Table 2.

The Six-Step Buckman Protocol (SPIKES) (Adapted from [22, 23])

STEP	DESCRIPTION
Setting up	Be prepared for bad news conversations: find a private space, introduce oneself, involve significant others, sit down, manage interruptions.
Patient Perception	Assess the patient’s perception of the situation and what he/she already knows and wants to know in order to tailor the bad news communication to the patient’s level, correct any misinformation and determine the patient’s understanding and/or denial.
Invitation	Assess how much information the patient wants to know and seek the patient’s willingness before sharing. If patients do not want to know the details, offer to be available and answer any questions as they may arise in the future. Determine the bare minimum of information that is necessary to share and begin by focusing on that.
Knowledge	Before informing the patient, signal the patient that bad news is about to be conveyed. When sharing information, avoid medical jargon and excessive bluntness; provide information in small chunks and periodically check the patient’s understanding; repeat information several times.
Emotions	Respond to the patient’s emotional responses (shock, disbelief, anger and/or grief). Let the patient express his or her feelings; offer support by naming the patient’s emotions and normalizing such feelings. Use empathic response also to acknowledge the clinician’s own emotions.
Strategy and Summary	Summarize the main points and, if the patients are ready, discuss the treatments options available or follow-up plans. Frame the information and future hope in terms of what it is most meaningful to the patient and still possible to accomplish.