Breaking Bad News
Bad news is any type of news which will negatively impact a person’s view of the future. The type of bad news a doctor is expected to deliver includes things like: the death of a loved one; a poor diagnosis; a poor prognosis. It is important because every doctor will have to deliver bad news as part of their jobs, and so, it is important to be able to do so in a professional and appropriate manner. In this article we will explore: some information and tips we think it is useful to know beforehand; different protocols for delivering bad news; advice for handling scenarios in which bad news has to be broken. In each section you will find subsections, each with a handy summary section which describes the key information to help you retain it❗
1. What you need to know before breaking bad news
2. 10 Models you may want to follow when breaking bad news
3. Different scenarios you may encounter when breaking bad news
What you need to know before breaking bad news
Before you deliver bad news, you should be aware of the following information. This will help to prepare you and make you feel more confident❗
What are patients are entitled to❓
😕 Accurate information ✅
😕 Choose whether or not they want to hear the bad news/how much of it 👂
😕 Choose who is present for the consultation in which bad news is divulged 👫
😕 Choose who is informed about the bad news 👫
😕 The legal age of consent to medical treatment is 16, however, parents should usually be involved when the patient is under 18 👪
😕 A trained independent interpreter if there is a language barrier
A patient has the right to decide whether or not they receive bad news and how much information they wish to receive.
Examples of how different people react to bad news:
😕 Acceptance 👍
😕 Sadness 😕
😕 Shock 😲
😕 Crying 😭
😕 Concern 😔
😕 Anger 😠
😕 Asking questions
😕 Guilt 😞
😕 Helplessness 😔
😕 Misinterpretation of information
Different people can react to bad news in a range of ways, including: denial, crying, and anger for example.
😕 “Unfortunately, I have some bad news” 😕
😕 “What I am going to tell you will be difficult to hear” 👂
😕 “You are sick enough to die” 💀
😕 “You should be prepared”
😕 “This is your final journey” 💀
😕 “I am afraid I have bad news” 😕
😕 “The results were not what we had hoped for”
😕 “The test results are concerning”
😕 “I can see this is a big shock” 😲
😕 “I am sorry to tell you”
You will have to deliver bad news regularly when working as a doctor, and so, you may find it useful to have some ‘useful phrases’ which you can draw from to help you when delivering bad news.
😕 You should show the patient/relatives that you acknowledge the emotions they are displaying, and have identified the cause e.g. “I can see you are upset. I know this is not the news you were hoping for” 😔
😕 This helps to validate the emotions they are feeling
😕 If the patient/relatives display anger, you should identify whether this needs to be challenged or whether they will work through it as they process the information 😠
😕 Offer to give the patient/relatives some time in private to process their emotions ⌛
😕 Offer follow up meetings to discuss the news when they have had time to process it ⌛
You do not want the recipient to feel like a burden, and so, it is very important to show empathy when delivering bad news, to make sure the patient/relatives feel supported and respected.
😕 Patients may ask difficult questions e.g. “Am I going to die?”, “How long do I have left?” etc.
😕 The best way to answer difficult questions is to tell the truth ✅
😕 Do not give specific time frames as this is not possible. Be broad and do not lie ⌛
Difficult questions often arise when you break bad news and you should answer these honestly, but avoid giving specific time-frames. This demonstrates that the patient/relatives are in capable hands and you can even practice your answers in advance to improve your confidence.
Looking after yourself
😕 As a doctor, breaking bad news can have a significant impact on you 😔
😕 You should take your own feelings into account and seek support when required
😕 You need to balance your practical problem solving with managing your natural emotional response
😕 Acknowledge your feelings and be compassionate to yourself 🏨
Taking care of yourself and your own feelings is very important as delivering bad news can have a significant emotional toll on doctors too. There are a number of support services available for you to utilise.
