5

Breaking bad news

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Breaking bad news is an inevitable part of medical practice. Most of us

worry about our ability to communicate sensitive and sometimes dis-
tressing news to patients and their relatives. This is not altogether
surprising, as the subject of breaking bad news is still not widely taught
in medical schools, and only rarely is reference made to the topic in
medical, surgical and psychiatric textbooks. Research has focused on
how patients and their relatives cope with bad news, rather than on
the process of breaking bad news. More is known about the psychologi-
cal consequences of bad news than how best to deliver it. But we also
know that what and how people are told affects their trust in their med-
ical practitioner as well as how they cope and adjust in the future.
The trend towards increased openness in the relationship between doc-
tors and their patients makes it important to focus attention in communi-
cations skills training on those procedures and hints that help us to deliver
bad news. Most patients nowadays are not satisfied with patronising
euphemisms and evasion. On the other hand, breaking bad news in a
direct and abrupt manner, without taking into account the patient’s need
for information, can be damaging. There is an increasing recognition that
bad news can be given tactfully and that the process can begin to prepare
patients and relatives for what may be ahead. This chapter considers what
bad news consists of, addresses why it is often difficult to break bad news
and describes an approach to giving bad news that can be adapted for dif-
ferent settings, with different patients and in relation to a range of issues.

What is bad news?

What would you consider bad news in your life? Finding out that you had failed an
Copyright 2009. Churchill Livingstone.

STOP AND THINK exam? Not getting the job you wanted? Hearing that a relative or someone close
to you was ill or had died? Being refused a bank loan? How was the bad news
given to you? Directly, in a roundabout way, in a letter or over the phone? What
was your first reaction? How did you cope? Did you feel differently about the
news 3 hours later? The next day? Could the news have been given to you
differently, or in a way that softened the blow?

60
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 Breaking bad news 61

The death of a patient or the diagnosis of serious illness, progressive dis-

ease or handicap is usually considered bad news. Some doctors would
add having to tell a patient that there is no bed available in the hospital,
that the patient’s medical notes have been misplaced or that an opera-
tion has had to be cancelled. Conventionally, the concept pertains to
situations where there is a feeling of no hope, a threat to an individual’s
mental and physical well-being, a risk of upsetting an established life-
style, or where a message is given which implies the person has fewer
choices in life. It may be tempting to consider whether news is good
or bad for an individual. Some people, when diagnosed with a terminal
illness, cope with the news, yet for others, minor ailments that are treat-
able can be distressing and are interpreted as signs of bad news. News,
of whatever kind, is information, whereas the idea that it is either good
or bad is a belief, value judgement or affective response from either the
provider or the receiver of the information.
There are many situations in which doctors might preface giving news
with ‘I am sorry to tell you that . . . ’, or ‘I am pleased to tell you . . . ’,
illustrating how value and meaning are attached to information from
the outset. Such preconceptions about what is good and bad news are
based on personal and professional experience. However, in some cases,
these preconceptions may directly influence a patient’s emotional
responses to this information. A patient who is given so-called good
news in the form of a negative HIV antibody test result may feel
ashamed to cry or discuss new problems. For that patient, for example,
there may be an element of bad news, as he or she then feels that there
are no excuses for failing in a sexual relationship, whereas previously the
fear of HIV had been a protection from meeting new partners. Similarly,
a patient who feels some relief about an AIDS diagnosis may be
concerned that the doctor may misconstrue this as denial, emotional
blunting or suggestive of psychiatric disorder.
Bad news is, therefore, a relative concept and should depend on the
patient’s interpretation of information and reaction to it. Where patients
feel the news will adversely affect their future, then it can be considered
bad news. Usually, we can predict what will be viewed as bad news, but
not with complete certainty. Clinical experience highlights the value of
sometimes waiting until the patient attaches new meaning to the infor-
mation before defining it as good or bad news. This does not mean that
we are unaffected by patients’ feelings and responses, but that we should
try to avoid making assumptions as to what these may be, and not
inhibit patients’ reactions by our own.

What is difficult about giving bad news?

