Breaking Bad News Stations

SPIKES Framework

1. S — Setting: private room, sit at same level, tissues available, introduce yourself, ask if they want anyone with them
2. P — Perception: "What do you understand so far?" "What have you been told about your results?" — assess baseline knowledge
3. I — Invitation: "Would you like me to explain the results?" "How much detail would you like?" — respect autonomy
4. K — Knowledge: deliver information in clear, simple language; use "warning shots" ("I'm afraid the news is not what we were hoping for"); avoid medical jargon; give information in small chunks; pause frequently
5. E — Emotions: acknowledge emotional response ("I can see this is very upsetting"); name the emotion; allow silence; offer tissues; do NOT rush to "fix" the emotion
6. S — Strategy and Summary: outline next steps; provide written information; arrange follow-up; ensure they have support; check understanding ("Is there anything you'd like me to go over again?")

Common MRCOG Part 3 Scenarios

• Fetal abnormality (e.g. trisomy 21 on amniocentesis, severe structural abnormality on anomaly scan)
• Cancer diagnosis (e.g. cervical cancer, ovarian cancer, endometrial cancer)
• Stillbirth / intrauterine death (explaining diagnosis and options for delivery)
• Miscarriage (including missed miscarriage — "the pregnancy has stopped developing")
• Poor prognosis (e.g. advanced cancer, inoperable condition)
• Unexpected intraoperative finding (e.g. ovarian cancer found at surgery)

Key Communication Skills

• Empathy statements: "I can see this is very difficult for you"; "I'm sorry to have to tell you this"; "It's completely normal to feel this way"
• Active listening: maintain eye contact (culturally appropriate), nod, use verbal encouragers ("I understand", "Go on")
• Avoid: minimising ("At least..."), false reassurance ("I'm sure everything will be fine"), overwhelming with information, using euphemisms that obscure meaning
• Silence: allow pauses after delivering difficult information; do not fill silence unnecessarily
• Check understanding: "Can you tell me in your own words what you've understood?" "Do you have any questions?"

Key Points Examiners Mark

• Establishes rapport and introduces self
• Assesses prior knowledge before delivering news
• Uses a "warning shot" before bad news
• Delivers information clearly without jargon
• Responds to emotions with empathy (not medical facts)
• Allows silence and does not rush
• Discusses next steps and offers follow-up
• Provides written information / support resources
• Checks understanding before ending
• Offers to speak again / provides contact details

Documentation Requirements

• Record the discussion in medical notes
• Document who was present
• Note the patient's response and any questions asked
• Record agreed plan and follow-up arrangements
• Ensure referral to appropriate support services (e.g. bereavement midwife, Macmillan nurse, ARC for fetal abnormality)

Common Pitfalls

• Jumping straight to the bad news without assessing perception first
• Using medical jargon ("There's a trisomy" instead of "The test shows the baby has Down syndrome")
• Providing too much information at once — overwhelming the patient
• Failing to acknowledge emotions — moving to "next steps" too quickly
• Offering false hope or reassurance when inappropriate
• Not checking understanding at the end
• Forgetting to offer written information and follow-up
• Not addressing the patient's specific concerns/questions

Clinically reviewed by NHS obstetricians and gynaecologists

MRCOG AI is an independent educational tool. It is not affiliated with, endorsed by, or connected to the Royal College of Obstetricians and Gynaecologists (RCOG).