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Discussing serious news

Discussing serious news
Stephanie M Harman, MD
Robert M Arnold, MD
Section Editor:
Susan D Block, MD
Deputy Editor:
Jane Givens, MD, MSCE
Literature review current through: Dec 2022. | This topic last updated: Jul 19, 2022.

INTRODUCTION — Discussing serious news, or breaking “bad news” is a common communication task in clinical care. Virtually every clinical specialty requires doctors at some stage to be the bearers of sad, bad, or difficult news. The ability to deliver “bad news” compassionately is a core skill for all primary care and subspecialty clinicians.

This topic will cover how we define “bad news,” review the evidence that exists regarding patients’ and families’ preferences about getting such news, summarize clinicians’ preferences and skills in disclosure, and review existing strategies for this communication task. Specific issues related to communication about prognosis in advanced, serious illness and estimating survival in individuals with advanced cancer are covered elsewhere, as are discussions on conveying the diagnosis of fetal demise and communication with families in the event of the death of a child. (See "Communication of prognosis in palliative care" and "Survival estimates in advanced terminal cancer" and "Stillbirth: Maternal care", section on 'Conveying the diagnosis of stillbirth' and "Assessment of the pediatric patient for potential organ donation", section on 'Family communication' and "Sudden unexpected infant death including SIDS: Initial management", section on 'Family communication and support' and "Pediatric palliative care", section on 'Communication and building relationships'.)

DEFINITIONS — “Bad news” has been defined as “any information likely to alter drastically a patient’s view of his or her future…” [1] or that “…results in a cognitive, behavioral, or emotional deficit in the person receiving the news that persists for some time after the news is received” [2]. Inherent in defining what constitutes "bad news" is that it depends heavily on the patient’s beliefs and perceptions. As an example, a hospitalized patient may be relieved by a diagnosis of liver abscess because they previously believed that the diagnosis was cancer. On the other hand, the diagnosis of diabetes may be viewed as horrific news if an individual believes that this means that they, perhaps like a parent, will need an amputation.

In this topic review, the term “serious news” will be used rather than “bad news.” This preference is based upon a qualitative study in which patients listened to these conversations and gave feedback about what they liked and disliked [3]. Patients did not like clinicians judging whether the news was bad, and they highlighted the value of framing the news as something to work through and manage with the guidance of the clinician rather than labeling it as “unfortunate or bad.” Another alternative term for “breaking bad news” is “sharing life-altering information” [4].

PATIENTS’ PREFERENCES WHEN RECEIVING SERIOUS NEWS — In considering how to conduct these conversations, it is important to take into account the preferences of patients and families or other loved ones regarding what information is disclosed, how the information is delivered, and who delivers it.

Many patients prefer to be informed of their diagnoses, with some studies demonstrating this preference in more than 95 percent of patients in differing countries [5,6]. There is some variation in what specific types of information patients want to know, particularly among those who are receiving a cancer diagnosis [5,7]. For patients with newly diagnosed cancer, the vast majority want to know about their chances for cure and the effectiveness of cancer-directed treatments [7,8], but a lower percentage wants to know their specific prognosis [8]. While older patients and men may be more reluctant to discuss prognosis, there are no other sociodemographic, illness severity, educational, or disease-specific factors that reliably predict who wants more (or less) information. (See "Communication of prognosis in palliative care", section on 'Assessing patient and/or family readiness to discuss prognosis'.)

Cultural differences in patient or family/loved ones’ preferences deserve special mention, particularly when the disease is cancer. For example, in multiple countries, oncologists usually inform patients of their diagnosis, and the vast majority of patients want to know their diagnosis and prognosis [9]. However, in some cultures, fewer than half of patients are told their diagnosis, and there is a higher prevalence of wanting to avoid discussing prognostic information. A systematic review of studies examining patient preferences for breaking serious news noted that the majority of patients in North American and European studies wanted to discuss life expectancy, but that figure decreased to 30 percent or fewer in studies of patients in Asia [8]. There is some evidence that things may be changing in some Asian populations. A 2015 study from Japan on communication preferences during the transition between active anticancer treatment and palliative care noted that the majority of patients preferred their physicians to be realistic about their likely future [10]. In a 2016 study of patients treated in an oncology clinic in India, 72 percent of patients wanted disclosure of the cancer diagnosis [11].

The reasons for these differences in disclosure practices and preferences are multiple:

In many cultures, a diagnosis of a serious disease like cancer is associated with social stigma and perceptions that diseases like cancer are incurable [12-15]. In other cases, particularly in Asian countries where there is a family-centered model of decision-making, families ask clinicians not to reveal the diagnosis and prognosis to patients [13]. One reason may be the fear on the part of families that the patient might commit suicide or otherwise die sooner out of despair or loss of hope [15,16], although there is no evidence to suggest that this occurs. Practical strategies to deal with families or other loved ones who request that information be withheld from the patient are presented elsewhere. (See "Ethical issues in palliative care", section on 'Requests from the family to withhold information'.)

Discussing serious news with people from different cultures is affected by fundamental cultural values and beliefs, as well as communication barriers, often based on language differences requiring the use of an interpreter and a lack of intercultural training [17].

How the news is delivered is just as important as what news is conveyed. Qualitative studies of patients’ views have revealed the importance of the manner in which patients are given serious news: in person rather than by telephone, an atmosphere that welcomes questions, using clear and direct language (without euphemisms or medical jargon), honesty, optimism rather than pessimism, and adequate time [18], privacy, reassurance of an ongoing plan, and appropriate support (having a trusted companion attend the meeting) are all important aspects [8,19,20]. A 2018 survey of patients with serious illness who were part of an online community confirmed these findings and also noted that empathetic physical touch was not considered important and was unwanted by some [21].

Patients differ in what information they want and how they want to receive it. In a study of 100 women with early breast cancer at six teaching hospitals in Sydney, Australia, 91 percent of women wanted to know their prognosis prior to commending adjuvant treatment, but 63 percent wanted the cancer specialist to check with them first before giving it [19]. Most wanted their oncologist to check their understanding, provide an opportunity to ask questions, and explain medical terms. Emotional support was desired by 79 percent, and 97 percent wanted their fears and concerns listened to.