How to listen successfully
- Do not interrupt the person speaking and do not speak too much: you are trying to listen to them and you cannot do this effectively if you are constantly speaking 👂
- Do not talk about yourself or your own thoughts/feelings: this is a distraction from what the person is saying or telling you ❌
- Pay attention to what they are saying: you should not be easily distracted as this will make the patient feel like a burden 👂
- Do not assume anything they have not told you: allow them to tell you what they want to, you should not jump to conclusions ❌
- Ask open-ended questions: to promote discussion rather than interrogating the person speaking with ‘yes/no’ questions
- Summarise and clarify what they have said back to them: to check you understood correctly and to show you are listening
- Do not judge the person speaking: everyone reacts differently to bad news and so judgement is inappropriate ❌
- Identify overtones/feelings: the way they say something or what they say can both reveal a lot which may support your understanding of their feelings
- Be caring: the person who is speaking will have just received bad news and will want to see a friendly face
- Be empathetic: attempt to understand how they may be feeling so you can act accordingly
- Be respectful: someone who has just received bad news is entitled to dignity when they are in an emotional state
- Be genuine: show that you really care and are genuinely listening, not just pretending to
Listening successfully requires you to be respectful and empathetic. You need to pay attention to what the patient/relatives are saying, identifying their feelings to help you ask appropriate open-ended questions, and importantly you should avoid interrupting the person speaking.
How to support bereaved people
- Encourage conversation about the deceased person(s) 💀
- Listen to them and demonstrate that you understand 👂
- Provide support and reassurance
- Be prepared for silences 👂
- Consider your own feelings, they may reflect how the bereaved person feels
- Do not take their anger personally ❌
- Do not try to ‘fix’ them ❌
Bereavement is an emotional situation, in which people often wish to vent their feelings, and as a doctor it is your job to listen to them in a respectful way to validate their feelings.
Different protocols/models for breaking bad news
There are many different protocols for you to follow when delivering bad news. Take a look at the different protocols we explain in this section and see what works for you. Whilst there is not one right way you’ll start to notice some trends which are included in all of the frameworks, showing their importance.
General tips for a doctor for breaking bad news:
- Try to reduce anxiety 😔
- Provide the important information e.g. prognosis, follow up information, treatment etc.
- Be willing to share your knowledge as they are likely to have lots of questions
- Provide support, helping them in whatever way you can 🏨
- Be sympathetic
- Assess the patient/relatives before and throughout the consultation to establish what they already know
- Match the language the patient uses to help them understand and not feel overwhelmed with medical jargon
- Prepare the patient with a ‘warning shot’ e.g. “I am afraid it is bad news” 😔
- Diagrams, drawing or leaflets may be useful to help explain the news 🏨
- Check that the patient/relatives understand what they are being told regularly
Follow these tips every time you deliver bad news to make sure you create a supportive environment and help the patient/relatives to understand the information as well as possible.
Below, we have described 10 different models you can follow when breaking bad news, you will notice some similarities between each of them. You may choose to follow one of these models or alternatively, to implement the general tips above when breaking bad news to a patient or relative.
➊ Breaking bad news framework
- Preparation: organise the session as soon as possible; set aside plenty of time and find a suitable, private environment; invite the individuals the patient wishes to be present; check you know all of the facts about the case/news 🏨
- Beginning the meeting: summarise what they already know; assess the situation by discussing their prior knowledge to establish their feelings
- Divulging the information: establish what the patient knows already; establish how much they wish to know; prepare them by giving a warning e.g. “it is not good news”; provide the key information in simple, comprehensible terms; repeat important information; assess their feelings as you unload information. You should explain HOW it happened, by offering any relevant information such as medical history/facts and explain anything that has changed in light of the news 🏨
- Displaying sensitivity: assess for their feelings e.g. tears/silence/language etc.; allow denial; ask if they would like further information or not; ask what their concerns are, be empathetic 😔
- Plan: having established their concerns, you can try to make these seem less insurmountable by breaking them down into manageable actions; suggest what to do next; if the news is a diagnosis, do not be specific with time frames, be broad; try to foster hope; say things like “we” to make them feel supported. Discuss the pros and cons of alternative options available, e.g. different treatment options. As a doctor, you should recommend the most appropriate actions to take and explain why it is appropriate 👍
- Follow up/conclusion: Explain what you anticipate will happen going forwards and the broad time-frame. Summarise the information and check their understanding; do not rush any next steps; offer to speak to other family members for them; set up appointments for the next stages. You want them to leave the consultation feeling somewhat hopeful if possible ✅
It is important to prepare before the meeting so that you know what you want to say and the best way to do so. You should then find out what they already know before breaking the news if they wish to hear it. You should be sensitive and expect an emotional response, then be proactive, addressing their concerns and the future, arranging any follow up appointments before summarising the information again.
