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Framework models for communicating serious news to patients and their families

Framework models for communicating serious news to patients and their families
SPIKES[1] ABCDE[2] GUIDE[3] BREAKS[4] Serious illness conversation guide[5]
S: Setting up the interview—arrange for privacy, sit down, manage interruptions. A: Advance preparation—arrange a time, ask about a support person being present, ask what the patient knows. G: Get ready—gather info, set up privacy and a quiet location, find out who needs to be there. B: Background, knowing the background of the patient/family and the clinical problem. 1. Set up the conversation
  • Introduce purpose
  • Prepare for future decisions
  • Ask permission
P: Assessing the patient's Perception—ask open-ended questions about how the patient perceives the medical situation. B: Build a therapeutic environment/relationship—arrange a private, quiet place, reassure about suffering and non-abandonment. U: Understand—ask the patient what they already know, then listen. R: Rapport, build rapport, provide ample space and time. 2. Assess understanding and preferences
I: Obtaining the patient's Invitation—how would the patient like the information disclosed. C: Communicate well—be direct, avoid jargon, allow for silence. I: Inform—deliver the news in a single sentence, then listen. E: Explore, start with what the patient knows. Involve other family or support as per the patient's preference. 3. Share prognosis
  • Share prognosis
  • Frame as a "wish…worry," "hope…worry" statement
  • Allow silence, explore emotion
K: Giving Knowledge and information to the patient—use nontechnical words and give information in small chunks. D: Deal with patient and family reactions—assess patient reactions, listen actively, explore feelings, express empathy. D: Deepen—observe and respond to emotions by acknowledging them; can give silence if the patient has turned away. A: Announce, give a warning shot, then deliver the news using straightforward language. 4. Explore key topics
  • Goals
  • Fears and worries
  • Sources of strength
  • Critical abilities
  • Tradeoffs
  • Family
E: Addressing the patient's Emotions with empathic responses—observe for emotion, identify it and its reason, let the patient know you've made this connection. E: Encourage and validate emotions—correct distortions, evaluate the effect of the news, address further needs, arrange follow-up. E: Equip—map out the next steps. Describe treatment options if you can. K: Kindling, address emotions as they arise. 5. Close the conversation
  • Summarize
  • Make a recommendation
  • Check in with patient
  • Affirm commitment
S: Strategy and Summary—discuss the plan going forward and summarize the discussion.     S: Summarize, give a summary of the session and set up treatment/care plans. 6. Document your conversation
        7. Communicate with key clinicians
  1. Baile WF, Buckman R, Lenzi R, et al. SPIKES—a six-step protocol for deliver bad news: application to the patient with cancer. Oncologist 2000; 5:302.
  2. Rabow MW, McPhee SJ. Beyond breaking bad news: how to help patients who suffer. West J Med 1999; 171:260.
  3. Back AL. (2013) Vital Talk (1.0) [Mobile Application Software] Retrieved from
  4. Narayanan V, Bista B, Koshy C. "BREAKS" protocol for breaking bad news. Indian J Palliat Care 2010; 16:61.
  5. Serious Illness Conversation Guide (Accessed on October 16, 2017). This material has been modified by UpToDate. The original content can be found at and is licensed by Ariadne Labs under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Ariadne Labs licenses the original content as-is and as-available, and makes no representations or warranties of any kind concerning the original content or concerning this material, which Ariadne Labs has not reviewed or endorsed.
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