Because it is difficult to predict individual preferences, these findings suggest that all patients should be asked how much and what type of information they want, in order to tailor the information disclosure to the patient's preferences.

A questionnaire has been developed to specifically explore patient preferences regarding the content and context of these conversations as they apply to cancer (the Measure of Patients’ Preferences questionnaire); such information can increase understanding of what is important to patients when they are told serious news [22].

CLINICIANS’ PREFERENCES WHEN COMMUNICATING SERIOUS NEWS — In considering how clinicians communicate serious news, it is helpful to understand the evolution in clinicians’ attitudes toward these conversations. At present, clinicians generally believe that patients should be informed of their diagnoses, but this represents a large shift from attitudes earlier in the 20th century. Western medicine has slowly transitioned from a paternalistic model to one that is based upon informed, shared decision-making. The doctrine of informed consent obligates clinicians to provide patients with information that is critical to their decision to accept or refuse treatments. Going beyond informed consent, the shared decision-making model promotes a bidirectional exchange of information so that patients and clinicians can deliberate collaboratively about the best course of action to take. (See "Informed procedural consent".)

However, clinicians generally prefer not to disclose all of the available information; a study of patients with esophagogastric cancer found that clinicians were more likely not to disclose a diagnosis that was associated with a poor prognosis as compared with one with a better prognosis [23]. Other studies have shown similar patterns of censoring how much information is disclosed when discussing serious news [24]. Factors that influence clinicians' behavior include lack of control (over time or setting), feelings of failure or inadequacy, fear of the patient’s emotions as well as one’s own emotions, and lack of knowledge to answer anticipated questions [25]. Provider and patient characteristics such as age, sex, race, and ethnicity may also influence communication [26-29]. (See "Communication of prognosis in palliative care", section on 'Rationale for discussing prognosis'.)

Information disclosure is also affected by geographic and cultural factors [30,31]. In a questionnaire study of 167 oncologists attending the 1999 Annual American Society of Clinical Oncology (ASCO) meeting about their attitudes and practices about giving serious news, physicians from Asia and South America were more likely to withhold unfavorable information at the request of the family, avoid the discussion entirely, and give treatments known to be ineffective so as not to destroy hope than were their Western counterparts from Europe and North America [30]. (See 'Patients’ preferences when receiving serious news' above.)

However, the available data suggest that most patients, even those within these cultures, actually want to know their diagnosis [32]. Fortunately, cultural barriers to giving serious news can be overcome through use of specific communication skills, including some widely used models such as SPIKES or SHARE [31,33,34]. Clinicians can and should promote hopefulness without endorsing unrealistic optimism [35-37]. (See 'Approaches to breaking serious news: existing models and key elements' below.)

Strategies to deal with situations where families or other loved ones ask that the diagnosis of a serious life-threatening disease be withheld from the patient are presented elsewhere. (See "Communication of prognosis in palliative care", section on 'Assessing patient and/or family readiness to discuss prognosis'.)

Views of patients and families on how clinicians communicate serious news — Patients’ experience of how clinicians deliver serious news has a profound impact on their understanding about their illness, decisions about treatment options, and later adjustment to the diagnosis.

In general, patients are quite critical of how clinicians deliver serious news, as evidenced by the following data:

A 2004 study of amyotrophic lateral sclerosis (ALS) patients and their caregivers showed that 56 percent of patients and 48 percent of caregivers thought that their providers had shown average or below-average communication skills when disclosing a new diagnosis of ALS [38]. However, a 2016 study of family caregivers of patients with motor neuron disease showed somewhat better satisfaction among family carers, 67 percent of whom rated the neurologists as above average in their skill [39].

In a study comparing cardiology patients’ communication preferences and cardiologists’ communication behavior, patients desired more open communication of stressful or unpleasant aspects of their illness [40].

A German study surveyed 344 patients on how their providers disclosed a new cancer diagnosis by asking them specific questions that paralleled the communication elements of the SPIKES framework model for communicating serious news (table 1) [41]. (See 'Approaches to breaking serious news: existing models and key elements' below.)

Only 46 percent of patients were satisfied with the communication from their provider; multiple critical components of SPIKES model were not done adequately from the patients’ perspective, such as addressing emotions and giving a clear explanation of the diagnosis. In addition, an explanation of the course of disease, which the patients wanted, was reported to have occurred in only 41 percent of cases. A limitation of this study is that the actual conversations were not recorded and the data were dependent on patients’ recall.

We are not aware of any data to suggest that retention of serious news conversations is worse than other conversations. There is a single qualitative study that showed responding to patient emotions can improve information recognition but not free recall [42].

Clinicians must endeavor to improve their communications skills when delivering serious news. The difficulty for most doctors is getting the balance right, of being honest but at the same time encouraging, hopeful, and supportive [35]. Approaches that are based upon existing models are discussed in detail below.

IMPACT OF COMMUNICATING SERIOUS NEWS ON PATIENTS AND CLINICIANS — Patients differ in their ability to integrate threatening information. The manner in which bad, sad, or difficult information is received depends on many factors, including expectations, previous experiences, and general personality disposition. Not surprisingly, some patients have significant negative emotional responses to receiving serious news. Multiple studies describe a range of negative emotions among patients or families/loved ones including shock, horror, feeling upset, disbelief, anger, and feeling depressed [43-46].

The way in which serious news is conveyed can substantially influence the impact of receiving this news, including the emotional response, beliefs and attitudes toward the medical staff, and how patients view their future [47]. Studies of patients with early breast cancer have identified negative feelings and experiences associated with certain clinician behaviors such as giving inadequate information or not adequately explaining the medical information, rushing the patient for a treatment decision, and not addressing patients’ feelings about the news. In one study, when doctors were willing to address patients’ feelings at the time of the serious news discussion, there were significantly fewer anxiety symptoms experienced 4 and 13 months after the initial disclosure of serious news [45]. Others have shown greater satisfaction, less anxiety, and more treatment compliance when doctors asked patients about their perceptions of and reactions to their problems and how their illness impacted their daily lives [48].