There are personal, professional and social reasons why giving bad news
to patients may be difficult (Table 5.1). Training in medicine empha-
sises treatment, healing and the reduction of suffering. Serious illness,
a deterioration in a patient’s condition, handicap, disability or death

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 62 Communication skills for medicine

Table 5.1 Why is it difficult to give bad news?

l The ‘messenger’ may feel responsible and fears being blamed

l Not knowing how best to do it
l Possible inhibition because of personal experience of loss
l Reluctance to change the existing doctor–patient relationship
l Fear of upsetting the patient’s existing family roles or structure
l Not knowing the patient, his or her resources and limitations
l Fear of the implications for the patient, e.g. disfigurement, pain, social and
financial losses
l Fear of the patient’s emotional reaction
l Uncertainty as to what may happen next and not having answers to some
questions
l Lack of clarity about one’s own role as a health care provider

all confront us with some of the limitations of modern medicine. In

some situations, we may feel responsible for inflicting emotional pain
or suffering on patients and their family. In the role of a messenger,
we may fear being blamed, and experience personal failure. Bad news
often implies the loss of well-being, youth, hope, health and relation-
ships. We mark a transition in life for patients and their family that
may be either premature or unwelcome, or both. The news ushers in
new family roles: perhaps a partner becomes a carer or a widow, a gen-
eration may end in the family and all others may move up in the family
structure. For the patient who is unwell, there is the sick role and the
associated social stigma. Many people may fear disfigurement, physical
pain, loneliness and infectiousness, as well as questions about emo-
tional, social and financial well-being.
Doctors and other health care professionals themselves are not
immune to the experience of personal loss. A recent experience of loss
or illness in our own family may make it difficult for us to break bad
news to our patients and to give them support. It may also be difficult
to anticipate how a patient or relative might react, and this unpredict-
ability may deter us from giving bad news. Some doctors worry that
their own emotional reactions – such as wanting to cry – might make
them appear unprofessional in the eyes of the patient.
Another reason for difficulty in giving bad news is a fear of extreme
reactions, such as the threat of violence, emotional distress and suicidal
thoughts. Other reasons for a reluctance to give bad news may be more
subtle. Telling a patient he or she has a chronic condition, such as dia-
betes or haemophilia, means that person will have a lifelong relation-
ship with the health care system. It may be difficult to countenance
such a relationship with certain patients and, instead, we might delegate
the task of giving the diagnosis to another doctor, such as a GP or hos-
pital specialist. On the other hand, bad news may spell the end of a
close professional relationship with a patient, and the personal loss
may be difficult for us to face.

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 Breaking bad news 63

A fear of ‘doing it wrong’, or giving incorrect information, may also

deter us. Lastly, the example of senior colleagues or one’s own position
as a professional in transition may make it difficult to know how to deal
with a patient. A few consultants still hold the view that patients should
not be told they are dying; this makes it difficult for a junior doctor to
deal openly with the patient’s expressed concerns and fears. Similarly,
medical students sometimes report that patients ask them to confirm
the diagnosis because the medical and nursing staff have not openly dis-
cussed it with them. Often this creates a dilemma for the student who
may be privy to important information but not have the authority to
talk about it openly with the patient.

Options for managing difficult situations

Before describing some guidelines for giving bad news, we need to consider
what options may be available for managing difficult clinical situations.
There are four main considerations, described below.

To whom should bad news be given?

Certain legal and ethical guidelines in clinical practice make it difficult
for a doctor to choose to withhold important and personal information
from the patient. It is almost impossible to justify doing so ‘to protect
the patient’ or ‘because it would hurt the patient to know’. Nonetheless,
circumstances may arise where other specific factors may need to be
taken into account before deciding to break bad news. It is good practice
first to discuss these situations with a colleague or within a multidisci-
plinary health care team. There are some specific situations in which
you may need to consider whether to give bad news. For example, if a
patient is deemed to be psychotic, and presumably may not understand
what has happened, there may be reason to withhold bad news. When
treating a child, one usually confers with the parent or guardian before
breaking bad news.

Who should give bad news?

For several reasons, it may be more appropriate for another doctor to
break bad news. For example, a patient sent to a hospital for special tests
may still expect his or her GP to reveal the results, rather than the hos-
pital consultant. The GP usually has an established relationship with the
patient and presumably could anticipate some of the problems that
might arise. Giving bad news usually requires time, so it may be inap-
propriate for someone to do so at the end of a shift. It may be preferable
to hand over the task to other colleagues, provided they are fully briefed
and acquainted with the case. But it is poor practice to delegate the task
to a colleague because you do not feel like confronting the patient
yourself.

