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Communicating Bad News 

Communicating Bad News
Communicating Bad News
A Field Manual for Palliative Care in Humanitarian Crises

Meaghann S. Weaver

and Michaela Ibach


Patients and family members appreciate clear, practical, compassionate, and honest communication delivered in a private setting. Communication of hard news can be considered according to the stages of the conversation, as depicted in Table 14.1.

Table 14.1. Tangible Tasks for Family Meetings

Time Frame



Before the meeting

  • Preparing academically with the appropriate medical information and review of patient chart and data

  • Preparing the medical team emotionally

  • Rushing into the meeting

  • Arriving unprepared

  • Holding the meeting in a public, unexpected place

Opening the meeting

  • Introducing everyone present

  • Inquiring what the family understands

  • Asking what the family hopes to obtain from the meeting

  • Making assumptions about what the family knows

  • Judging the family’s knowledge of prognosis or diagnosis

During the meeting

  • Asking about the family’s goals

  • Listening actively

  • Pausing between statements

  • Responding appropriately to emotion

  • Using medical jargon

  • Dominating the conversation

  • Over-speaking or interrupting

Closing the meeting

  • Summarizing the meeting content

  • Exploring the family’s understanding

  • Ensuring ongoing support

  • Ending without asking about whether questions and concerns have been addressed

  • Leaving without committing to a follow-up plan

After the meeting

  • Documenting meeting content

  • Reflecting with self and interdisciplinary team members

  • Forgetting self-care and team care or ignoring the emotions associated with the meeting

SPIKES Protocol

The SPIKES protocol offers a practical approach to breaking bad news or sharing sad news (Table 14.2).1

Table 14.2. SPIKES Protocol


Actionable Approach

1. Setting: plan ahead to establish the environment

  • Find a quiet, private location if possible and minimize interruptions.

  • Invite the appropriate people to be present based on necessary staff member inclusion and patient preference on family member presence.

  • Have tissues nearby.

  • Ensure enough chairs and sit down with the family.

2. Perception: explore what the patient knows already

  • “Tell me what you understand about your illness.”

  • “What have the other doctors told you about your illness?”

  • Look for knowledge and emotional information in the patient’s response.

3. Invitation: information-sharing preferences

  • “Would it be okay for me to discuss the results of your tests with you now?”

  • “How do you prefer to discuss medical information in your family?”

  • “Some people prefer a global picture of what is happening and others like all the details; what do you prefer?”

4. Knowledge: give the information

  • Give a warning: “I have something serious we need to discuss” or “I’m sorry to say that I have some bad news.”

  • Avoid medical jargon.

  • Say it simply and stop (e.g., “The tumor has grown—the cancer is getting worse despite our best treatments.”)

5. Empathy: respond to emotion

  • Wait quietly for the patient.

  • Use silence therapeutically—silent, supportive presence can be a form of caring well.

  • “I know this is not what you expected to hear today.”

  • “This is very difficult news.”

6. Summary: discuss next steps and follow-up plan

  • “We’ve talked about a lot of things today, please tell me what you understand as the main messages from our meeting.”

  • “Let’s set up a follow-up appointment.”

Ask-Tell-Ask Method

The Ask-Tell-Ask method serves as an additional communication tool to foster relationship building, a listening presence, and clarification of agenda and understanding when communicating challenging news.

Bonus PRE-ASK: Invest in a pre-ask question to “personalize the patient” and open the conversation with individualized and relational communication. Consider asking a parent to share about a child’s personality, asking an adult child what brings their parent comfort or joy, or asking a spouse what strengthens their partner.

ASK: Ask the patient to describe their current understanding of the diagnosis or prognosis or medical issue.

Example questions:

  • “To make sure we are on the same page, can you tell me about your medical condition?”

  • “What have your other health providers been telling you about your diagnosis or prognosis since the last time we spoke?”

Ask for permission to then “tell” the message of medical update.

TELL: Share the medical news in straightforward language. Craft your “tell” message to take the patient’s level of knowledge, emotional state, and degree of education into account.

Stop short of giving a long lecture or huge amounts of detail. Information should be provided in short, digestible chunks with strategic pauses to allow for comfortable silence and processing. A useful rule of thumb is not to give more than three pieces of information at a time. Avoid medical jargon.

ASK: Consider asking the patient to restate what was said in their own words to offer the opportunity to clarify facts and understanding. Provide a chance for the patient or family to ask questions or to request further details.

Tell Me More

A powerful tool in communicating bad news is the phrase “Tell me more, please.”2

“Tell me more” question tools are as follows:

  • Tier 1: Could you tell me more about what information you need at this point?

  • Tier 2: Could you say something about how you are feeling about what we have discussed?

  • Tier 3: Could you tell me what this means for you?

Responding to Emotion

Practical strategies for responding to emotion include the following:

  • Help the patient to name the emotion through suggestion (never tell a patient how he or she feels): “It sounds like you feel . . . ” or “I wonder if you are feeling . . . ” or “some people hearing this news would feel. . . .”

  • After helping to name the emotion, consider sharing a word of acknowledgment, respect, and empathetic support (e.g., “You’re right, this is incredibly [emotion]. I wish things were different and I’m here to support you.”).

  • Consider involving additional members of the care team, such as the bedside nurse or social worker or behavioral health specialist, to explore different ways to continue to partner with the patient and family.3


1. Back A, Arnold RM, Baile WF, Tulsky JA, Fryer-Edwards K. Approaching difficult communication tasks in oncology. CA Cancer J Clin. 2005;55:164–177.Find this resource:

2. Stone D, Patton B, Heen S. Difficult Conversations: How to Discuss What Matters Most. New York: Viking; 2000.Find this resource:

3. Silverman J, Kurtz S, Draper J. Skills for Communicating with Patients. Abingdon Oxon, UK: Radcliffe Medical Press; 1998.Find this resource:

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