In particular, communication about prognosis in patients with metastatic disease can be emotionally difficult. How to discuss prognosis in the context of palliative care is discussed in detail elsewhere. (See "Communication of prognosis in palliative care", section on 'Discussing prognosis'.)

Communicating serious news can also negatively impact the clinician. Multiple clinician surveys demonstrate that clinicians find discussing serious news stressful [49,50]. Many doctors have difficulty handling their own emotions, which may include sorrow, guilt, identification, and feeling like a failure. There is little evidence that these difficulties get easier as doctors become more experienced.

The stress of these conversations can last hours and up to several days after the actual conversation [49]. Oncologists highlight this type of communication as a contributing factor to burnout [51-53]. Inadequate training in communication skills has been cited as a reason why breaking serious news contributes to clinician stress [54-57]. “Balint groups” or training in mindfulness have been suggested as ways to improve oncology trainees’ self-reflective skills, and emotional resiliency as well as reduce burnout [58].

Issues regarding communication of prognosis in palliative care are discussed in detail elsewhere. (See "Communication of prognosis in palliative care".)

INFLUENCE ON CLINICAL OUTCOMES — There is compelling evidence from the literature demonstrating that good, patient-centered communication is associated with many important and meaningful health outcomes, including adherence to drug regimens, pain control, patient satisfaction, trust in the clinician, and physical health outcomes [47,59-61]. However, there have been relatively few high-quality studies examining how enhanced communication skills to deliver serious news directly impact patient/family outcomes [62,63]. A review of 245 publications on the topic of breaking serious news to cancer patients found that less than 2 percent were rigorous intervention studies that addressed psychosocial outcomes [62]. Furthermore, the results of these intervention trials are mixed:

A 1995 trial that randomly assigned 69 primary care providers to no training or communication courses on emotion-handling or problem-defining skills demonstrated lower emotional distress in the patients of clinicians who had received a communication course, which persisted as long as six months [64].

Another randomized controlled trial of 69 physicians who were exposed or not to two four-hour communication skills workshops found that while the clinicians’ self-reported ratings of their communication skills moderately improved, patient satisfaction scores were not better [65].

Similarly, another randomized trial conducted in Belgium demonstrated no impact on patient anxiety when clinicians underwent a basic two-and-a-half-day communication skills course in addition to six three-hour consolidation workshops versus no consolidation workshops [66].

This same group conducted a randomized controlled trial with oncology nurses in which the intervention group received a 105-hour training course that resulted in some improvement in patient satisfaction [67].

Several systematic reviews have examined the benefits of communication training:

In a review of data from 15 separate randomized controlled trials involving oncology clinicians, communication skills training programs improved clinician skills, but there was no evidence of improvement in patient outcomes [68].

An earlier Cochrane review of 43 randomized controlled trials examining communication intervention studies in a variety of clinical consultation settings showed mixed results regarding patient-based outcomes, such as health status or patient satisfaction and health behaviors [69].

A systematic review of 11 randomized trials of communications interventions for generalist palliative care providers showed positive effects on clinician empathic behavior, but no effect on patient outcomes and high levels of heterogeneity among the included studies [70].

A benefit for communication skills training of oncology nurses was suggested in a trial in which 89 patients who had a physician consultation informing them of a new diagnosis of cancer were randomly assigned to receive nursing support (three one-on-one nurse interviews on the day of, one week after, and one month after diagnosis) from nurses who had or had not been specifically trained in communication skills [71]. Support by nurses who had completed a communication skills training program was associated with less psychologic distress and improved coping.

When focusing on more specific clinician skills related to discussing serious news, there is growing evidence that clinician empathy, as rated according to observable communication skills, influences and improves health outcomes, with at least two studies showing improvement in clinical outcomes for patients with diabetes in conjunction with higher clinician empathy scale scores [72,73].

Can communication skills be taught and learned? — While there are no consistent findings from randomized interventional studies that demonstrate better patient outcomes after modifying communication skills to deliver serious news, there have been a number of studies demonstrating that clinician skills in these conversations can be improved among trainees as well as post-graduate level clinicians [4,31,63,74-81]. As examples:

Improvements and acquisition of communication skills in oncology fellows were seen after four-day intensive retreats that emphasized skills practice, simulation, and small group work [75]. The primary outcomes were observable participant communication skills in giving bad news and discussing transitions to palliative care as measured during standardized patient encounters before and after the workshop. Within these encounters, participants improved skills in eliciting the patient’s perception of their illness, asking permission to give the serious news, the act of sharing the news itself, and attending to the patient’s emotions.

Multiple studies using simulated patients, including randomized controlled trials, have shown similar improvement in these skills in house staff, particularly in internal medicine and pediatrics [76-78].

The benefit of attending a communication skills course for attending clinicians was shown in a controlled study in which 160 senior oncologists were randomly assigned to attend a communication skills course, receive written feedback, receive written feedback plus the course, or control (neither coursework nor feedback) [82]. The outcomes of the study were videotapes of actual patient encounters at baseline, post-intervention, and six months later. Course attendance was associated with significant improvements in multiple communication skills to share serious news, such as showing empathy and summarizing the information in actual patient encounters; written feedback had no effect. Interestingly, these benefits were even more pronounced at six months post-intervention.

Computer-based training is also effective. In one trial, 48 general, gynecologic, or radiation oncologists were randomly assigned to receive a communication lecture alone or the lecture plus a computerized, interactive CD-ROM which included training on responding to patients’ negative emotions and provided specific feedback to the clinician [83]. Subsequent clinic encounters were recorded. The intervention oncologists used more empathic statements and were significantly more likely to respond to negative emotions empathically than control oncologists. Their patients also reported higher trust in their oncologists, although there was no significant difference in perception of communication skills.

