Breaking Bad News to Patients
When delivering bad news, use a structured approach centered on the SPIKES protocol: ensure privacy, assess the patient's understanding first, deliver the news clearly in plain language, pause for emotional response, respond empathically, and conclude with next steps and commitment to ongoing support. 1
Preparation and Setting
Before the conversation begins, secure a private, uninterrupted environment and mentally prepare for the patient's potential emotional reactions. 1, 2
- Consider having supportive colleagues (nurses, social workers) present to help support the patient during and after the conversation 1, 2
- Plan in advance what specific information needs to be conveyed and anticipate how the patient might respond emotionally 1
- Recognize that most patients will bring family members or companions who will actively participate—be prepared to address the needs of everyone in the room, not just the patient 1, 3
Assess Patient Understanding and Information Preferences
Start by asking what the patient already understands about their situation using open-ended questions like "What have other doctors told you?" or "What is your understanding of why we're meeting today?" 1, 3
- This establishes baseline comprehension and tells you where to begin the conversation 1, 2
- Determine how much information the patient wants to know—some patients want detailed information while others prefer less 1
- For ambivalent patients, discuss the pros and cons of knowing detailed information 1
- Attempt to get input from each participant in the room about their information preferences, not just the patient 3
Deliver the Bad News
Give a "warning shot" by saying something like "Unfortunately I don't have very good news for you. Are you ready to hear this?" 1, 2
- This prepares the patient psychologically for what's coming 1
- Deliver the bad news clearly and succinctly in plain, nontechnical language (e.g., "Your cancer unfortunately has spread to your liver") 1
- Avoid pathophysiologic discussions and medical jargon—these are confusing and unhelpful 1, 2
- Pause after delivering the bad news and use supportive silence to allow the patient to absorb what has been said 1
Respond to Emotional Reactions
Wait for the patient to respond before saying anything more—if they remain silent, ask "What's going through your mind?" or respond empathically (e.g., "You look overwhelmed") 1
- Acknowledge and name emotions when patients or family members display them 3
- Express solidarity with statements like "I wish I had better news" 1
- Do not try to reduce patient distress by minimizing the bad news or changing the subject—this is a common pitfall that undermines trust 1
- Titrate the amount of additional information to the patient's emotional state—when patients are highly emotional, they have difficulty processing new information 1, 3
Provide Information in Manageable Pieces
Recognize that most bad news conversations involve multiple pieces of difficult information, not just one central piece of news. 1
- Break information into small, discrete chunks and check regularly for understanding 1
- Provide information in multiple formats (words, numbers, ranges) 1
- Use mixed framing (e.g., chance of cure AND chance of relapse, or best/worst/most likely outcome) 1
- Make clear transitions between pieces of information and explicitly explain how different pieces relate to each other 1
Conclude with Strategy and Support
Before ending the conversation, discuss the meaning of the findings and establish clear next steps. 1
- Summarize what was discussed and the plan going forward 1, 2
- Affirm your commitment to supporting the patient with statements like "It's my job to help you get the best care possible" or "I'll continue to take care of you whatever happens" 1
- Encourage patients to ask questions by saying "What questions do you have?" and use silence to create space for concerns 1
- Help the patient find additional sources of support (family, friends, support groups, therapist, social worker) as appropriate 1
Critical Pitfalls to Avoid
Do not assume the conversation will follow a linear script—be prepared to adapt as the discussion unfolds in unpredictable ways. 3
- Companions often ask more questions than patients (62% vs 38%)—address everyone's needs, not just the patient's 3
- Be prepared for potential conflicts between family members' wishes and patient preferences 3
- Don't make assumptions about what constitutes "bad news" for a particular patient—what seems minor to you may be devastating to them 3
- Inquire about religious and spiritual needs, as spiritual issues are central to the existential crisis of serious illness and understanding these values improves communication 1, 2