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 64 Communication skills for medicine

When should bad news be given?

Where patients are diagnosed as having a chronic or degenerative medical
condition, or where an infant is born with a handicap that is not immedi-
ately apparent, there is usually the option of withholding the bad news
until a later stage. One advantage is that you can try gradually to break
the news; this in turn gives the patient and relatives time to adjust. On
the other hand, withholding the news may deny them the opportunity
to face up to it and begin to make the necessary adjustments in their
personal lives.
In some situations, it can actually be hazardous to withhold bad
news until a later stage. If the patient has an infectious disease or condi-
tion (e.g. hepatitis C or HIV infection), he or she can inadvertently
infect someone else, or be denied the benefits of early medical informa-
tion if not fully informed of this condition. A further disadvantage of
withholding the news at an early stage is that when the patient becomes
physically very unwell, he or she is less likely to have the emotional and
practical resources to make the necessary adjustments (e.g. say goodbye
to children, or settle financial matters). Of course, there are obviously
some situations where there is no choice and bad news must be given
immediately (e.g. informing relatives of a death).

Should you give hope and reassurance along with

bad news?
You can reassure patients that their fears for the future are probably
worse than the reality. This option may be difficult to resist because,
by conveying hope, it can result in an immediate reduction of a patient’s
anxiety and distress. It is a form of emotional first aid that may be indi-
cated where patients appear to be isolated and in extreme distress. How-
ever, reassurance is sometimes inappropriate and may serve to sweep
fear under the carpet that will only resurface later on. Where doctors
repeatedly reassure patients, they may take on some of their patients’
anxiety and assume responsibility for some decisions that could other-
wise be shared. This can lead to feelings of burnout and stress, and doc-
tors also run the risk of colluding with patients’ denial of the severity of
problems, or potential problems, if false hope is offered.

How to give bad news

(p. 191) Exercise 6 There are several practical and logical steps that can be followed when
giving bad news (Table 5.2). Although these serve as guidelines, there
are no firm rules for what is often one of the most challenging aspects
of medical practice. It is always a matter of clinical judgement and pro-
fessional experience as to how bad news should be broken, and each
situation must be treated differently. There are five main considerations:

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 Breaking bad news 65

Table 5.2 The process of giving bad news

Give information
#
Check the patient’s understanding of the information
#
Identify the patient’s main concerns
#
Elicit the patient’s coping strategies and personal resources
and give realistic hope

1. personal preparation
2. the physical setting
3. talking to the patient and responding to concerns
4. arranging follow-up or referral
5. feedback and handover to colleagues.

Personal preparation
It takes time to give bad news properly and instil confidence and sup-
port by being available to answer questions. For this reason, it is not
usually appropriate to break bad news in the middle of a busy clinic
or during a ward round. Before seeing the patient, you should first take
a few moments to consider what information is known and what needs
to be addressed. The following points should be considered:
l Is the patient expecting bad news, or am I ‘going in cold’?
l Should anyone else be present (such as a nurse or relative)?
l What does the patient already know about the illness, or what has
happened?
l What personal resources does the patient have?
l Have I got sufficient time to spend with the patient?
l Can someone else look after my bleep for an hour?
l Are there any ‘what if . . . ’ questions I should prepare myself for? (e.g.
‘What if he discharges himself?’; ‘What if she gets angry with me?’)
Pause, think and pre-empt difficulties before seeing the patient. In giv-
ing bad news, more difficulties arise from not thinking clearly about
what you are doing and how best to achieve it than from not having
answers to some of the patient’s questions.

The physical setting

The ideal setting is a private room that is reasonably comfortable, free
from interruptions, and has a calm ambience. Of course, such a setting
is not always possible, and bad news is often given in open wards, semi-
private rooms, casualty departments and patients’ homes. In these

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 66 Communication skills for medicine

settings, some attempt should be made to ensure privacy and comfort.