➋ Delivering bad news to a child
😕 You should discuss with the child’s parents/guardians how it is best to break the news to them 🏨
😕 You must explain the news in language that the child will comprehend
😕 They should be told as soon as possible as they may already be aware that something is wrong ⌛
😕 You must answer any questions the child has with patience, as clearly as possible so that they can understand your answer
Delivering bad news to a child can be even more emotionally challenging, and so, you should make sure you are prepared ahead of time and discuss the best way to do so with the parents/guardians. You must explain the information in a way the child will understand and offer and emotional support they require.
➌ The 4 W’s for delivering bad news
😕 Who: you should first identify the correct patient and any family members they wish to be present for the consultation. The lead consultant or senior doctor on the case should usually break the news, and another member of staff should normally be present 🏨
😕 Where: a private room where the patient/relatives feel comfortable e.g. comfortable chairs and a ‘do not disturb’ sign 🏨
😕 When: you should tell the patient/relatives as soon as possible after the news has been confirmed, assuming they are supported and in a suitable state to receive it ⌛
😕 What: it is most important to tell the truth, and to check how much they wish to know so as not to overload them with information
'Who' refers to who are you telling and who should do it. 'Where' refers to finding a suitably private location. 'When' refers to informing the patient/relatives as soon as possible. 'What' refers to telling the truth and breaking the information down into comprehensible sections.
➍ The ABCDE mnemonic for breaking bad news
Adapted from: VandeKieft GK. Breaking bad news. Am Fam Physician. 2001 Dec 15;64(12):1975–8.
😕 Advanced preparation: prepare to break the bad news by reviewing patient history and understanding the diagnosis/news you are delivering, then rehearsing what you will say. You must also make sure you are mentally/emotionally prepared and if necessary, bring someone along for support 💻
😕 Build a therapeutic environment: find a private location with sufficient seating for everyone. Maintain eye contact, and use the listening skills listed above e.g. be considerate and respectful
😕 Communicate well: do not use medical jargon, speak clearly, explaining the news in simple terms and checking the patient/relatives understand 👂
😕 Deal with the patient and family reactions: explore the thoughts/feelings/emotions of the patient/relatives. Be empathetic and actively listen 👫
😕 Encourage and validate emotions: allow the patient/relatives to express their emotions, validate their emotions and be sympathetic
Preparation is key to make sure you deliver the news in an appropriate manner. You should make sure the environment is private and comfortable as you do not want to be interrupted and want them to feel respected. Clear communication is key, and you should try to explore the emotions that arise in response to the news, to validate their feelings.
➎ Breaks Protocol for breaking bad news
Adapted from: Narayanan V, Bista B, Koshy C; 'BREAKS' Protocol for Breaking Bad News. Indian J Palliat Care. 2010 May16(2):61-5. doi: 10.4103/0973-1075.68401.
😕 Background: you must understand the case thoroughly, and be confident that you will be able to answer any questions the patient/relatives may have ✅
😕 Rapport: establishing good rapport with the patient/relative is key for delivering bad news as they must feel comfortable and you should be able to work out how/when it is best to deliver the bad news based on the rapport you have built 👂
😕 Exploring: you should explore what the patient/relatives know about their condition/situation first, so you know whether you are confirming news or delivering new information. You should explore the history, investigations, difficulties, thoughts and beliefs
😕 Announce: do not deliver the news like a bomb, instead you should ease the conversation towards it. You should announce the bad news in clear and simple terms, avoiding the use of medical jargon. Short sentences are advised to ensure the patient/relatives understand what you are telling them
😕 Kindling: when delivering bad news a variety of emotional responses can be expected. For example, some patients/relatives will cry, others will be silent, some will pace the room and some may use humour etc.
😕 Summarise: your final task when delivering bad news is to summarise the information the patient/relatives have received and their concerns. Offering a summary in written form is very useful as they are unlikely to have absorbed all of the information due to their initial emotional response 👂
The BREAKS protocol is suitable for delivering bad news as it ensures the physician is suitably prepared and delivers all of the necessary information in an appropriate manner. It involves: preparing by understanding the background of the case; establishing good rapport; exploring what they already know; announcing the news in clear, simple terms; expecting a range of emotional responses. Maintaining optimism is vital as bad news can have a profound emotional effect on people.
