Breaking bad news to patients

• Prepare for ‘bad news’ conversations – plan what you want to say and how you will say it.  
• Demonstrate concern and an appreciation of the patient’s perspective and response. 
• Answer questions and agree on a plan with the patient and make sure they know how to follow up and have more questions answered. 

On any normal working day you could be delivering news to a patient that might change their life. Bad news may be related to issues such as a terminal diagnosis, an athlete’s prognosis after a significant injury, or a young woman’s fertility issues.  

If possible, plan how you will advise a patient of a serious diagnosis or poor prognosis. Even if it’s only a few moments before you see the patient, collect your thoughts and think about how to approach the discussion. Some doctors find it helpful to have planned for and practised common scenarios in their field. 

Consider whether you are the right person to have the conversation with the patient and whether any other practitioners should be involved. Before the consultation:  

• Select a meeting place that is private.  
• Allow enough time so you don’t appear rushed or impatient.  
• Consider whether the patient might want culturally appropriate support such as friends, family or spiritual advisers, and whether they need an interpreter.  
• Be adequately prepared with information about the patient’s clinical situation – this includes being familiar and up-to-date with the facts and results.  
• Have contact details and information about relevant referral and support services and information about the diagnosis or prognosis they may want to read later.  
• Rehearse parts of the conversation that may be difficult for you.  

Evidence-based guidelines for these conversations, including suggestions of phrases that may help you, are available at the end of this factsheet. 

Consider the patient’s perspective

Keep in mind that a patient’s or family member’s perspective of bad news will most likely be different from yours. Each will have their own, very personal fears and are likely to have a different clinical understanding. Be mindful of the impact of the news on their life, hopes and goals.

Showing that you care is essential. Even if you don’t know a patient well, showing respect and concern can greatly support the patient. Sometimes you may need to deliver bad news to a patient you don’t know at all. Simple things like greeting the patient by name, introducing yourself and explaining your role in their care can make a difference.  

Understand the patient's current knowledge

Even if you have an existing care relationship with the patient, it is important not to make assumptions about their knowledge or concerns. Questions such as, “Can you tell me what you understand about your condition?” or “What have others told you about your condition?” might assist you to focus on the patient’s particular needs for information. These can also help you to understand what the patient is expecting to hear.  

Details about the clinical situation and treatment options

Try to gauge how much information the patient wants. Some patients want to know every detail of their clinical situation, others cannot process too much information at once, and others prefer some initial information and more detail later.  

Giving information in small chunks gives the patient the opportunity to understand it. Speak clearly and avoid medical jargon. It can also help to warn the patient before you deliver difficult news. As an example, saying “The news is not what we had hoped for” might be appropriate under some circumstances if you know the patient.  

Ideally, treatment options should be discussed over more than one consultation to help the patient gain a full understanding of each option. Ensure this is a two-way conversation allowing the patient to consider their options and ask questions about each option. Written materials with diagrams (if appropriate), can help to facilitate the patient’s understanding. It’s also important to provide a broad timeframe of the next steps to be taken. 

Answer patient questions

Answer the patient’s questions to the best of your ability. If you don’t know the answer, explain when you expect to have an answer. Discuss potential treatment options and realistic goals, expectations and coping strategies, but do not offer false or misleading hope.  

Acknowledge emotions and fears and reassure

Show care and understanding. Give the patient an opportunity to express their worries, concerns and emotions. Moments of silence can allow the patient to feel comfortable raising questions. Sometimes it can be helpful to acknowledge their emotion and ask them what is on their mind.  

Patients often feel very alone and threatened when given bad news, even if it is not totally unexpected. Exploring and, where possible, working alongside the patient to mitigate their fears can be helpful. You might reassure them that you, or a team, will support them as their care proceeds. This reassurance can help the patient feel less alone.  

Managing shock

Sometimes a patient will be shocked immediately after hearing bad news. In this case, don’t rush through complex details but try to be empathetic while providing support. It may be best to offer another appointment to go over the detailed information. A patient may not remember much if they are in shock. 

Sharing the news with others

You can offer to speak with the patient’s relatives or carers if that’s what they would like or you might offer to support them while they tell their family and friends. Identify support systems for the patient, their family and friends as appropriate.  

It can be important for the patient’s care team to know what the patient has been told. Discuss with the patient the plan for informing other healthcare practitioners. 

Throughout the conversation assess the patient’s response and be alert to any significant psychological concerns. Additional support or expertise may sometimes be needed.

Summarise the discussion and:

• encourage the patient to contact you (or a colleague) directly with further questions and provide appropriate contact details
• advise about follow-up appointments with other healthcare practitioners and/or tests as needed
• ensure the patient is aware of relevant support services
• provide pamphlets, factsheets or other reputable resources and warn about the limitations of an internet search.

If possible, try to end with reassurance, for example: “Although this is a serious condition, I want you to know I am here to work together with you.”

Finally, make sure the patient can make their way home safely and arrange transport or a support person for them if needed.

Document the discussion

The impact of psychological shock means patients often fail to remember, or mishear, information they are given in a bad news consultation. It is essential to thoroughly document the details of the consultation, including the names of anyone else present, the matters discussed with the patient and information provided.

Dealing with patients’ distress can be draining for even the most experienced practitioner. It is important to acknowledge that these conversations can affect you and find ways of looking after yourself.  

At the most practical level, if you know you will be delivering bad news in a consultation, arrange for a long consultation so you don’t have to deliver the bad news quickly and allow yourself some time afterwards to recover your own emotions.  

It can help to discuss with colleagues ways of taking time out or supporting each other after a difficult encounter.  

Always make sure you seek assistance and support if you require it.  

Clinical practice guidelines published in the Medical Journal of Australia provide a good reference including useful phrases that might help you with some of the more difficult aspects of delivering bad news.