Breaking Bad News

Breaking bad news is one of the most challenging aspects of communication. Whether in everyday life or clinical practice, telling someone something that will significantly change their life requires sensitivity, honesty and compassion.

For many people, breaking bad news does not come naturally. Even experienced doctors often find these conversations emotionally demanding. However, it is an essential skill that can be developed through training, practice and reflection.

Medical schools recognise the importance of this skill, and breaking bad news may feature as a role-play exercise during interviews.

What is Bad News?

Bad news is any information that has a significant negative impact on an individual's expectations, future plans or emotional wellbeing.

Examples include:

Informing a patient they have a serious illness.
Explaining that treatment has not been successful.
Telling someone that a loved one has died.
Informing a patient that their condition is incurable.
Explaining that an operation carries significant risks.

In interview role-play, scenarios may also be non-medical.

Examples include:

Telling a neighbour you can no longer care for their dog while they are away.
Informing a friend that you cannot fulfil an important commitment.
Explaining to a teammate that they have not been selected for an event.

The interviewers are usually assessing how you communicate rather than what you know.

What Are Interviewers Looking For?

They want to see evidence that you can:

Communicate clearly and honestly.
Show empathy and compassion.
Listen carefully.
Recognise and respond appropriately to emotions.
Remain calm under pressure.
Demonstrate professionalism.
Check understanding.
Avoid making assumptions.
Adapt your communication to the individual's needs.

A Simple Structure for Breaking Bad News

1. Prepare

Before beginning:

Introduce yourself if appropriate.
Ensure privacy where possible.
Sit down if appropriate.
Minimise interruptions.
Ask if the person would like someone with them for support.

Example:

"Is there anyone you would like to have with you while we talk?"

2. Find Out What They Already Know

Start by understanding their current knowledge.

Examples:

"Can you tell me what you understand about your situation so far?"
"What have you been told already?"

This allows you to tailor the conversation appropriately.

3. Give a Warning Shot

Prepare the person before delivering the news.

Examples:

"I'm afraid I have some difficult news."
"Unfortunately, the results are not what we had hoped."

This helps reduce the shock of the information.

4. Deliver the News Clearly

Be honest.

Use simple language.

Avoid medical jargon.

Speak slowly.

Pause frequently.

Example:

"The tests show that you have cancer."

Avoid vague phrases that may cause confusion.

5. Allow Silence

People often need time to process difficult news.

Do not rush to fill every silence.

Allow the person to react in their own way.

They may:

Cry.
Become angry.
Ask questions.
Remain silent.
Seem shocked.

All of these reactions are normal.

6. Respond with Empathy

Acknowledge the person's emotions.

Examples:

"I can see this is a great deal to take in."
"I'm so sorry this is not the news you were hoping for."
"It's completely understandable that you're feeling upset."

Avoid dismissive comments such as:

"Don't worry."
"Everything will be fine."
"Stay positive."

7. Check Understanding

Ask gentle questions to ensure they understand what has been discussed.

Examples:

"Would you like me to explain anything again?"
"Can I clarify anything for you?"

8. Discuss the Next Steps

Avoid overwhelming the person with excessive information.

Instead:

Explain what will happen next.
Offer further support.
Reassure them that they will not face the situation alone.

Example:

"Today we've discussed the diagnosis. We'll arrange another appointment to talk through your treatment options in more detail."

Communication Skills

Throughout the conversation:

Speak calmly.
Use simple language.
Maintain appropriate eye contact.
Listen more than you speak.
Avoid interrupting.
Allow pauses.
Be patient.
Be compassionate.
Remain professional.

Remember that body language often communicates as much as words.

Handling Difficult Questions

The person may ask questions you cannot answer.

For example:

"How long have I got?"

Rather than guessing:

"I understand why you're asking. At this stage I don't have enough information to answer that accurately, but your specialist will discuss this with you in detail."

Never provide false reassurance or inaccurate information.

Common Mistakes

Avoid:

Rushing the conversation.
Using medical jargon.
Talking continuously without pauses.
Giving too much information at once.
Arguing with emotional reactions.
Making promises you cannot keep.
Guessing answers.
Ignoring the person's emotions.

Example Role-Play Question

Scenario

You are asked to tell your neighbour that you can no longer look after their dog during their holiday, despite previously agreeing to do so.

