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Knowing how to break bad news well is an essential skill for OSCEs and clinical practice. From an early stage, doctors find themselves in situations where they need to convey difficult news to patients and/or relatives. Bad or distressing news is never easy to hear, but having someone deliver the news well can make the person receiving it feel respected and supported going forwards.
Clinical communication: general tips
Prepare for the consultation by choosing an appropriate environment (see the ‘setting’ section below) and performing sufficient background reading to ensure you have a good understanding of the patient’s situation.
Wash your hands and don PPE if appropriate.
Introduceyourself including your full name and role.
Check you have the correctpatient and confirm they are happy to be called by their name (e.g. Joanna or Mrs Smith).
Explain the purpose of the interview (e.g. ‘I have been asked to speak to you about some recent investigations you have had.’).
If you are seeing the patient instead of their usual doctor – apologise for the change and explain that you are stepping in for whatever reason.
Gainconsent to discuss the topic with the patient and explain that the discussion will be confidential.
Display activelisteningskills throughout the consultation:
Maintain an appropriate level of eye contact throughout.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Nod to acknowledge what the patient is saying where appropriate.
Avoid interrupting the patient throughout the consultation.
Try to establish a rapport with your patient:
Ask how they are, offer them a seat and a glass of water.
Empathise with any emotion they display/verbalise and acknowledge the difficulty/stress of situations they could be experiencing (watch them carefully).
Listen and respond to the things the patient says.
Structuring the consultation
SPIKES is an effective way to structure your consultation.¹
It’s important to breakbadnews in an appropriate setting:
The discussion should occur in a comfortable, quiet and private room. Although this is not always possible, make sure you have at least some privacy and that the patient and family have somewhere to sit. Bad news should never be broken standing in a corridor!
Make sure to have some tissues available.
Ensure both you and the patient/relative are sitting down.
Arrange the chairs if necessary (e.g. at approximately 45-degree angles to each other), avoiding physical barriers between you and the patient (e.g. a desk).
Ensure you have uninterrupted time during the meeting (turn off beepers and phones).
Otherpeople who may be helpful to have in the room when breaking bad news:
Other healthcare workers can provide support in breaking the diagnosis, for example, a nurse specialist.
Ask the patient if they want anyone to be with them: “Would you prefer to have a family member or friend here?”. Likewise, if there is someone else already in the room, check to see if your patient would prefer to be told alone.
Begin by discussing the sequenceofevents leading up to this point (e.g. scans, biopsies, etc) and assess the patient’s current emotional state.
Ask about any symptoms the patient may have been experiencing up to this point. Here you could agree with the patient and say something like: “Yes, the reason we wanted to do the tests were so we could find out why you have been experiencing the symptoms you just described to me. Were you aware of what sort of things the investigations might show?”
Establish what the patient already knows or is expecting, the patient may or may not have been made aware of the possible diagnoses. If they don’t know of the possible diagnoses, you could say something like: “Symptoms like the ones you’ve been describing can sometimes be as a result of an infection, but sometimes they can be as a result of more serious underlying conditions”. This can also act as a warning shot.
Check if the patient wants to receive their results today – in an OSCE setting the answer will always be yes, however, on the wards, be aware that some patients may recognise the news may not be what they hoped for and may want to put it off until family are present: “I have the result here today, would you like me to explain it to you now?”.
Ensure you deliver the information in sizeablechunks, and regularly check the patient’s understanding.
Use a warningshot to indicate that you have unfortunate news: “As you know we took a biopsy/did a scan, and unfortunately the results were not as we hoped”.
Allow a largepause if necessary, so the patient is able to digest what you have told them.
Then provide the diagnosis using simplelanguage: “I’m sorry to tell you this, but the results from the investigations show you have cancer”.
Deliver information in chunks, pausing between each piece of information. After giving the diagnosis, it’s wise to wait for the patient to re-initiate the conversation.
“I’m afraid it’s not the news we were hoping for Mrs Brown.”
“Unfortunately, the lump is due to a more serious underlying cause.”
“I’m so sorry to tell you, but you have breast cancer.”
PAUSE until the patient speaks, or seems ready to talk again.
Make sure your tone is respectful, at a slow pace and clear.
It is very natural for the patient to have an emotional reaction at this stage. They may go quiet, ask questions in disbelief, deny that this is happening, start crying, become hysterical or angry. These are all normal reactions to hearing bad news and each person will respond in their own way.
Give the patient TIME to have their emotional reaction. People often find it very uncomfortable watching patients like this but it is important to give the patient space to react.
Questions in disbelief such as “This can’t be happening, can it?” or “But how am I supposed to deal with this?” are often asked at this stage. Make a judgement about whether you need to answer the questions directly, saying something like “I’m so sorry I had to break this news to you today” might be all you need to say at this point.
If they are making eye contact with you and asking questions like “So what will happen next?” then it is probable that they are ready to receive answers to their questions.
Emotions and pathway
Recognize and respond to emotions with acceptance, empathy and concern. Acknowledge and reflect their emotions and body language. Do not lie when the patient asks questions about prognosis – it is not kind to give false hope. If you do not know information, tell them that, and suggest that you can refer their case to a specialist or that more information is needed.
“I’m so sorry, but at this stage, I don’t have enough information to answer that. Hopefully in the next few weeks once we’ve completed other tests I can be clearer. Sorry, I can appreciate that it’s frustrating to be left with unanswered questions’.’
Some usefulphrases may include:
“I can see this is a huge shock for you”
“I can see that this is not the news that you expected, I’m so sorry”
Strategy and summary
Make a plan together to meet the patient again and inform them of what the nextsteps are.
Reassure the patient that they are going to be referred to the appropriate team of specialists.
Try not to rush the patient to make decisions about their treatment (if possible), it is respectful and considerate to let them process what has been told to them.
Check the patient’sunderstanding of the bad news you have delivered.
Summarise: respectfully and gently repeat any important points – patients who are shocked or upset will not take in much information.
Ensure to answer any questions or concerns that can be addressed at this stage (and listen out for any implicit ones).
Offer ongoing assistance to the patient should they think of any further questions – this may involve giving them details of a clinical nurse specialist.
Offer assistance to tellothers (e.g. other family members) the bad news.
Highlight where the patient can go to gather moreinformation or gather any support (support groups, websites).
Offer writtenmaterials if relevant and available.
If appropriate, consider asking about religiouspreferences, and whether the patient would like the Chaplain.
After the consultation
Dispose of PPE appropriately and wash your hands.
Be aware that breaking bad news can be emotionally challenging for you as a healthcare professional, particularly if you have built a rapport with the patient.
Think through your own thoughts, and reflect on how you’re feeling. Take time out if needed.
Breaking bad news is not only done in the context of cancer. There are a wide variety of possible situations in which the strategies discussed here can be applied to (e.g. sexually transmitted infection results, diagnosis of type 1 diabetes, miscarriages).
Think about how a patient might feel when giving them any new information about their condition, and how it may impact their lives.
Use the correct language – cancer is cancer, death is death. It is important that there is no ambiguity about what the results show.
Avoid euphemisms and medical jargon.
Baile, W., Buckman, R., Lenzi, E., Glober, G., Beale, E., & Kudelka, A. SPIKES – a six-step protocol for delivering bad news: Application to the Patient with Cancer. Oncologist 2000; 5(4):302-311.