➏ Karl Rogers’ approach
Adapted from: Rogers CR. Foundations of the person centred approach. Educ. 1979;100:98–107.
- Be genuine and congruent
- Offer unconditional positive regard 👍
- Feel and communicate deep empathetic understanding
😕 The patient/relative knows what is hurting them and how to move forwards following bad news
😕 Doctors should use their insight into the patient/relatives to decide how to break the news 🏨
😕 A patient-centred approach is most successful when delivering bad news 🏨
😕 Delivering the news in a empathetic, genuine and respectful way is extremely important
😕 Blocking behaviours should be avoided (e.g. premature reassurance, saying ther reaction is ‘normal’, making jokes, or changing the subject) ❌
Karl Rogers’ approach focusses on the importance of empathy and being genuinely concerned for the patient/relatives. This is useful when delivering bad news as it is respectful and patient-centred.
➐ Kaye’s 10 step approach to breaking bad news
Adapted from: Kaye P. Breaking Bad News: A 10 Step Approach. Northhampton, Australia: EPL Publications; 1996.
- Preparation: make sure you are well prepared for the meeting and know all of the information/facts and objectives. Find a private place, find out who they patient wants to hear the news and then introduce yourself when the meeting begins 💻
- What does the person know❓ Ask the patient or relative to tell you what they already know about the situation using open-ended questions
- Is more information wanted❓ Ask the patient/relative if they would like you to explain it a bit more or not before continuing
- Give a warning shot: do not divulge the bad news immediately, you should prepare the patient/relative by saying e.g. “I am afraid it is not good news” and give them time to react/respond to this ❗
- Allow denial: some patients/relatives will use denial as a coping mechanism and so you should allow them to control the information they receive
- Explain: if they request more information, you should offer this in a step by step approach to make it more comprehensible, this is important as the way you explain it is what they will remember
- Listen to concerns: ask what their concerns are having heard the news and allow them to express them 👂
- Encourage ventilation of feelings: allow the patient/relatives to express their feelings and listen to them in a non-judgemental way, this shows empathy ✅
- Summarise and plan: summarise their concerns and, if appropriate, make a referral/dollow up plan in order to inspire hope or give closure. You may wish to give them the news in written format for them to read later on
- Offer availability: it is likely that the patient/relative will want further information once they have had time to process the information, and so, it is important to offer your availability or recommend other
Kaye’s 10 step approach involves: prepare for the consultation; check what they already know; give a ‘warning shot’; expect and allow denial; explain the news clearly; allow them to express their concerns; allow them to express their feeling; summarise what you have told them and make a plan; offer availability for them to talk to you/others.
➑ SPIKES (The Six-step Protocol for Delivering Bad News)
Adapted from: Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. The Oncologist. 2000;5(4):302–11.
😕 Setting up the interview: make sure you have all of the information and have a suitable location where you will not be interrupted. Find out if the patient wants anyone else to be present 💻
😕 Perception: establish what the patient knows about their illness so far and what they think it means 😔
😕 Invitation: obtain invitation to divulge the information to the information. The patient may not want to hear the news at present, and they are entitled to this make decision, however, you will need to tell them at another opportunity due to informed consent rules dictating that patients must make informed decisions
😕 Knowledge: When telling the patient/relatives the bad news, in order to make sure you cover everything, you should remember these 4 steps: diagnosis, treatment plan, prognosis and support. Do not forget to give a ‘warning shot’; break the information up into small sections; repeat important points; avoid medical jargon; check understanding and concerns 🏨
😕 Emotions: be empathetic when acknowledging the patient’s/relatives’ emotions; allow them to express them and reflect on them 😔
😕 Stragegy/Summary: your job is to help them make sense of the information, and so, making a plan in which you prepare for the worst but hope for the best is important, as it helps the patient/relative feel supported going forwards ✅
This acronym stands for Setting up the interview; Perceiving what is already know; Invitation to break the news from the patient/relatives; Knowledge sharing; Emotional response; Summary and planning.
➒ REDMAP Framework:
Adapted from:Effective Communication For Healthcare. 2021. COVID-19: Effective communication for professionals (RED-MAP resources). [online] Available at: <https://www.ec4h.org.uk/covid-19-effective-communication-for-professionals/> [Accessed 25 February 2021].
