Breaking Bad News:
One of the most important jobs of
a physician is to be a clear
And one of the toughest challenges
for a communicator is to deliver
Communicating bad news to
patients well is not an optional skill;
it is an essential part of
“The bad news about breaking bad
news is that bad news is bad
Even though the message is bad,
the messenger can be seen as part
of the support system.
Physicians frequently must break
bad news to patients.
According to one estimate, over the
course of a career an oncologist
will break bad news to patients
about 20,000 times, from the first
shocking facts of the diagnosis to
the news that death is near.
What is meant by bad news ?
Bad news is any information that
adversely and seriously affects an
individual’s view of his or her
It is often associated with a
terminal illness such as cancer.
However, bad news can come in
many forms, for example :
the diagnosis of a chronic illness
(e.g. diabetes mellitus)
disability or loss of function (e.g.
a pregnant woman’s ultrasound
verifies a fetal demise.
a middle-aged woman’s magnetic
resonance imaging scan confirms
the clinical suspicion of multiple
an adolescent’s polydipsia and
weight loss prove to be the onset
It might simply be a diagnosis that
comes at an inopportune time,
such as unstable angina requiring
angioplasty during the week of a
or it may be a diagnosis that is
incompatible with one’s
employment, such as a coarse
tremor developing in a
So bad news is a relative concept
and the news may be considered to
be bad by the patient and the
family, if they feel that it is likely to
adversely affect their future in
What is difficult about giving bad
Feel responsible and fear being
Not know how to give the news
Worry that is will change the
existing doctor-patient relationship
Fear the patient’s reaction on
hearing bad news
Uncertainty of what may happen
Worry about not having answers to
the questions that may be asked
Worry about their own feelings and
reaction to it
Fear of doing it wrong or of giving
the wrong information
Whom to tell
When to tell
What to tell
How to tell
With regard to what to tell and how
to tell the patient, there are two
options. These are-
Full disclosure ( to give the patient
the full information)
Individualized disclosure ( to use a
In Asian cultures, individualized
disclosure would be the best option
Who should break bad news?
Depends on the circumstances and
their own level of competency.
When giving the news of any life
threatening disorder such as
cancer, a senior member of the
medical who has undertaken
communication skills training
should undertake the consultation.
Ideally this should be a consultant.
A nurse or other healthcare
professional should accompany the
doctor at this time.
The old concepts regarding
disclosure of bad news :
Withholding bad news from
patients was commonly practiced.
The recent trend :
In recent decades, the paternalistic
model of patient care has been
replaced by one that emphasizes
patient autonomy and full
Honest disclosure of diagnoses,
prognoses, and treatment options
allows patients to make informed
healthcare decisions that are
consistent with their goals and
How to break bad news?
Key to breaking bad news well is to
try to slow down the transition
from a patient’s perception that
they are well to a realisation that
they have a life threatening or life
The various protocols have been
developed for breaking bad news.
The one described by Vandekieft in
2001 follows the simple mnemonic
The ABCDE Mnemonic for
Breaking Bad News:
- Arrange for adequate time, privacy
and no interruptions (turn pager
off or to silent mode).
- Review relevant clinical
- Mentally rehearse, identify words
or phrases to use and avoid.
- Prepare yourself emotionally.
Build a therapeutic
- Determine what and how much the
patient wants to know.
- Have family or support persons
- Introduce yourself to everyone.
- Warn the patient that bad news is
- Use touch when appropriate.
- Schedule follow-up appointments.
- Ask what the patient or family
- Be frank but compassionate;
avoid medical jargon.
- Allow for silence and tears;
proceed at the patient's pace.
- Have the patient describe his or
her understanding of the news;
repeat this information at
- Allow time to answer questions;
write things down and provide
- Conclude each visit with a
summary and follow-up plan.
Deal with patient and family
- Assess and respond to the patient and
the family's emotional reaction; repeat
at each visit.
- Be empathetic ( objective awareness of
and insight into the feelings, emotions,
and behaviour of another person and
their meaning and significance)
- Do not argue with or criticize colleagues
Encourage and validate emotions:
- Explore what the news means to the
- Offer realistic hope according to the
- Use interdisciplinary resources.
- Take care of your own needs; be
attuned to the needs of involved house
staff and office or hospital personnel.
Other protocol such as the SPIKES
protocol are also commonly used
for breaking bad news.
The grief reaction:
This follows five stages, identified
by Kubler- Ross
Denial and isolation
Stages do not necessarily occur in
this order, and >1 stage can be
present at once.
Physicians need to individualize
their manner of breaking bad news
based on the patient’s desires and
A physician’s attitude and
communication skills play a crucial
role in how well patients cope
when they receive bad news.
“Breaking bad news is never easy
or pleasant: but at least having
some plan or approach increases
the professional’s feeling of
confidence- and that is often
perceived as increased
Breaking bad news is a skill, which
can be learnt and improves with
Current medical diagnosis and
treatment; 48th edition;2009
Lecture notes in family medicine;
Nandani de Silva
Murtagh’s general practice; 4th
Breaking bad news; American
Family Physician; Dec 15, 2001