Table 1.

Patients' Need to Know and to Feel Known: An integrated SPIKES Model of Breaking Bad News^* and NURSE^† Model of Empathy Expression

Component	Need to Know	Need to Feel Known
SPIKES/NURSE
Setting	Analyze key medical information (pre-meeting) and discuss it, if needed, with other medical providers who have been involved in the patient's care.	Analyze key personal information (pre-meeting) and discuss it, if needed, with other medical providers who have been involved in the patient's care.
	Invite key family and interdisciplinary medical team players (pre-meeting).
	Arrange proper physical setting (quiet, private room with adequate seating, tissues, and water).
	At meeting start, address the agenda/meeting goals.	At meeting start, sit down and make introductions.
Patient perception/perspective	“I have already reviewed all of the medical information, but please tell me what the doctors have already told you about what's going on.”	“I know all the medical details, but tell me more about who you were before this illness and how this has affected you and your loved ones.”
	“What is your understanding of the current medical situation?”
Invitation/information	“Would it be okay if I shared the medical information with you?”
	“Some people prefer very detailed information, others prefer to hear only the rough picture, and then there are those in the middle. What kind of person are you?”
Knowledge	If appropriate, fire warning shot eg, “I'm afraid I have some bad news.” or “Unfortunately the tests did not reveal what we hoped they would.”
	Avoid medical jargon or too much all at once, check in frequently, and speak clearly but sensitively.	Recognize the difficult nature of receiving bad news, use silence after breaking bad news.
	“Given what's happened medically and what your perspectives and goals are, I would recommend …”
Empathize/explore emotions
Empathy/NURSE†
Name emotion		“You seem very upset by the news.”
		“You seem quiet. Can you tell me what you are feeling?”
Understand		“I can't imagine how difficult this news must be for you.”
		“Your reaction to news like this is completely natural.”
Respect		“You've done such a good job of coping thus far with the situation.”
		“You've shown a lot of courage in talking about/coming to grips with the situation.”
Support		“I wish things were different.”
		“No matter what happens, we are going to be here to support you and your family through this.”
Explore emotion		“We've just discussed a lot. Tell me more about what you are feeling right now.”
		“What are your most pressing concerns?”
Strategize/summarize	“What questions do you have?”
	Reiterate availability of team to field additional questions/concerns.
	Summarize the next steps and appointments.
	Ensure appropriate follow-up and delivery of contact information.

NOTE. The concrete examples provided are meant to be neither exhaustive nor prescriptive but can serve as useful guides for both clinical practice and teaching. All components need not be used in one conversation, nor should they always proceed in this order. In particular, empathizing may be necessary more than once and at any time during an encounter. Finally, these steps are often best used as part of an ongoing relationship-building process instead of a one-time event. Interested readers might also benefit from the work of Baile et al,²⁵ Pollak et al,²⁸ Back et al,²⁷ Saraiya et al,³¹ and Campbell et al³² for examples on the SPIKES and NURSE methods.

^*Adapted from Baile et al.²⁵

^†Adapted from Pollak et al.²⁸ and Back et al.²⁷