😕 Ready: check the patient is ready to receive the information ✅
😕 Expect: ask what they already know or are wondering
😕 Diagnosis: tell them what you know or do not know 🏨
😕 Matters: ask what matters/is important to them
😕 Action: tell them what will be useful and what will not ❌
😕 Plan: planning good care for the patient and their family going forward is the final step
Check the patient is Ready; ask them what they know or Expect; explain the Diagnosis; ask what Matters to them in light of this; tell them which Actions will be useful or not; make a Plan.
➓ The Grief TEAR model
😕 Grief is a unique journey which is different for everyone
😕 Grief is experienced in numerous circumstances: when a loved one dies; physical illness; mental illness; when a loved one is missing; new disabilities; migration (grieve loss of culture); end of relationships
😕 The TEAR model describes the ‘grief tasks’ which can be achieved in any order
😕 To accept the reality of the loss ❗
😕 Experience the pain of the loss 😖
😕 Adjust to the new environment without the deceased person 💀
😕 Reinvest in the new reality and new life
Grief is different for everyone and can happen in a variety of scenarios. TEAR is a useful acronym for the 'grief tasks' one must achieve. It stands for: To accept the loss; Experiencing the pain of it; Adjusting to life without the deceased; Reinvesting in the new life.
Advice for different scenarios in which bad news must be broken
There are many different scenarios in which bad news must commonly be broken and we will explain some of these in this section.
😕 The most experiences staff member should break the news to the relatives 💀
😕 The doctor should then leave the family in the care of a nurse who can answer their questions
😕 Pastoral care should be involved as soon as possible e.g. social workers 🏨
😕 Relatives should be prepared in advanced e.g. tell them it is not good news over the phone
😕 The family should be informed as soon as death is confirmed, in a clear (e.g. say ‘dead’) and compassionate (use the patient’s name) way 💀
😕 Offer a private, dignified viewing which can confirm the identification of the patient and help the family accept the death ✅
😕 If appropriate, discuss post-mortem with the family 🏨
😕 Return the patient’s personal belongings to the family in special family handover bags, never is a plastic bag❗
😕 If appropriate, offer the family to return to speak to staff 🏨
😕 Provide the family with grief/bereavement group information 💀
😕 Inform the multidisciplinary team of the patient’s death 💀
In cases of sudden death it is important that a senior doctor informs the family, and that they are offered support such as social workers to help them come to terms with their unexpected loss. You should attend to formalities such as paperwork and post-mortem in a respectful way, and most importantly you must make sure the family are supported and have the chance to ask any questions they need to.
Delivering bad news by telephone
😕 Should only be done in exceptional circumstances ❗
😕 You must: make sure the recipient has accurate information beforehand; identify yourself and the hospital at the start of the call then repeat it at the end; the recipient must confirm their identity, which you should document, and be over the age of 18; if possible the recipient should not be alone
This is not an ideal method communicating bad news, however it may be necessary in exceptional circumstances. It is important to remember that the recipient of the phone call will be in an emotional state and so you must not rush the conversation, and you should offer any support or advice you can.
Steps of mourning
- Accepting the loss: this is the first stage as you must accept that the individual(s) are gone in order to start moving on ✅
- Working through grief: once you understand that the individual(s) are gone, you must recognise your feelings and emotions in order to work through them
- Adjusting to life without the deceased: with the absence of the deceased in your life, things will change and so you need to start finding out what has changed and how you can adjust to it
- Move on with life: finally, you need to move on after the loss of a friend or relative, and whilst this may seem difficult at first you will eventually be able to do so (this does not mean forgetting the deceased) ❌
When supporting somebody who is in the process of mourning, it can be helpful to recognise the different steps of this process. The initial task is to accept the loss, then work their way through their grief until they are ready to start adjusting to life without the deceased individual and finally, moving on with their life.
- Breaking bad news is an important part of a doctor's job
- Many different protocols have been proposed for breaking bad news, whilst there are differences and you can choose which works for you, try to identify the many similarities between them to work out what is most important
- Top tips: be empathetic; answer questions as clearly as possible; speak in short sentences, breaking up the information; try to reflect the individual’s language; offer follow up support