SPIKES_Protocol_for_Breaking_Bad_News.pdf (

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