A 2017 guideline from the American Society of Clinical Oncology (ASCO) recommends communication skills training for oncologists and presents best practices for core communication skills when clinicians are communicating with patients and their loved ones about goals of care, prognosis, treatment options, and end-of-life care (table 2) [84]. Alternatively, several web-based tools (eg, VitalTalk) are available to assist in improving communication skills for discussing serious news.

APPROACHES TO BREAKING SERIOUS NEWS: EXISTING MODELS AND KEY ELEMENTS — While the communication skills needed to disclose serious news represent a distinct type of communication, they are built upon fundamental communication skills that are used in more ubiquitous clinician-patient communication models such as in the approach to the medical interview. The fundamental prerequisites for effective communication are that the amount of information is adequate, and that it is understood, believed, remembered, and, hopefully, acted upon.

These same skills have been incorporated into more complex communication processes, such as discussing goals of care and end-of-life care issues (see "Advance care planning and advance directives"). There are also models incorporating these skills for discussing prognosis as a specific type of serious news (see "Communication of prognosis in palliative care"). For example, the Serious Illness Care Program combines a structured conversation guide that offers different ways to share prognosis in the context of serious illness. Studies of the use of this conversation guide with communication training and health system implementation did not improve goal-concordant care; this multimodal approach has been shown to improve the frequency, timing, and quality of conversations in oncology and primary care settings [85,86].

During the last decades, a range of guidelines or models have been developed that serve as a framework for communicating serious news. Most follow a linear approach essentially consisting of similar steps: preparation for disclosure (getting the setting right, finding out how much the patient knows and wants to know); disclosure (using clear, direct language, delivered empathically, and checking for understanding); and follow-up (responding to emotions, answering questions, identifying next steps, closing the interview).

The most commonly used and cited model in the literature was developed by Walter Baile and colleagues and is called SPIKES (table 1) [87]. While it was initially developed for patients with cancer, the model is applicable to a wide variety of clinical scenarios. Several guidelines, including those used for sharing life-altering information in pediatrics, are based upon this framework [4,31]. Since then, there have been several other models created, including ABCDE, GUIDE, and BREAKS (table 1) [87-90]. All of these models have their major communication elements in common, with some variation in the specific terms used and the sequence of the elements.

Preparation and setting — Clinicians should make efforts to create a quiet place, set aside adequate time protected from interruptions (ie, quieting pagers and cell phones), and determine in advance who the patient would like to be present with them for the conversation. This is the time to gather the medical information needed, including the relevant data (imaging, test results, etc) and the options for next steps such as treatment options and possible care plans. In some circumstances, preparation requires having conversations with consultants who may be involved in the patient’s care so that the patient receives consistent information. A medical interpreter should be scheduled for patients with limited English proficiency. (See "The patient’s culture and effective communication", section on 'Language and literacy'.)

Asking the patient/family what they understand or perceive — Early in the conversation, it is helpful to ask patients what they know already and use active listening techniques (cues such as leaning in, eye contact, an open posture) as patients, families, or other loved ones respond. This prepares the clinician to fill in gaps in information and understand how the patient may respond to the new information, and it prevents unnecessary confusion before new information is delivered. Example phrases include:

“To start, I want to make sure we are on the same page. What is your understanding of your medical situation?”

“What have your doctors told you so far?”

“You had a CT scan of your belly yesterday; what did the doctors say about why we did the CT?”

Sharing the serious news itself — In delivering information, utilize simple and direct language with attention to keeping the news brief. A 2019 study of patient and clinician interpretations of the word “treatable” underscored that there is implied meaning in certain words, and that while patients, families, and other clinicians may be able to repeat what has been said, they may not have a shared meaning of certain words [91]. Some models suggest “firing a warning shot” (eg, “I am sorry that the test did not show what we hoped for”), although a 2011 article suggested that patients did not like this [3]. Avoid medical jargon, and remember that the average health literacy level in America is intermediate (eg, can follow instructions on a medication bottle but cannot determine what their health insurance costs) [92]. After giving the information, pause and allow the patient or family/loved ones time to respond. This may be a long period of silence (10 seconds or more); they are likely to need some time to process the information.

“Your CT scan showed new spread of the cancer into your liver.” Then, pause.

“Because of this new stroke, he can’t get a liver transplant anymore.”

If part of the serious news is introducing uncertainty (as when talking about prognosis), it may be helpful to use a statement pairing hope and worry which can convey uncertainty and express the clinician’s partnership with the patient [93]. For example, a clinician may say, “While I hope your lungs will get better, I worry that your breathing will continue to get worse and we may need to make some important decisions.”

Attending to emotions as they arise — Emotions run deep and stakes are high in these conversations. Clinicians should expect and plan for emotions of the patient and family/loved ones in response to the news. In fact, one of the ways to know that the patient heard the news is that they will respond with an emotion. Acknowledging emotions supports others through the process. A study of women with breast cancer who watched videos of doctors found that 40 seconds of empathic behavior was noted and preferred. A communication tool we find helpful for addressing emotion is the “NURSE” mnemonic (table 3), which offers several different ways to respond to emotion: naming the emotion, expressing understanding, giving respect (or praise), offering support to the patient, and exploring the emotion further [94,95]. “PEARLS” is another mnemonic that does the same thing and stands for partnership, emotion, apology/acknowledgment, respect, legitimization, and support [96].

Often, a question immediately after receiving serious news reflects emotion rather than a cognitive inquiry (“Am I going to die?”). We would recommend hearing such a question as an expression of emotion, identifying the emotion behind the question, and then responding to the emotion (eg, “This is shocking to hear”). Patients and families/loved ones cannot effectively process information when they are emotionally overwhelmed. Thus, it may be best to check in before you turn to giving a plan or discussing the news’ implications (“Is it ok that I talk about the next steps?”).

Sometimes patients may be quiet for an extended period (one minute) after hearing serious news. In this situation, it can help the patient to begin processing the news by asking “What is it like for you to hear this news?”