A curtain should be drawn around a patient on an open ward if it is
not possible to move to a private room. A ‘do not disturb’ sign should
be posted on the door of the room used by others in a busy setting, such
as a casualty department.
Your physical position in relation to the patient is important. Being
seated conveys that you intend to stay and that the meeting will not be
rushed. If the patient is in bed, it is more difficult to maintain the same
eye level. It is a matter of personal choice where one sits. Some doctors
prefer to sit on the side of the bed, but this can feel intrusive and too
close for the patient. Sitting on an office chair beside the bed is preferable
to lounging back in a comfortable chair. Others prefer to adopt the defen-
sive position of leaning against a wall close to the patient: this conveys a
relaxed posture and a commitment to remain in the room.
There are some obvious things you should not do:
l Don’t give bad news at the end of a physical examination while the
patient is still undressed.
l Don’t give bad news in corridors and over the telephone (if this can
be avoided).
l Don’t pace around, keep looking out of the window or become dis-
tracted by activities nearby.
We sometimes rely on props in difficult situations. Where possible,
avoid fumbling through clinical notes or fixing drips while talking to
the patient. It is important to maintain eye contact. Undo your jacket
or hang up your white coat, if you prefer: this creates a more personal
and friendly ambience and also punctuates the uniqueness of the situa-
tion. It is preferable not to wear a stethoscope around your neck or have
your bleep in view. Potential sources of distraction (telephone, televi-
sion and radio) should be avoided.

Talking to the patient and responding to concerns

Whatever you tell the patient, it is essential that you do it slowly, or at
least at the pace dictated by the patient. Conversation usually becomes
more formal and embroidered when giving bad news. Monosyllabic
replies are avoided. It would be unusual to reply with an emphatic
‘no’ to a relative and walk away on being asked if a patient had survived
an operation. Instead, one might say:
“As you know, your uncle was very unwell before the operation. We did the
best we could, but I’m afraid that was not enough. He never regained con-
sciousness, and I’m sorry to tell you he died shortly after the operation.”
Complex information should be delivered with the minimum of medi-
cal jargon and the doctor should be empathic to the patient’s needs and
concerns. Failure to attend to these points may render the encounter
ineffective, unhelpful or destructive to the patient. Breaking bad news
requires:

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 Breaking bad news 67

l empathy
l starting with what the patient or relative already knows or understands
l finding out what the patient wants to know
l active listening, giving information, inviting feedback and addressing
concerns
l eliciting the patient’s own resources for coping
l instilling realistic hope.

Empathy
It should not be too difficult to empathise with someone who has suffered
loss or been give bad news as most of us can readily identify with someone
who faces or experiences adversity. As we saw earlier in Chapter 2 in the
section on empathy, being able to put yourself in the place of another per-
son, particularly someone who may be distressed, helps us to communi-
cate with that individual more compassionately and effectively. Whilst
some people can more easily communicate with patients about highly
sensitive and potentially emotive topics, everyone can benefit from
acquiring or enhancing their skills in this area. Empathy is conveyed in
two different ways. Listening attentively to patients and attempting to
understand their predicament more fully is one description of empathy.
You are also being empathic by not introducing new information too
quickly, and not imposing views and making assumptions. For example:
DR FRYER: The results suggest that it’s not just an ‘ordinary’ lump.
MRS BLACK: This sounds like bad news.
DR FRYER: I was hoping to be able to reassure you. It seems that some of
the cells we looked at were abnormal. It is important, though,
that we picked this up early.
MRS BLACK: Are you saying it’s the big ‘C’?
DR FRYER: Yes, it probably is cancer.
MRS BLACK: We all know what that means . . . .
DR FRYER: I realise this probably comes as a shock to you.

Warmth and caring should be conveyed to the patient. The way in which
you introduce the topic of bad news will influence, to some degree, how
the patient responds. It is sometimes helpful to embroider a little and use
prefaces such as: ‘I was wondering whether you had ever thought what it
would mean if this infection does not clear up as quickly as last time?’ Put-
ting yourself down also encourages the patient to talk more freely. For exam-
ple: ‘You may think that some of my questions are a bit odd, but I can’t help
wondering whether . . . ’. Showing patients that you are not afraid to discuss
their concerns, no matter what these may be, is a way of showing empathy.

