PLAB 2 Breaking Bad News Station: SPIKES Framework, Empathy & Free Practice

Hold these differentials in your head

Bracket the deadly causes first. If you fail to consider any of these in your reasoning out loud, the clinical-management domain will suffer.

• Cancer diagnosis - solid tumour
  The most common breaking-bad-news scenario in PLAB 2. The exam may use bowel, breast, lung, prostate or pancreatic cancer. The framework is the same - SPIKES throughout.
• Cancer relapse or progression
  Telling a patient that previously treated cancer has come back or progressed. Often more emotionally loaded than the original diagnosis - the patient has already been through one course of treatment.
• HIV diagnosis disclosure
  Sharing a positive HIV result. Carries unique psychosocial and confidentiality considerations - partner notification, occupational implications, stigma.
• New diagnosis of life-changing chronic disease
  Multiple sclerosis, type 1 diabetes, motor neurone disease, dementia, end-stage renal failure. Same framework, with extra time spent on long-term implications.
• Sudden death of a relative
  Telling a family member that someone they love has died, often unexpectedly. Setting and pace matter even more; the framework still helps.
• Genetic or inherited diagnosis
  Sharing a diagnosis that has implications for siblings or children. Brings consent and confidentiality issues - whether to encourage family testing, how to discuss the family.
• Loss of pregnancy or stillbirth
  Confirming miscarriage, fetal demise or stillbirth. One of the highest-distress scenarios; warmth and time are the entire mark scheme.

Step-by-step approach

This is the structure that scores. You do not need to follow it verbatim, but every numbered block below maps to a cluster of marks in the rubric.

1. 1. Setting - prepare the environment

   The S in SPIKES. Verbalise the setup even if the cubicle is simulated.

   • Quiet, private room - no interruptions, phone off.
   • Sit down at the patient's level - not standing over them.
   • Offer water and tissues within reach.
   • Ask who, if anyone, the patient would like in the room - and offer to wait for them.

2. 2. Perception - what does the patient already know

   The P in SPIKES. Start here, before you tell them anything.

   • "Before I share the results, can I ask - what have you been told so far?"
   • "What do you understand about the tests we did?"
   • "What were you expecting today?"
   • Listen for what they suspect - many patients have already worked it out.

3. 3. Invitation - how much do they want to know

   The I in SPIKES. Some patients want all the detail. Some do not.

   • "Some people want all the details upfront, others prefer one step at a time. What would be most helpful for you?"
   • Respect their answer and adapt accordingly.
   • Most patients will say they want to know everything.

4. 4. Knowledge - the warning shot, then the news

   The K in SPIKES. Give a brief warning, then say the word clearly.

   • Warning shot: "I'm afraid the news isn't what we hoped for."
   • Brief pause - lets them prepare.
   • Deliver the diagnosis plainly: "The biopsy from your colonoscopy showed that this is cancer - colon cancer."
   • Use the word "cancer" out loud. Euphemising ("a growth", "something nasty") is marked as a fail.
   • Stop talking. Do not narrate through the moment.

5. 5. Empathy - tolerate the silence

   The E in SPIKES, and the highest-graded interpersonal block. This is where most candidates lose marks.

   • Stay quiet. The pause might last 10-15 seconds. Do not fill it.
   • When they speak, acknowledge: "I'm so sorry. I can see this is a lot to take in."
   • Offer tissues, water, a moment.
   • Do not jump to next steps until the patient is ready.

6. 6. Address their concerns - ICE in real time

   Let the patient lead. Common concerns include prognosis, treatment, family.

   • "What is going through your mind right now?"
   • "Is there anything in particular you are worried about?"
   • Common concerns: colostomy bag, chemotherapy, dying, telling family, work, dependants.
   • Respond to their concern first, not the medical agenda.

7. 7. Strategy - explain the plan, chunked

   The S in SPIKES. Small chunks, check understanding between each.

   • Stage in plain English: "The CT scan suggests it is in the bowel and a few nearby lymph nodes but has not spread to other organs."
   • Treatment: "The team recommends an operation to remove the section of bowel, then we'll see if you need chemotherapy."
   • MDT context: "A team of specialists has already discussed your case."
   • Pause and check after each chunk: "How are you doing? Is that making sense so far?"

8. 8. Handle the prognosis question honestly

   "How long do I have?" is the question candidates fear most. The mark scheme is clear: be honest without being cruel.

   • Do not give specific survival percentages.
   • Do not say "don't worry, we'll cure this" - false reassurance is a safety-critical fail.
   • A workable line: "It's hard to give a precise answer until we know more about how it responds to treatment. The team can give you a clearer picture once the surgery is done."
   • Acknowledge the underlying fear: "I can see this is the question that weighs most. We will talk about it again as we know more."

9. 9. Practical support and resources

   Lifts the management band and shows the patient you are not abandoning them.

   • Offer a clinical nurse specialist or Macmillan nurse contact.
   • Offer written information - leaflets, Macmillan website.
   • Address dependants: carer support, social services if they care for someone.
   • Suggest bringing a partner or family member to the next appointment.

10. 10. Close - summarise, invite questions, follow up

    End with clarity. Do not let the patient leave with nothing in their hands.

    • Summarise what you have discussed in two or three sentences.
    • Explicitly invite any other questions: "What else can I answer for you today?"
    • Confirm follow-up - when, with whom, in what setting.
    • Offer a way to contact the team between appointments.
    • Thank them, acknowledge their courage in coming today, close.

Common pitfalls

• Not using the word "cancer" (or the honest equivalent) - this is a safety-critical fail in the station.
• Talking through the silence after delivering the news. The pause is the empathy.
• Giving false reassurance like "don't worry, we'll cure this" or quoting a survival percentage - another safety-critical fail.
• Using unexplained jargon - "adenocarcinoma", "T3 N1 M0", "anterior resection" - without translating.
• Rushing to the management plan before addressing the patient's emotional reaction.
• Ignoring the patient's specific concerns (the wife with dementia, the colostomy fear, the chemotherapy worry).
• Forgetting to offer practical support - clinical nurse specialist, Macmillan, written information.
• Closing without explicitly inviting further questions.

Frequently asked questions