Journal of Current Emergency Medicine Reports


Use of Spike’s Protocol in Emergency and Intensive Care Unit While Breaking the Death News to The Patient’s Attendant in A Tertiary Care Hospital in New Delhi

Priya Govil1, Surjeet Acharya2*ORCID ID and Kishalay Datta3

1Senior Consultant, Emergency Medicine, Max Super Speciality Hospital, Shalimar Bagh, Delhi

2Post Graduate trainee, Emergency Medicine, Max Super speciality Hospital, Shalimar Bagh, Delhi

3Director and HOD, Emergency Medicine, Max Super Speciality Hospital, Shalimar Bagh, Delhi

*Corresponding Author: Acharya S, Post Graduate trainee, Emergency Medicine, Max Super speciality Hospital, Shalimar Bagh, Delhi. E-mail:

Citation: Govil P, Acharya S, Datta K. Use of Spike’s Protocol in Emergency and Intensive Care Unit While Breaking the Death News to The Patient’s Attendant in A Tertiary Care Hospital in New Delhi. Journal of Current Emergency Medicine Reports. 2022;2(2):1-4.


Copyright: © 2022 Acharya S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received On: 2nd March,2022     Accepted On: 8th April,2022    Published On: 18th April,2022


Declaring the news of death of loved ones is the most difficult and stressful part faced by a healthcare professional. This requires patience, good communication skills, and empathy. The bad news can be delivered in various ways but the most common method used in this study is SPIKES protocol. In this study we aim to discover the use of SPIKES protocol by healthcare professionals especially Emergency room and Intensive care units.

Keywords: SPIKES protocol; patient; Intensive Care Unit


The SPIKES protocol is a six-step process used to deliver the bad news in healthcare setup. The “Bad news” is any news that negatively affects and alters the life of patients or their family members [1]. The SPIKES protocol was first established by three doctors in the ontological field namely Dr. Robert Buckman, Dr. Micheal Levy, Dr. Walter Baile in the year 1998.  The paper was published in 2000 under Dr Baile’s name.

The main approach in the study was “before you say, you ask”. In this study, we used questionnaires prepared after detailed review of literature and the questionnaire was distributed to the healthcare professionals of the Emergency room (ER) and Intensive care unit (ICU) including the doctors and nursing staff in a tertiary care hospital, Delhi.

Review of Literature

Breaking the bad news is a team approach task which can be managed successfully if it is done correctly [2]. Breaking the bad news to the family needs specialized skills on the part of the clinicians, nursing care and other people involved in the care of the patient.

Unfortunately, there is very poor guidance on the approach for this very sensitive work field [3]. A well-trained highly specialized and educated doctor in this field will have a better knowledge to handle the daunting task of breaking the bad news [4]. It is high time now to include this subject into the undergraduate medical curriculum.

                In general, apart from the diagnosis of the patient, death can also take place in hospital majorly under two circumstances. The first and most common is the natural death of the person, where the patient’s relatives are aware of the poor prognosis and natural death is expected. The second situation is the sudden and unexpected death. In the first instance, relatives are mentally aware of the final outcome and it is relatively easy to declare such deaths as and when they occur [5]. But, when death occurs unexpectedly and suddenly, it is difficult to cope with the bad news. It is difficult for the relatives to believe the sudden loss of their loved ones. In this situation, the relatives will become very sensitive and emotionally charged [6]. In this situation, if there is any lack of compassion and kindness by the healthcare team, it may trigger violent grief reactions, and the anger may be directed towards the hospital staff.

The relatives perceive sudden death may show one of the following grief reactions:

  • Initial shock
  • Denial
  • Anger
  • Guilt

When an inpatient becomes seriously ill in the hospital, the caregiver team tries their best to save the patient’s life. However, all these efforts take place behind the closed doors of the ER or ICU. It is very important to brief the relatives about the efforts being taken to save the life of their relative. Else, this may cause serious doubts in the minds of the relatives about the ongoing situation and circumstances, which lead to the death of their beloved one. The health care team must make use of the limited time available to prepare the relatives mentally for the bad news. This short vital communication gives the relatives some time to cool their nerves and prepare themselves for the bad news. Hospitals across the globe and the subcontinent have adopted various protocols and guidelines to break the sad news and providing emotional and empathetic support to the patient’s family to cope with the loss and the unexpected death of a loved one. [6,15,16].

There are various guidelines for breaking the bad news to the patient’s relatives, the most popular one is the SPIKES protocol [1], which we use in this study article.


The study was done in a tertiary care corporate hospital in New Delhi.

Inclusion criteria:

All the healthcare professionals working in the ER and ICU of hospital (Max Super speciality hospital, Shalimarbagh, New Delhi)

Exclusion criteria:

People not willing participation / filling questionnaire for the study

The study questionnaire is developed after detailed review of studies done in similar settings [1]. All the data was collected from healthcare personnels (doctor and nurse). A structured questionnaire was made and given to participants for recording their responses online or in person. The study questionnaire used can be seen by the link below:


The study included a total of 100 active participants across the Emergency and ICU departments of our hospital. The study had no separate list for ICU and Emergency team and was counted in one list. Majority of participants were female (68) when compared to male (32). The experience of the clinical staff varied from 1-5 years and fresher also. Shockingly, only 52% of the participants knew about the SPIKES protocol, its application and use and adequate details about it. Very small percentage of people in this study knew the exact alphabetic meaning of “S-P-I-K-E-S” in SPIKES protocol.