Start with what the patient already knows

Before giving bad news, it is useful to have an up-to-date impression of
what the patient understands and believes about the illness. This will
directly affect how you give the news. A patient who is overly optimistic

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 68 Communication skills for medicine

or who does not apparently understand the serious implications of the

illness will need to be introduced to the news more gradually. There
are a number of questions that can be asked in order to find out what
the patient already knows and may be expecting. For example:
“Did Dr Smith discuss with you what he had in mind in sending you to this
clinic?”
“How have things been for you? What do you make of that?”
“Have you had any thoughts about what this may be?”
“What first went through your mind when you found the lump?”
In order to discern the patient’s understanding of the prognosis (and,
therefore, the seriousness of the situation), you could also ask:
“Do you know anyone else who has had a similar problem? What has hap-
pened to them?”
“Do you know about any of the treatments that can be used for this?”
“How worried are you about this?”
In some cases, patients may give the impression of knowing very little
about their condition despite previous consultations. They may either
be hoping that new information has come to light that contradicts pre-
vious hints of bad news, or they may not want to hear bad news. These
both indicate denial of the severity of the illness, and it may be neces-
sary first to remind the patient of the previous conversations in a non-
confrontational manner. Similarly, you should pay close attention to
the patient’s responses to questions, emotional state and intellectual
level, as these directly affect what may need to be explained in more
detail, and how best to do this. It is important to check patients’ under-
standing of certain terms. Some patients, for example, may think that a
tumour means they don’t have cancer, or they may mistakenly assume
that common symptoms, such as nausea and weight loss, can be treated
and cured as successfully as if they did not have cancer.

Find out what the patient wants to know

Having established what the patient already knows, you can begin to
update the patient’s knowledge and understanding. However, because
you may not be clear about what the patient wants to be told, and at
what stage, you first need to find out by asking: ‘What would you like
to be told? Is there anything you would prefer not to hear about?’ Once
the rules for communication are established, you are free from having to
make difficult judgements about what to say. You thus avoid being
blamed, or feeling embarrassed. The patient feels a sense of control over
his or her management. Problems that later present in the doctor–
patient relationship may be traced back to a lack of clarity about what

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 Breaking bad news 69

the patient wanted to be told. The following questions help to open up

conversation on this important issue:
“It is helpful to us to hear from you what you want to be told about your
condition. Is there anything you would prefer not to be told?”
“What would you like to be told about the diagnosis?”
“How will we know from you what you want to be told?”
“Do you want to know all the details about the diagnosis, tests and treat-
ments, or do you just want to have an outline of what is going on?”
“You say you only want to be told when there is ‘good news’. What should
we do if we have bad news?”

Active listening, giving information, inviting feedback and

addressing concerns
First establish rapport and trust. Active listening involves responding to
questions and concerns while at the same time leading the conversation.
This can be facilitated by the use of questions in conversation. For example:
DR WATTS: Now, is there anything you would like to ask me?
MRS PARKER: What happens if the treatment is unsuccessful?
DR WATTS: In many cases, the symptoms come back. We can control
symptoms such as nausea and pain with certain drugs. Do
you have any other concerns?
MRS PARKER: I don’t know what to say to my children – or to my mother.
DR WATTS: This is all very recent news and perhaps you have not yet had
enough time to think about how to tell others. Is there any-
one else’s opinions and advice you would value in deciding
how to deal with your children and mother?
MRS PARKER: My sister. She’s the one we all turn to at difficult times.

One advantage of eliciting the patient’s concerns at an early stage is that

problems and practical issues can be attended to, thereby reducing anx-
iety. Patients can also be helped to plan ahead of crises and to think in
advance about problems and how they might cope with them. On the
other hand, some patients may not want to look to the future, feeling
that such a conversation might tempt fate. Others might become unset-
tled, so they should not be pushed into a discussion about their future.
Information should be given incrementally. Start with known facts,
add to them, and conclude with an opinion of what all the information
may mean. Once the patient has understood these details, introduce
options for treatment and care. For example:
DR MILLER: If you remember, after you told us about the numbness in your
legs and dizziness, we carried out some neurological tests.
When we examined you, you also said you were having some

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 70 Communication skills for medicine

difficulties with your vision. I mentioned to you earlier on that

one of the possibilities we have to consider is multiple sclerosis.
At this stage, I would like to carry out some further tests.
MR FRANKS: But there’s no cure for MS.
DR MILLER: I’m afraid that’s right. But there are certain treatments and
new drugs that are being tried out.

Remember that helping a patient understand the implications of bad

news is not a psychotherapy session. However, it is important at least
to elicit their feelings and address concerns. For example:
DR SEEDAT: What is your main concern now that I have told you what
may happen?
MR THOMAS: Being in pain. And not being able to look after myself.
DR SEEDAT: I can understand your concerns. I’d like to discuss both of
them with you.