Planning and discussing next steps — This element involves discussing the plan. Serious news disrupts one’s expectations about the future. This step is important because it makes the future less scary and more predictable. From our experience, this is the element that is consistently considered very important from the patient’s/family’s view. Patients have described the importance of guidance on the part of the clinician; even with the gravest of news, they want to know what comes next and what the clinician will do [3]. This does not necessarily mean that the patient or family/loved ones need to make decisions on treatment plans immediately. It may mean discussing follow-up appointments and upcoming tests so as to make the future more predictable and decrease one’s fear of the unknown. As this step signals the ending of the encounter, it is also an opportunity to check in with the patient as to what other questions they have as well as their understanding of the new information and the plan moving forward.

“There are several options for treatment that we can discuss right now; you don’t have to make any decisions today. I’m going to refer you to our surgeon, Dr. X, to discuss the surgical option…and I will set up a follow-up appointment to see you again next week.”

It is important to realize that many patients, despite wanting “all the information” will not remember most of the details [97,98]. It may help to think of the provision of information as helping the patient cope with their disrupted future rather than to educate the patient. In addition, given the low information transfer, one should start the next visit by inquiring what the patient took away from the last visit and being willing to review previously stated information.

Approach to patients with intellectual disabilities — The task of delivering serious news to patients with intellectual disabilities and their caregivers can pose challenges for clinicians. Reasons clinicians avoid sharing serious news include: wanting to prevent patient distress; possible limitations to the patient’s capacity to understand the concepts of illness, treatments, and death; the clinician’s sense of a lack of time; conflicting views among stakeholders about whether, what, and how to disclose news; and a lack of knowledge as to how to best deliver the news on the part of the bearer [99]. Among the reasons to disclose the serious news are the right to know, the sense that knowledge helps the person cope, and the need for involvement in order to plan the future.

Attempts to adapt existing guidelines to the needs of such individuals, keeping a similar step-by-step approach but allowing for more complex communication needs, have met with mixed success [100-102]. Patients with intellectual disabilities may not easily process verbal information in a clinical setting. Newer models have been proposed in which information is broken down into singular chunks of knowledge that can be added over time to patients’ existing framework of knowledge [99,103]. Some have proposed use of a single guiding question in consultation with the range of stakeholders, including family or other loved ones, and paid and unpaid carers: What parts of the truth should the person be helped to understand, and when? The answer to this question should be informed by an assessment of the person’s capacity to understand abstract concepts, their concept of time, their need to understand current and future changes in their lives, their need for involvement, their background (life) experiences and ways of coping, and their own preferences around disclosure. An algorithmic approach to disclosure is presented (algorithm 1). Determining decision-making capacity is discussed elsewhere. (See "Assessment of decision-making capacity in adults".).

A simpler model has been proposed that was based upon a study involving focus groups and interviews of patients with intellectual disabilities, family or other informal carers, and medical providers [99].

Additional resources for communication of serious news during the COVID-19 pandemic — During the coronavirus disease 2019 (COVID-19) pandemic, there have been a number of resources and articles published to facilitate virtual communication via videoconferencing or telephone while patients, caregivers, and family members or other loved ones have limited access to in-person visits [104,105]. Strategies for holding serious illness conversations via telemedicine are available in the table (examples are in the setting of COVID-19 but applicable to other illnesses) (table 4). (See "Telemedicine for adults", section on 'Serious illness and hospice'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Palliative care".)


Discussing serious news is a common communication process that clinicians and patients can find challenging. Virtually every clinical specialty requires doctors at some stage to be the bearers of sad, bad, or difficult news. (See 'Introduction' above.)

The term “serious news” is preferred to “bad news” as what constitutes “bad news” depends heavily on the patient’s beliefs and perceptions. (See 'Definitions' above.)

In general, patients would like clinicians to share serious news in a quiet, private setting, use straightforward language without medical jargon, and offer support and a clear plan for next steps. Preferences vary in terms of how much information they want providers to give and whom they would like to have present. (See 'Patients’ preferences when receiving serious news' above.)

The manner in which bad, sad, or difficult information is received depends on many factors, including expectations, previous experiences, and general personality disposition. Not surprisingly, some patients have significant negative emotional responses to receiving serious news. (See 'Impact of communicating serious news on patients and clinicians' above.)

The core elements of a conversation to deliver serious news include preparation and setting, asking the patient/family/loved ones what they understand, sharing the news and avoiding jargon, attending to emotions, and planning for next steps. (See 'Approaches to breaking serious news: existing models and key elements' above.)

While there are no randomized interventional studies demonstrating improved patient outcomes after modifying skills to deliver serious news, a number of studies demonstrate that clinician skills in these conversations can be improved in both trainees and more senior clinicians. (See 'Influence on clinical outcomes' above.)

A 2017 guideline from the American Society of Clinical Oncology (ASCO) recommends communication skills training for oncologists and presents best practices for core communication skills when clinicians are communicating with patients and their loved ones about goals of care, prognosis, treatment options, and end-of-life care (table 2) [84]. Alternatively, several web-based tools (eg, VitalTalk) are available to assist in improving communication skills for discussing serious news. (See 'Can communication skills be taught and learned?' above.)