The SPIKES protocol study has been the first study to be carried out in the ER and ICU in the state capital. Therefore, we conducted a survey based on the items of the SPIKES protocol and asked the healthcare professionals whether they used the SPIKES protocol while delivering the bad news to the patient relatives. This protocol has been in literature for long time now but its application for breaking the bad news is at least followed in the state capital and other regions of the country (best to my knowledge). The SPIKES protocol uses 6 steps in breaking the bad news to patients or relatives. They are – (1) Setting up for the interview, (2) assessing the Perception of the patient and attendants, (3) Inviting patient and attendants for discussion, (4) Knowledge impartment to the patient and relatives, (5) Emotional and empathic support (6) Summarizing.  

This study suggests the overall quality of breaking bad news thus emphasizes the importance for a high-quality communication process in bad-news delivery among the ER and ICU Healy professionals. The lack in proper training appeared to play the major role leading to this problem, as many of respondents not only had any didactic training but also did not have any significant opportunity to gain experi- ence by observing other clinicians breaking the bad news.

Several papers have demonstrated that communication skills can be taught and can be retained [8,9,10,11]. The SPIKES protocol for breaking the bad news is a specialized form of skill training for physician-patient communication, which is employed for enhancing communication skills in all medical settings [12]. Most medical undergraduate and postgraduate programs do not usually offer specific training in breaking bad news [13].  Various studies have shown that the SPIKES protocol in combination with experimental techniques such as role play, has increased the confidence of the faculty and the fellows in applying the SPIKES protocol [8]. Various undergraduate teaching experiences also showed that the protocol increased medical students’ confidence in formulating a plan for breaking bad news [14].


Our study has revealed that the healthcare professionals are not very familiar with the usage of SPIKES protocol for breaking the bad news. Lack of knowledge and clinical application is a common reason. Also, the need for separate counselling rooms are required for making this procedure more smooth and safe for the healthcare professionals to avoid any unwanted aggression from the patient’s relatives. More exposure and knowledge of the healthcare professionals for using SPIKES protocol is required both at undergraduate level and at regular intervals during the course of practise. Evaluation of the SPIKES protocol is sparse and insufficient and incomplete, and further studies are needed.

Source(s) of support

Tintinalli’s textbook of Emergency Medicine, Google search engine, Institute’s Library.

Conflict of Interest

There is no conflict of interest to declare. This article was written without any sponsorship and so the authors have no financial disclosures.

Abbreviations Used

ER – emergency room

ICU – intensive care units


  1. Buckman R. Breaking Bad News: A guide for Health Care Professionals-Johns Hop. 
  2. Barnett MM, Fisher JD, Cooke H, James PR, Dale J. Breaking bad news: consultants’ experience, previous education and views on educational format and timing. Medical education. 2007 Oct;41(10):947-56. 
  3. Cook P, White DK, Ross-Russell RI. Bereavement support following sudden and unexpected death: guidelines for care. Archives of Disease in Childhood. 2002 Jul 1;87(1):36-8. 
  4. VandeKieft G. Breaking bad news. American family physician. 2001 Dec 15;64(12):1975. 
  5. Kent H, McDowell J. Sudden bereavement in acute care settings. Nursing Standard. 2004 Oct 20;19(6). 
  6. Williams AG, O’Brien DL, Laughton KJ, Jelinek GA. Improving services to bereaved relatives in the emergency department: making healthcare more human. The Medical Journal of Australia. 2000 Nov 1;173(9):480-3. 
  7. Fallowfield L, Jenkins V. Communicating sad, bad, and difficult news in medicine. The Lancet. 2004 Jan 24;363(9405):312-9. 
  8. Baile WF, Lenzi R, Kudelka AP, Maguire P, Novack D, Goldstein M, Myers EG, Bast Jr RC. Improving physician—patient communication in cancer care: outcome of a workshop for oncologists. Journal of Cancer Education. 1997 Sep 1;12(3):166-73. 
  9. Baile WF, Kudelka AP, Beale EA, Glober GA, Myers EG, Greisinger AJ, Bast Jr RC, Goldstein MG, Novack D, Lenzi R. Communication skills training in oncology: description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness. Cancer: Interdisciplinary International Journal of the American Cancer Society. 1999 Sep 1;86(5):887-97. 
  10. Maguire P, Fairbairn S, Fletcher C. Consultation skills of young doctors: I–Benefits of feedback training in interviewing as students persist. Br Med J (Clin Res Ed). 1986 Jun 14;292(6535):1573-6. 
  11. Vaidya VU, Greenberg LW, Patel KM, Strauss LH, Pollack MM. Teaching physicians how to break bad news: a 1-day workshop using standardized parents. Archives of pediatrics & adolescent medicine. 1999 Apr 1;153(4):419-22. 
  12. Keller VF, Carroll JG. A new model for physician-patient communication. Patient Education and Counseling. 1994 Jun 1;23(2):131-40. 
  13. Tulsky JA, Fischer GS, Rose MR, Arnold RM. Opening the black box: how do physicians communicate about advance directives? Annals of internal medicine. 1998 Sep 15;129(6):441-9.
  14. Garg A, Buckman R, Kason Y. Teaching medical students how to break bad news. Cmaj. 1997 Apr 15;156(8):1159-64. 
  15. Dubin WR, Sarnoff JR. Sudden unexpected death: intervention with the survivors. Annals of emergency medicine. 1986 Jan 1;15(1):54-7. 
  16. Walters DT, Tupin JP. Family grief in the emergency department. Emergency medicine clinics of North America. 1991 Feb 1;9(1):189-206.




Call for Papers

Journal of Current Emergency Medicine Reports