Elicit the patient’s resources for coping, and instil realistic hope
You should discuss how the patient has previously coped with personal
difficulties. This helps make explicit what resources the individual has
and what additional support the patient may need. The patient’s natural
support network should also be identified. Here are some examples of
questions:
“Have you ever been given news in the past that made you feel frightened
and unsure how to respond?”
“How did you deal with it?”
“How might this experience help you in what we have been discussing today?”
Information about treatments may enable patients to consider other
possible outcomes of their illness. This helps to convey some hope for
the future, as shown in the following example:
DR BECK: These drugs should help to reduce the size of the lump. That
should mean that you will probably have full use of your
arm again. The other infections will probably have to be trea-
ted differently. What do you know about treatments for
cancer?
MRS DAVIS: Chemotherapy. But that makes your hair fall out, doesn’t it?
DR BECK: Yes, there are some unpleasant side-effects. I’m not sure that
we need to consider that at this stage. We should first see
whether a series of injections will help.
MRS DAVIS: Will I be cured or do I have to be treated for life?
DR BECK: We hope that things will get better after this course of treat-
ment. You may find that the treatment is unpleasant. I can’t
say whether you’ll be cured. We will need to keep a close eye
on things and repeat this course of treatment.

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 Breaking bad news 71

Arranging for follow-up or referral

After a patient has been given bad news, the last few moments of the
meeting are particularly important, as the patient’s main concerns inev-
itably arise now if they have not already been addressed. It is tempting
to assume that patients have retained and understood what they have
been told. Asking patients to summarise what they remember is a way
to check what they have retained. If you do not correct any misunder-
standings now, patients may recall only the positive or negative aspects
of the news, both of which may increase the risk of reactive depression,
denial, anxiety and even suicide. A plan should be made for follow-up
contact to contain some of their anxiety and provide a further opportu-
nity to address concerns. In some cases it may be appropriate to make a
referral to another professional, such as a psychologist or counsellor, for
specialist help with bereavement, anxiety and depression, and personal
and relationship difficulties.

Feedback and handover to colleagues

It is good practice to inform colleagues about the meeting with the
patient, summarise what the patient, and others, have been told and
understand, and what possible problems or reactions can be expected.
This helps others caring for the patient to know what to say without
confusing or upsetting the patient with different information about
prognosis and treatment. Discussion and consultation with colleagues
can also make the task of giving bad news easier by increasing profes-
sional support and exploring ideas about how else the patient could
have been managed.

Case example 5.1 Mrs Ball (46 years old) had a malignant growth surgically removed from
Breaking the news of her breast after several weeks of worrying about the lump. She had felt
breast cancer too frightened to tell her husband or doctor but eventually went to
her GP when she started to lose weight and had difficulty sleeping. After
being told the results of various tests, she was seen together with her
husband. This case illustrates the important skills in delivering bad
news, even when there is uncertainty as to the prognosis: convey sympa-
thy; be practical; be circumspect; and display an openness about the
prognosis and the patient’s views on management.
MRS BALL: It’s all my fault. If I’d come earlier, it wouldn’t have turned out
this way.
DR DAY: It seems unlikely that you could have done anything to change
what has happened. The fact that you came so that we could
operate on you and treat you is important.
MR BALL: My wife always blames herself. If only she had told me earlier.
It really upsets me that you worried about this all on your own.
Will she get better, doctor?

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 72 Communication skills for medicine

DR DAY: From the tests we have carried out, we’re confident that we are
able to remove all of the tumour from the breast. We will need
to find out now if it has spread to anywhere else. If it has, it
will depend on where it has spread to and what damage it
has already caused. How worried are you both about this?
MRS BALL: I’m a pessimist. My husband is the eternal optimist. I know
that when you start to lose weight, that’s a bad sign.
DR DAY: Mr Ball?
MR BALL: I feel I have to be optimistic, but this time I’m very worried.
DR DAY: What is your main worry?
MR BALL: That I’ll lose my wife (cries, the couple embrace).
DR DAY: It is not easy saying this, but there is a chance that your wife
may not get any better. Are there any immediate decisions or
problems facing you?
MRS BALL I was going to start working again in the next few months and
(CRYING): one of the children is going to university later on this year.
DR DAY: How do you see your illness affecting these?
MRS BALL: We’ll have to put everything on hold until we know where all
this is going to. But I don’t want my daughter staying home
to look after me.
DR DAY: Have you thought about how you are going to tell your
children?
MR BALL: We will be completely open with them both. If things don’t
improve, can we still expect my wife to come home soon?
DR DAY: I can’t see why not. It is important to keep an open mind about
decisions until we have more information from the tests and
investigations. I cannot yet be certain as to what the outlook
is. We will try to arrange for your wife to leave hospital towards
the end of the week. I realise it must be stressful for you both
not yet having a clear idea of how things will turn out. You
can help me by telling me what you would like to know about
the results.
MRS BALL: You can tell us everything. But I would prefer it if my husband
were here with me when you have the results.
DR DAY: We will certainly try to arrange for you to be seen together.