  1. Buckman R. Breaking bad news: why is it still so difficult? Br Med J (Clin Res Ed) 1984; 288:1597.
  2. Ptacek JT, Eberhardt TL. Breaking bad news. A review of the literature. JAMA 1996; 276:496.
  3. Back AL, Trinidad SB, Hopley EK, et al. What patients value when oncologists give news of cancer recurrence: commentary on specific moments in audio-recorded conversations. Oncologist 2011; 16:342.
  4. Wolfe AD, Frierdich SA, Wish J, et al. Sharing life-altering information: development of pediatric hospital guidelines and team training. J Palliat Med 2014; 17:1011.
  5. Cox A, Jenkins V, Catt S, et al. Information needs and experiences: an audit of UK cancer patients. Eur J Oncol Nurs 2006; 10:263.
  6. Rajasooriyar C, Kelly J, Sivakumar T, et al. Breaking Bad News in Ethnic Settings: Perspectives of Patients and Families in Northern Sri Lanka. J Glob Oncol 2017; 3:250.
  7. Rutten LJ, Arora NK, Bakos AD, et al. Information needs and sources of information among cancer patients: a systematic review of research (1980-2003). Patient Educ Couns 2005; 57:250.
  8. Fujimori M, Uchitomi Y. Preferences of cancer patients regarding communication of bad news: a systematic literature review. Jpn J Clin Oncol 2009; 39:201.
  9. Jenkins V, Fallowfield L, Saul J. Information needs of patients with cancer: results from a large study in UK cancer centres. Br J Cancer 2001; 84:48.
  10. Umezawa S, Fujimori M, Matsushima E, et al. Preferences of advanced cancer patients for communication on anticancer treatment cessation and the transition to palliative care. Cancer 2015; 121:4240.
  11. Rao A, Ekstrand M, Heylen E, et al. Breaking Bad News: Patient Preferences and the Role of Family Members when Delivering a Cancer Diagnosis. Asian Pac J Cancer Prev 2016; 17:1779.
  12. Bou Khalil R. Attitudes, beliefs and perceptions regarding truth disclosure of cancer-related information in the Middle East: a review. Palliat Support Care 2013; 11:69.
  13. Wuensch A, Tang L, Goelz T, et al. Breaking bad news in China--the dilemma of patients' autonomy and traditional norms. A first communication skills training for Chinese oncologists and caretakers. Psychooncology 2013; 22:1192.
  14. Back MF, Huak CY. Family centred decision making and non-disclosure of diagnosis in a South East Asian oncology practice. Psychooncology 2005; 14:1052.
  15. Tse CY, Chong A, Fok SY. Breaking bad news: a Chinese perspective. Palliat Med 2003; 17:339.
  16. Jiang Y, Liu C, Li JY, et al. Different attitudes of Chinese patients and their families toward truth telling of different stages of cancer. Psychooncology 2007; 16:928.
  17. Bousquet G, Orri M, Winterman S, et al. Breaking Bad News in Oncology: A Metasynthesis. J Clin Oncol 2015; 33:2437.
  18. Akbar F, Mark G, Warton EM, et al. Physicians' electronic inbox work patterns and factors associated with high inbox work duration. J Am Med Inform Assoc 2021; 28:923.
  19. Lobb EA, Kenny DT, Butow PN, Tattersall MH. Women's preferences for discussion of prognosis in early breast cancer. Health Expect 2001; 4:48.
  20. Figg WD, Smith EK, Price DK, et al. Disclosing a diagnosis of cancer: where and how does it occur? J Clin Oncol 2010; 28:3630.
  21. Mirza RD, Ren M, Agarwal A, Guyatt GH. Assessing Patient Perspectives on Receiving Bad News: A Survey of 1337 Patients With Life-Changing Diagnoses. AJOB Empir Bioeth 2019; 10:36.
  22. Parker PA, Baile WF, de Moor C, et al. Breaking bad news about cancer: patients' preferences for communication. J Clin Oncol 2001; 19:2049.
  23. Wittmann E, Beaton C, Lewis WG, et al. Comparison of patients' needs and doctors' perceptions of information requirements related to a diagnosis of oesophageal or gastric cancer. Eur J Cancer Care (Engl) 2011; 20:187.
  24. Fallowfield L, Jenkins V. Communicating sad, bad, and difficult news in medicine. Lancet 2004; 363:312.
  25. Friedrichsen M, Milberg A. Concerns about losing control when breaking bad news to terminally ill patients with cancer: physicians' perspective. J Palliat Med 2006; 9:673.
  26. Bazargan M, Cobb S, Assari S, Bazargan-Hejazi S. Preparedness for Serious Illnesses: Impact of Ethnicity, Mistrust, Perceived Discrimination, and Health Communication. Am J Hosp Palliat Care 2022; 39:461.
  27. Ingersoll LT, Alexander SC, Priest J, et al. Racial/ethnic differences in prognosis communication during initial inpatient palliative care consultations among people with advanced cancer. Patient Educ Couns 2019; 102:1098.
  28. Lamont EB, Christakis NA. Prognostic disclosure to patients with cancer near the end of life. Ann Intern Med 2001; 134:1096.
  29. Vogliotti E, Pintore G, Zoccarato F, et al. Communicating Bad News to Older Patients from the Physician's Point of View: Focus on the Influence of Gender and Length of Work Experience. Gerontology 2022; 68:903.
  30. Baile WF, Lenzi R, Parker PA, et al. Oncologists' attitudes toward and practices in giving bad news: an exploratory study. J Clin Oncol 2002; 20:2189.
  31. Pang Y, Tang L, Zhang Y, et al. Breaking bad news in China: implementation and comparison of two communication skills training courses in oncology. Psychooncology 2015; 24:608.
  32. Fielding R, Hung J. Preferences for information and involvement in decisions during canceer care among a Hong Kong Chinese population. Psycho-oncology 1996; 5:321.
  33. Costantini A, Baile WF, Lenzi R, et al. Overcoming cultural barriers to giving bad news: feasibility of training to promote truth-telling to cancer patients. J Cancer Educ 2009; 24:180.
  34. Tang WR, Chen KY, Hsu SH, et al. Effectiveness of Japanese SHARE model in improving Taiwanese healthcare personnel's preference for cancer truth telling. Psychooncology 2014; 23:259.
  35. Whitney SN, McCullough LB, Frugé E, et al. Beyond breaking bad news: the roles of hope and hopefulness. Cancer 2008; 113:442.
