Giving Bad News: An Effective Three-Step Approach

By Edward Leigh, MA

"Breaking bad news is not as much a delivery as it is a dialogue between two people."
– Rabow MW, McPhee SJ. Beyond breaking bad news: how to help patients who suffer. West J Med 1999;171:260-3.

One of the most difficult tasks for a healthcare professional is to deliver bad news. It is never an easy activity even for the most seasoned of professionals. However, there are steps we can take to be sure the news is delivered in the most effective and caring manner.

The Definition of "Bad News"

We tend to think of bad news as telling a patient they have a terminal disease. However, that is a type of bad news. There are multiple types of bad news. For example, telling a construction worker he can’t lift heavy objects for six months is bad news if that is his livelihood. Also, telling a person they have a chronic disease, such as diabetes, is also a type of bad news.

Bad news can be any type of news that will negatively impact a patient in any way.

Is it Always Necessary to tell a Patient the Bad News?

Fifty years ago, it would not be unusual to withhold a terminal cancer diagnosis from a patient. However, recent studies have shown that patients do want to know this information. It is important that patients are given all the details of their health situation; they have a right to know. They may want to make decisions regarding wills and other legal matters.

Based on a case-by-case basis, there may be situations where withholding information may be a good option, such as in the case where a patient may have a mental breakout or harm themselves. In some cases, the patient themselves may ask not be told. This should be looked at as a type of informed consent.

Steps in Giving the Bad News

I. Before Giving the News

Think about the agenda before you meet the patient, so that you have the significant information available. There are several items to consider when planning what to say: specific diagnosis, treatment plans, prognosis, and support strategies. For a patient who has been shown to have hypertension, this would be an appropriate manner of discussing: specific diagnosis (describe diagnosis of high blood pressure, avoid medical jargon like the term hypertension), treatment plans (discuss different options to treat high blood pressure), prognosis (discuss successful options for treating, however be careful of not guaranteeing 100% success), and support strategies (provide resources to help cope).

Prepare for the conversation with the patient. Think about what you want to say. Mentally rehearse your words so you feel more comfortable sharing the news.

Have a box of tissues in the room in case the patient begins to cry.

II. Giving the News

Physical setting: Find a quiet private place to share the news. Be sure you are seated at eye level with the patient. Avoid any physical barriers, such as a desk. Ask the patient who else should be present; let the patient decide who, if anyone, should be present in the meeting. Silence all beepers and request no interruptions unless it is an absolute emergency.

Communication strategies:

• Give the patient a warning that difficult news is forthcoming, such as by stating, "I'm afraid the results reveal the situation is more serious than we would have hoped for...")
• The patient is your first priority, however if the patient has other people present (e.g., spouse), be sure to attend to those people as well.
• Speak slowly, clearly and concisely.
• Provide the information in small chucks; do not give a long lecture which can be overwhelming to an already anxious patient.
• After discussing each segment, pause to allow the patient to take in what you have stated. This is known as "chunk and check."
• Be honest about the prognosis; do not give false hope. Be sensitive, yet direct.
• Use empathy in the discussion (e.g., "I know this is difficult news.")

Assess current level of knowledge. Determine how much the patient already knows, such as by asking, “What have you already been told about your illness?” Pay close attention to what the patient says to evaluate their level of sophistication regarding the illness and their current emotional state.

Ask the patient how much they would like to know. Inquire as to whether they want all the details or just the “big picture.” Emphasize the fluidity of the dialogue, so they know they could always ask more questions at a later time.

III. After Giving the News

Be very attentive to the patient’s feelings. After you have shared all the news, listen very carefully to the patient’s reaction while observing body language. Use empathy (e.g., "I know this has been very stressful to hear.")

Emphasize your role as a partner. Let the patient know you are working with him or her on this medical issue ("We will be working together to help you."). Confirm your role as an advocate for the patient.

Follow up plan. This is a time for reviewing, summarizing and making next steps. Develop a step-by-step plan, review the plan with the patient and then agree on follow up plans. Provide resources, which could be a referral to a counselor (if needed), brochures, phone numbers and websites.

Closing Thoughts

Healthcare professionals are taught technical skills to attend to the patients' physical needs. However, when giving bad news, the greatest skill is effective communication. Unfortunately, during a healthcare professionals' formal education, communication skills are often not given the vital importance they deserve. A growing body of evidence illustrates how the communication skills of the healthcare professional will greatly influence how well a patient will cope with the bad news.

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