‘What to do if . . . ’
Medical students and doctors often ask: ‘What do I do if a patient cries,
or becomes angry, or threatens suicide?’ Although these reactions are
common, it is nearly impossible to predict how a patient will react to
bad news, even if the patient is well known to us. It is important, how-
ever, to act in a supportive and professional manner. Whatever advice
may be appropriate to the specific situation, only act in a way that is
congruent with your own feelings and within the limits of professional
conduct. For example, if you are uncomfortable holding a patient’s

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 Breaking bad news 73

hand while he cries, do not do so; it will probably come across as

contrived and awkward.

What if the patient cries?

Usually, you would give the patient some tissues, or pause, or say: ‘I can
see you are very upset’. Although some doctors advocate touching (for
example, on the shoulder or arm), be careful not to seem intrusive.
It is usually inappropriate, for example, to hug or kiss a patient. After
a few moments, you should continue talking, even if the patient is still
crying. Very few patients will object, or feel offended, provided the doc-
tor remains sympathetic. For example: ‘I am sorry to have to give you
this news. It’s not easy for me. Were you expecting to hear this?’ By
way of contrast, it would be inappropriate to say ‘Cheer up. Things
could be worse’.
How would you react if a close friend shared some recent bad news with you and
STOP AND THINK started to cry? What do you think the friend might expect of you? How would you
know what to do?

What if the patient becomes angry or violent?

Think about a situation – such as someone trying to take your parking space – and
STOP AND THINK you get into an argument. What is likely to inflame the situation and possibly lead
to violence?
If confronted by an angry patient, you should stand up. The patient will
usually have already stood up, and it is important to be at the patient’s
eye level, and to show your preparedness. You should be polite and firm.
The threat of violence should always be taken seriously, and the occasion
of giving bad news is no exception. In an apologetic, but firm tone, you
might say: ‘I’m sorry to have to give you this news. I realise that you were-
n’t expecting to hear this. However, you may also want to speak to some-
one else and get their opinion’. It is sometimes helpful to add: ‘I can see
that you are upset and annoyed. I would be happy to try and answer any
of your questions’. As a last resort, if you fear for your safety, open the door
or leave the room. Having a colleague nearby may diffuse the situation.

If the patient threatens suicide

In most cases, patients can be talked out of harming themselves or
resorting to suicide. However, this demands patience, care and reassur-
ance. If the patient hints at suicide, make your concerns explicit. For
example: ‘I was wondering where you’re going from here?’ Open discus-
sion about suicidal feelings can be containing for the patient and con-
veys that you are not afraid to confront sensitive issues. A patient who
hints at or who threatens suicide should not be discharged or left alone.

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 74 Communication skills for medicine

The opinion of a psychiatrist or psychologist must be sought in cases

where the patient remains suicidal.