  36. Rosenberg A, Arnold RM, Schenker Y. Holding Hope for Patients With Serious Illness. JAMA 2021; 326:1259.
  37. Jalmsell L, Lövgren M, Kreicbergs U, et al. Children with cancer share their views: tell the truth but leave room for hope. Acta Paediatr 2016; 105:1094.
  38. McCluskey L, Casarett D, Siderowf A. Breaking the news: a survey of ALS patients and their caregivers. Amyotroph Lateral Scler Other Motor Neuron Disord 2004; 5:131.
  39. Aoun SM, Breen LJ, Oliver D, et al. Family carers' experiences of receiving the news of a diagnosis of Motor Neurone Disease: A national survey. J Neurol Sci 2017; 372:144.
  40. Farin E, Gramm L, Schmidt E. The congruence of patient communication preferences and physician communication behavior in cardiac patients. J Cardiopulm Rehabil Prev 2011; 31:349.
  41. Seifart C, Hofmann M, Bär T, et al. Breaking bad news-what patients want and what they get: evaluating the SPIKES protocol in Germany. Ann Oncol 2014; 25:707.
  42. Visser LNC, Tollenaar MS, van Doornen LJP, et al. Does silence speak louder than words? The impact of oncologists' emotion-oriented communication on analogue patients' information recall and emotional stress. Patient Educ Couns 2019; 102:43.
  43. Ablon J. Parents' responses to their child's diagnosis of neurofibromatosis 1. Am J Med Genet 2000; 93:136.
  44. Gilbey P. Qualitative analysis of parents' experience with receiving the news of the detection of their child's hearing loss. Int J Pediatr Otorhinolaryngol 2010; 74:265.
  45. Schofield PE, Butow PN, Thompson JF, et al. Psychological responses of patients receiving a diagnosis of cancer. Ann Oncol 2003; 14:48.
  46. Okazaki S, Iwamitsu Y, Masaru K, et al. The psychological responses of outpatient breast cancer patients before and during first medical consultation. Palliat Support Care 2009; 7:307.
  47. Zwingmann J, Baile WF, Schmier JW, et al. Effects of patient-centered communication on anxiety, negative affect, and trust in the physician in delivering a cancer diagnosis: A randomized, experimental study. Cancer 2017; 123:3167.
  48. Maguire P. Improving communication with cancer patients. Eur J Cancer 1999; 35:1415.
  49. Ptacek JT, Ptacek JJ, Ellison NM. "I'm sorry to tell you ..." physicians' reports of breaking bad news. J Behav Med 2001; 24:205.
  50. Shaw J, Brown R, Heinrich P, Dunn S. Doctors' experience of stress during simulated bad news consultations. Patient Educ Couns 2013; 93:203.
  51. Armstrong J, Holland J. Surviving the stresses of clinical oncology by improving communication. Oncology (Williston Park) 2004; 18:363.
  52. Eelen S, Bauwens S, Baillon C, et al. The prevalence of burnout among oncology professionals: oncologists are at risk of developing burnout. Psychooncology 2014; 23:1415.
  53. Shanafelt TD, Gradishar WJ, Kosty M, et al. Burnout and career satisfaction among US oncologists. J Clin Oncol 2014; 32:678.
  54. Otani H, Morita T, Esaki T, et al. Burden on oncologists when communicating the discontinuation of anticancer treatment. Jpn J Clin Oncol 2011; 41:999.
  55. Fallowfield L. Can we improve the professional and personal fulfillment of doctors in cancer medicine? Br J Cancer 1995; 71:1132.
  56. Ramirez AJ, Graham J, Richards MA, et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer 1995; 71:1263.
  57. Blanchard P, Truchot D, Albiges-Sauvin L, et al. Prevalence and causes of burnout amongst oncology residents: a comprehensive nationwide cross-sectional study. Eur J Cancer 2010; 46:2708.
  58. Bar-Sela G, Lulav-Grinwald D, Mitnik I. "Balint group" meetings for oncology residents as a tool to improve therapeutic communication skills and reduce burnout level. J Cancer Educ 2012; 27:786.
  59. Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care 2009; 47:826.
  60. Venetis MK, Robinson JD, Turkiewicz KL, Allen M. An evidence base for patient-centered cancer care: a meta-analysis of studies of observed communication between cancer specialists and their patients. Patient Educ Couns 2009; 77:379.
  61. Zandbelt LC, Smets EM, Oort FJ, et al. Medical specialists' patient-centered communication and patient-reported outcomes. Med Care 2007; 45:330.
  62. Paul CL, Clinton-McHarg T, Sanson-Fisher RW, et al. Are we there yet? The state of the evidence base for guidelines on breaking bad news to cancer patients. Eur J Cancer 2009; 45:2960.
  63. Kissane DW, Bylund CL, Banerjee SC, et al. Communication skills training for oncology professionals. J Clin Oncol 2012; 30:1242.
  64. Roter DL, Hall JA, Kern DE, et al. Improving physicians' interviewing skills and reducing patients' emotional distress. A randomized clinical trial. Arch Intern Med 1995; 155:1877.
  65. Brown JB, Boles M, Mullooly JP, Levinson W. Effect of clinician communication skills training on patient satisfaction. A randomized, controlled trial. Ann Intern Med 1999; 131:822.
  66. Liénard A, Merckaert I, Libert Y, et al. Factors that influence cancer patients' anxiety following a medical consultation: impact of a communication skills training programme for physicians. Ann Oncol 2006; 17:1450.
  67. Delvaux N, Razavi D, Marchal S, et al. Effects of a 105 hours psychological training program on attitudes, communication skills and occupational stress in oncology: a randomised study. Br J Cancer 2004; 90:106.
  68. Moore PM, Rivera Mercado S, Grez Artigues M, Lawrie TA. Communication skills training for healthcare professionals working with people who have cancer. Cochrane Database Syst Rev 2013; :CD003751.
  69. Dwamena F, Holmes-Rovner M, Gaulden CM, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev 2012; 12:CD003267.
  70. Selman LE, Brighton LJ, Hawkins A, et al. The Effect of Communication Skills Training for Generalist Palliative Care Providers on Patient-Reported Outcomes and Clinician Behaviors: A Systematic Review and Meta-analysis. J Pain Symptom Manage 2017; 54:404.
