Breaking Bad News
by Gregg K. Vandekieft, M.D. (Am Fam Physician. 2001;64(12):1975-1979):
🔍 Definition and Context
- Bad news: Any news that drastically alters a person’s view of their future.
- Not limited to terminal illness – includes diagnoses like fetal demise, MS, or new-onset diabetes.
- Emotional impact may be worsened by timing or social context (e.g., during major life events or affecting employment).
⚠️ Why It’s Difficult for Physicians
- Concern about distressing the patient.
- Historical precedent of paternalism (e.g., Hippocrates, AMA 1847) discouraging full disclosure.
- Fear of emotional response or confrontation.
- Lack of training in communication skills.
- Time constraints and unsuitable environments.
- Fear of “taking away hope.”
- Discomfort → physician disengagement.
📊 Patient Preferences
- 50–90% of patients prefer full disclosure.
- Preferences vary; individualised communication is necessary.
- Important to ask how much information the patient wants to know.
🧠 Educational and Evidence Limitations
- Few guidelines are evidence-based.
- Most literature lacks original data; methodological limitations exist.
- Nonetheless, focused communication training improves satisfaction and physician confidence.
🧠 Key Communication Needs (from family perspectives after trauma)
- Attitude of the news-giver.
- Clarity of message.
- Privacy.
- Capacity to answer questions.
✅ ABCDE Mnemonic for Breaking Bad News
| Step | Key Actions |
|---|---|
| A – Advance Preparation | • Review clinical info and prognosis. • Allocate adequate time and privacy. • Turn off pager/avoid interruptions. • Mentally rehearse phrases; script key words. • Prepare emotionally. |
| B – Build a Therapeutic Relationship | • Ascertain patient’s preferences (info and who should be present). • Introduce everyone. • Use forewarning: “I have some difficult news…” • Use touch appropriately. • Avoid humour unless relationship allows. • Plan follow-up appointments. |
| C – Communicate Well | • Ask what the patient knows first. • Be clear, direct (avoid jargon/euphemisms). • Use terms like “cancer” or “death” if appropriate. • Allow silence/tears. • Encourage questions and repeat information. • Provide written info or diagrams. • Summarise and plan next steps. |
| D – Deal with Reactions | • Recognise coping styles (e.g. denial, anger). • Watch body language. • Be empathetic; appropriate to say “I’m sorry.” • Avoid arguing or blaming colleagues. • Assess for risk (e.g. suicidal thoughts). |
| E – Encourage and Validate Emotions | • Offer realistic hope aligned with patient goals. • Explore emotional, spiritual needs. • Use supports (e.g. palliative care, hospice). • Don’t disengage. • Reflect on your own emotional needs—consider debriefing. |
🧾 Final Takeaway
- Therapeutic presence is vital when a cure isn’t possible.
- Breaking bad news is not just a skill—it is a core communication task of professional practice.
- More empirical research is needed, but attitude and communication style significantly affect patient coping and satisfaction.