Telling parents they have an abnormal baby

Pregnancy and childbirth are emotional experiences, and to this can be
added the fear of parents that their baby might die or be born with a dis-
ability. Nearly 1 in 40 babies are born with a handicap or abnormality.
The following events are associated with having to give bad news to the
parents and family:
l fetus dies during pregnancy or labour
l fetus has a detectable abnormality, for which a termination may be
indicated
l fetus has a detectable abnormality not requiring termination
l an abnormality is detected only after the baby is born
l a congenital condition becomes detectable in the infant’s first weeks
or months of life.
Tests and scans make it easier to diagnose many conditions at an early
stage, and for this reason parents expect to learn of problems much ear-
lier on in the pregnancy. The following guidelines can be followed when
telling parents that their child has an abnormality:
1. Parents should be told of the problems as soon as possible. They
should preferably be told together. A single mother should be asked
if she would like someone with her, such as a parent, or close friend
or relative. Parents often have hints that all is not well from the
facial expressions of those caring for them. Telling them early on
helps them to adjust to the bad news, before they have to face
telling excited and hopeful friends and relatives.
2. The most senior person should break the news to them. A consul-
tant paediatrician may need to work closely with the obstetrician
in planning how to do this.
3. It may be helpful to make a drawing of the abnormality. Say, for
example: ‘It looks something like this, but not as large.’ The expla-
nation should be brief and simple. Those characteristics or features
should be pointed out that lead one to think that it is an abnormal-
ity. Avoid giving too much detail at this stage.
4. Parents are often afraid of what they will see. Encourage them first
to hold the baby. The baby should be wrapped in a blanket with
only its face showing. This allows the couple to be gradually intro-
duced to the baby and the abnormality. The couple should also be
persuaded to name the baby, and the name should be used by the
doctor and colleagues. For example: ‘Little Ewan has a strong grip’,
or ‘Hannah has a lovely smile’.
5. Positive features should be emphasised, although a balanced and
realistic view should be presented. For example: ‘He seems very
healthy, though you will probably find that because of the problem

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 Breaking bad news 75

with his lip it is difficult to breast-feed him. We will need to give

you some advice about this’.
6. The parents often have a mixed response to the child. On the one
hand, they want to cuddle, nurture and protect the baby. On the
other hand, they may feel bereaved, and experience feelings of guilt,
sadness and loss, or they may be inclined to reject the child. Firstly,
the parents should be reassured that this is a normal reaction. Sec-
ondly, they should not feel responsible for the abnormality.
7. Some parents may not believe what they are being told and may
ignore or dismiss problems. A failure to thrive and the loss of devel-
opmental milestones may become evident in the future (such as
with some children born with HIV infection), and parents should
be given follow-up appointments so that the child can be moni-
tored at regular intervals.
8. Counselling can help parents to overcome their embarrassment and
reluctance to inform relatives and friends. It can also help them
bond with the baby where they may have ambivalent feelings
towards it.
9. When parents and baby leave hospital, they lose a supportive envi-
ronment. Many new problems may only become obvious at this
time. Parents should be given details of organisations that can pro-
vide further information and support.
10. If the baby has died, there are practical considerations (such as sup-
pression of lactation for the mother and making arrangements for
the funeral). The parents should have the opportunity to say good-
bye to the baby, and they may want to hold and cuddle it in the pri-
vacy of a quiet room. Some parents want to keep a memento, such
as a lock of hair or a blanket.
11. As in clinical situations where bad news must be given, it is impor-
tant to ensure that the feelings of professional colleagues (e.g. mid-
wives, health visitors) are attended to through discussion and
support.

Key points
n Giving bad news is among the most challenging of tasks in medical
practice.
n The way bad news is given affects how people cope and adjust.
n Keep an open mind as to what is ‘bad news’. Some patients are
distressed by seemingly good news, whereas others experience
some relief on hearing bad news.
n Before giving bad news, consider to whom it should be given, who
should give it, when it should be given and what are the likely
consequences of giving it.
n It helps to find out what the patient already knows and may want to
be told. Making assumptions about either of these can lead to
serious problems in management.

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 76 Communication skills for medicine

n Giving bad news requires time, a setting free from distractions or

interruptions, empathy, active listening and humility to say that
you may not have the answers to certain questions.
n Elicit the patient’s own resources for coping and instil realistic hope.
n Ensure that colleagues know what the patient has been told.
n Provide support for the patient’s relatives and your professional
colleagues.

FURTHER READING
Barnett M 2002 Effect of breaking bad news on patients’ perceptions of doctors.
Journal of the Royal Society of Medicine 95: 343–347
Buckman R 1992 How to break bad news. Papermac, London
Fallowfield L, Jenkins V 2004 Communicating bad, sad and difficult news in
medicine. Lancet 363: 312–319
Leff P, Walizer E 1992 The uncommon wisdom of parents at the moment of
diagnosis. Family Systems Medicine 10: 147–168
Ptacek J, Ellison N 2001 I’m sorry to tell you . . . Physicians’ reports of breaking
bad news. Journal of Behavioural Medicine 24: 205–217
Simpson R, Bor R 2001 I’m not picking up a heartbeat. Experience of sonogra-
phers giving bad news to women during ultrasound. British Journal of Medi-
cal Psychology 74: 255–272

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