  71. Fukui S, Ogawa K, Ohtsuka M, Fukui N. A randomized study assessing the efficacy of communication skill training on patients' psychologic distress and coping: nurses' communication with patients just after being diagnosed with cancer. Cancer 2008; 113:1462.
  72. Del Canale S, Louis DZ, Maio V, et al. The relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in Parma, Italy. Acad Med 2012; 87:1243.
  73. Hojat M, Louis DZ, Markham FW, et al. Physicians' empathy and clinical outcomes for diabetic patients. Acad Med 2011; 86:359.
  74. Maas M, Beets-Tan RG, Lambregts DM, et al. Wait-and-see policy for clinical complete responders after chemoradiation for rectal cancer. J Clin Oncol 2011; 29:4633.
  75. Back AL, Arnold RM, Baile WF, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med 2007; 167:453.
  76. Alexander SC, Keitz SA, Sloane R, Tulsky JA. A controlled trial of a short course to improve residents' communication with patients at the end of life. Acad Med 2006; 81:1008.
  77. Szmuilowicz E, el-Jawahri A, Chiappetta L, et al. Improving residents' end-of-life communication skills with a short retreat: a randomized controlled trial. J Palliat Med 2010; 13:439.
  78. Tobler K, Grant E, Marczinski C. Evaluation of the impact of a simulation-enhanced breaking bad news workshop in pediatrics. Simul Healthc 2014; 9:213.
  79. Fujimori M, Shirai Y, Asai M, et al. Development and preliminary evaluation of communication skills training program for oncologists based on patient preferences for communicating bad news. Palliat Support Care 2014; 12:379.
  80. Liénard A, Merckaert I, Libert Y, et al. Is it possible to improve residents breaking bad news skills? A randomised study assessing the efficacy of a communication skills training program. Br J Cancer 2010; 103:171.
  81. Epstein RM, Duberstein PR, Fenton JJ, et al. Effect of a Patient-Centered Communication Intervention on Oncologist-Patient Communication, Quality of Life, and Health Care Utilization in Advanced Cancer: The VOICE Randomized Clinical Trial. JAMA Oncol 2017; 3:92.
  82. Fallowfield L, Jenkins V, Farewell V, et al. Efficacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial. Lancet 2002; 359:650.
  83. Tulsky JA, Arnold RM, Alexander SC, et al. Enhancing communication between oncologists and patients with a computer-based training program: a randomized trial. Ann Intern Med 2011; 155:593.
  84. Gilligan T, Coyle N, Frankel RM, et al. Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline. J Clin Oncol 2017; 35:3618.
  85. Paladino J, Bernacki R, Neville BA, et al. Evaluating an Intervention to Improve Communication Between Oncology Clinicians and Patients With Life-Limiting Cancer: A Cluster Randomized Clinical Trial of the Serious Illness Care Program. JAMA Oncol 2019; 5:801.
  86. Lakin JR, Koritsanszky LA, Cunningham R, et al. A Systematic Intervention To Improve Serious Illness Communication In Primary Care. Health Aff (Millwood) 2017; 36:1258.
  87. Baile WF, Buckman R, Lenzi R, et al. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000; 5:302.
  88. Rabow MW, McPhee SJ. Beyond breaking bad news: how to help patients who suffer. West J Med 1999; 171:260.
  89. Narayanan V, Bista B, Koshy C. 'BREAKS' Protocol for Breaking Bad News. Indian J Palliat Care 2010; 16:61.
  90. Back AL. (2013) Vital Talk (1.0) [Mobile Application Software] (Accessed on January 13, 2015).
  91. Batten JN, Kruse KE, Kraft SA, et al. What Does the Word "Treatable" Mean? Implications for Communication and Decision-Making in Critical Illness. Crit Care Med 2019; 47:369.
  92. U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy. (Accessed on January 13, 2015).
  93. Lakin JR, Jacobsen J. Softening Our Approach to Discussing Prognosis. JAMA Intern Med 2019; 179:5.
  94. Fischer GS, Tulsky JA, Arnold RM. Communicating a poor prognosis. In: Topics in Palliative Care, Portenoy RK, Bruera E (Eds), Oxford University Press, New York 2000. Vol 4.
  95. Smith RC. Patient-Centered Interviewing: An Evidence-Based Method, 2, Lippincott Williams & Wilkins, Philadelphia 2002.
  96. Chou CL, Cooley L. Communication Rx: Transforming Healthcare through Relationship-Centered Communication, McGraw-Hill Education, New York 2017.
  97. Dunn SM, Butow PN, Tattersall MH, et al. General information tapes inhibit recall of the cancer consultation. J Clin Oncol 1993; 11:2279.
  98. Nguyen MH, Smets EMA, Bol N, et al. Fear and forget: how anxiety impacts information recall in newly diagnosed cancer patients visiting a fast-track clinic. Acta Oncol 2019; 58:182.
  99. Tuffrey-Wijne I, Gitras N, Butler G, et al.. Developing guidelines for disclosure or non-disclosure of bad news around life limiting illness and death to people with intellectual disabilities. J App Res Intell Disabilities 2013; 26:231.
  100. Read S. Breaking bad news to people with a learning disability. Br J Nurs 1998; 7:86.
  101. Tuffrey-Wijne I, McEnhill L. Communication difficulties and intellectual disability in end-of-life care. Int J Palliat Nurs 2008; 14:189.
  102. Tuffrey-Wijne I, Bernal J, Hollins S. Disclosure and understanding of cancer diagnosis and prognosis for people with intellectual disabilities: findings from an ethnographic study. Eur J Oncol Nurs 2010; 14:224.
  103. Tuffrey-Wijne I. A new model for breaking bad news to people with intellectual disabilities. Palliat Med 2013; 27:5.
  104. Chua IS, Jackson V, Kamdar M. Webside Manner during the COVID-19 Pandemic: Maintaining Human Connection during Virtual Visits. J Palliat Med 2020; 23:1507.
  105. Flint L, Kotwal A. The New Normal: Key Considerations for Effective Serious Illness Communication Over Video or Telephone During the Coronavirus Disease 2019 (COVID-19) Pandemic. Ann Intern Med 2020; 173:486.
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