A Good Response

"Thank you for meeting with me. I'm really sorry, but I need to tell you something difficult. Unfortunately, due to an unexpected family commitment, I won't be able to look after your dog while you're away as we'd planned. I realise this is disappointing, especially at short notice, and I'm very sorry for the inconvenience. I'd be happy to help you think about other options if that would be useful."

Why is this effective?

Honest.
Clear.
Apologetic.
Empathetic.
Takes responsibility.
Offers practical support.

Top Tips for Interviews

Remember the CARE approach:

Communicate clearly.
Acknowledge emotions.
Respond with empathy.
Explain the next steps.

Interviewers are not expecting applicants to break bad news like experienced consultants. They are looking for kindness, honesty, emotional intelligence and the ability to communicate calmly under pressure. Demonstrating empathy, active listening and respect for the other person's feelings will score far more highly than trying to sound overly medical or using complex terminology.

The Spikes Model

The SPIKES model was first published in The Oncologist in 2000 as a protocol for delivering bad news to cancer patients. Since then it has been adopted more widely, and is used by clinicians in various circumstances to communicate difficult news to patients in a clear, supportive and compassionate way.

There are 6 steps or stages to the process:

STEP 1: SETTING UP the Interview
STEP 2: Assessing the patient’s PERCEPTION
STEP 3: Obtaining the patient’s INVITATION
STEP 4: Giving KNOWLEDGE and information to the patient
STEP 5: Addressing the patient’s EMOTIONS with empathic responses
STEP 6: STRATEGY and SUMMARY

Here is an example of the SPIKES model in practice:

S – Setting
First, choose the right setting and time to speak to your patient.

Choose a time when you can speak to them for as long as they need.
Ensure the room is private with no interruption. Tell staff members that you need privacy.
Next, make sure that everyone who needs to be present is there.
Before breaking the news, make sure proper introductions are made with everyone.
Ensure everyone is seated and comfortable.

P – Perspective/Perception
Find out what your patient knows, or suspects, by asking questions such as:

How do you feel?
What do you know about your illness?
Do you know why Dr Jones has sent you to see me?
Tell me what you know about your mother’s health.

I – Invitation
Determine how much the patient or their family wants to know about their situation. Patients have the right to know about their condition. They may only want generality without details. Some may want to know everything possible regarding their illness and treatment.
Ask questions such as:

We have these lab tests back. Can we talk about them?
How much would you like to know about your illness?

K – Knowledge
Once you understand the level of information your patient wants, it is time to deliver the news and inform them about their health.

Give them information in small chunks, then pause to give them time to digest what you have told them, or to ask questions. Pausing also gives you the opportunity to check that they are processing the information.
Check how you are delivering the information by asking if you are making sense.
Repeat important points to ensure the patient can comprehend information.

E – Empathy/Emotion
While sharing information, you also need to be empathetic. Some patients will have an emotional response, others won’t. There is no way to predict how your patient will feel.
If your patient does react strongly, use the NURSE technique to respond to their anger (you can ready more about this technique online). Help them normalize how they feel, respect their emotions and help support them.

Naming
Understanding
Respecting
Supporting
Exploring

S – Summary/Strategy
Use simple clear statements to convey that the whole team is on their side to help. Develop a plan for going forward and answer any questions they have.

Helpful questions to ask / useful things to say:

Give your patient the opportunity to ask if there was anything they did not understand, and, if there is, take the time to go over it again.
Ask them how they feel. Is there anything they are concerned about?
Even with the worst diagnoses, always tell you patient that you and your team are not giving up on treatment.
Tell you patient that they are not alone and that a support team will be put in place.
In case they didn’t take in all the information, tell your patient that they can come back, either by themselves, or with a family member or friend to talk further to the team.
Finally, even with the worst news, never leave things on a negative note, but find a positive way to end

https://www.ucat.ac.uk

https://www.medschools.ac.uk

https://www.ucas.com

https://www.gmc-uk.org

https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice

https://www.gmc-uk.org/ethical-guidance

https://www.england.nhs.uk

https://www.healthcareers.nhs.uk

https://www.nice.org.uk

https://www.bma.org.uk

https://www.bmj.com

https://careers.bmj.com