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  1. Understanding PLAB 2: The Foundation Course
  2. /
  3. Module 3: Difficult Conversations

Understanding PLAB 2: The Foundation Course

Course Progress
0 of 45 lessons completed (0%)
Module 1: Understanding PLAB 2
4
Module 2: The Consultation Toolkit
9
Module 3: Difficult Conversations
6
Module 3 Introduction
Lesson 3.1: Breaking Bad News: SPIKES and Bereavement
Lesson 3.2: Delivering Unwanted Results and Chronic Diagnoses
Lesson 3.3 : Counselling Stations: Understanding Before Explaining
Lesson 3.4 : Angry Patients, Difficult Relatives, and Self-Discharge
Lesson 3.5: Communicating with Relatives and Third Parties
Module 4: Ethics and Professionalism
9
Module 5: Examination Stations
8
Module 6: Procedures, Emergencies, and Prescribing
9

Lesson 3.1: Breaking Bad News: SPIKES and Bereavement

Module 3: Difficult Conversations

Lesson 3.1: Breaking Bad News — SPIKES and Bereavement

SPIKES is the standard framework for delivering serious news. It works across cancer diagnoses, terminal prognoses, unexpected test results, and any situation where the patient is about to hear something that will change their life. The goal is not to soften the blow beyond recognition, it is to deliver truth with humanity.

LetterStepWhat to Do
S Setting Up Before you begin: ensure privacy, close the door. Sit down — standing signals you are about to leave. Remove physical barriers where possible. Offer a support person if available. Minimise interruptions: 'I've set aside this time for you.'
P Perception Find out what the patient already knows before you say anything. "Before I share the results, could you tell me what you've been told so far, and what you've been thinking might be going on?" This tells you: how much they already know, what they are expecting, and how much the news will be a shock.
I Invitation Check that the patient is ready and willing to receive the information. "I have the results back and I want to make sure we go through them properly. Would it be okay if I explained what we've found? I want to be completely honest with you." Most patients say yes. Some say 'I'd rather not know right now' — explore this preference and do not pressure them.
K Knowledge Deliver the news. Use a warning shot, then be clear. "I'm afraid I have some difficult news to share with you." Then pause, give the patient a fraction of a second to brace. Say 'cancer' if that is the word. Ambiguity is not kindness — 'a shadow' or 'a growth' leaves patients more anxious, not less. Give the headline, then stop. Let the patient absorb it before saying more.
E Emotions After delivering the news, stop. Wait. The patient will have a reaction. Your job is to respond to the emotion before moving to the plan. Silence is powerful — count to 5 if you have to. Resist the urge to fill the space. If the patient cries: 'Take your time. I'm not going anywhere.' If the patient is angry: acknowledge without becoming defensive. If they ask 'How long do I have?': be honest about uncertainty. Give a range if you have one. Never say 'nothing more can be done' — there is always something: comfort, support, time.
S Strategy & Summary Once the initial emotional response has settled, even partially, move to next steps. What will happen next? When will they hear? Who is their point of contact? Offer written information. Offer a follow-up appointment specifically to address questions. Signpost support: Macmillan Cancer Support, Samaritans, or relevant disease-specific charity. Safety-net: 'If you feel overwhelmed before your next appointment, please call us or go to your GP.'

SPIKES in Three Common PLAB 2 Scenarios

ScenarioKey FocusAvoid
New cancer diagnosis Patient may not suspect — shock reaction likely. Focus heavily on the E step. End with clear, specific next steps. Do not give a prognosis unless you have staging information: 'We need to do more tests first.'
Terminal prognosis Patient may already know and want clarity. Give a time range if asked. Explore what matters to them now. Never say 'nothing can be done.' Pivot to quality of life, symptom control, and support.
Unexpected HIV diagnosis Shame and stigma are common. Normalise from the outset: 'HIV is a medical condition, not a judgement.' Partner notification must be explored sensitively. Discuss partner notification as a possibility, not a demand. Do not immediately threaten confidentiality breach.

Do not rush to explain a finding you have no information about. Arrange a proper appointment rather than delivering this in a rushed encounter. Be honest about what you know and do not know: 'We've found something that needs further investigation — I don't have enough detail yet, but I want you to know about it and I'm going to arrange the right review.'

Bereavement — Telling a Relative Their Loved One Has Died

Telling a relative that a patient has died is one of the most significant things you will do as a doctor. The approach here is for when the relative does not yet know.

  1. Invite to a private room. Never deliver this in a corridor. Introduce yourself and confirm your role.
  2. Confirm the relationship: "Could I check your relationship to Mr Davies?"
  3. Warning shot: "I'm afraid I have some very difficult news for you."
  4. Deliver clearly: "I'm so sorry to tell you — Mr Davies died at 2:15 this afternoon."
  5. Pause. Allow the news to land fully. Respond to whatever emotion comes — do not immediately move to explanation.
  6. Acknowledge: "I'm so sorry for your loss."
  7. Explain what happened — what was the clinical course, what was done, what could not be prevented. Use plain language.
  8. Practical matters (gently, once the immediate shock has settled): viewing the body, coroner referral if applicable, death certificate, chaplaincy or bereavement support.

Use 'died' in your opening statement, not 'passed away'. 'Passed away' is so softened that relatives sometimes do not register that a death has been communicated. You may say 'passed away' in subsequent conversation as comfort language, but the initial delivery must be clear.

Specific Bereavement Scenarios

ScenarioKey Points
Unexpected death in A&E The relative may not have known the patient was ill. Explain the sequence of events simply. Acknowledge the shock. Offer to let them see the body — this is important for the grief process.
Coroner referral Required for: sudden unexplained death, violent or unnatural cause, following an accident, in custody, or where cause is unknown. Explain: 'Because the death was unexpected, we are required by law to refer to the coroner. This is standard practice and does not mean anything went wrong. A post-mortem may be needed — you will be kept informed at every step.'
Stillbirth or neonatal death Use the baby's name if the parents have given one. Acknowledge the baby as a person, not a clinical event. Offer time with the baby. Do not offer explanations or reassurances prematurely — listen first. Offer SANDS referral. Explain that a post-mortem may help understand why this happened.