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Discussing serious news

Authors:
Stephanie M Harman, MD
Robert M Arnold, MD
Section Editor:
Susan D Block, MD
Deputy Editor:
Diane MF Savarese, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Oct 2017. | This topic last updated: Sep 26, 2017.
What's New
New ASCO guideline aims to improve communication skills (September 2017)
The way in which serious news is conveyed can substantially influence the emotional response to the
news, beliefs and attitudes toward the medical staff, and how patients view their future. While there are
no consistent findings from randomized interventional studies that show better patient outcomes after
modifying communication skills to deliver serious news, a number of studies have shown that clinician
communication skills can be improved by training. 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 1) [1]. (See 'Can communication
skills be taught and learned?'.)
Read more

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. From telling an adolescent that she has
mononucleosis, or a woman that she is not in labor, or an athlete about a knee injury, to talking
about a life-limiting illness, 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 "Fetal death and stillbirth: Maternal care", section on 'Conveying
the diagnosis of fetal demise' 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
patients 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 patients
beliefs and perceptions. As an example, a hospitalized patient may be relieved by a diagnosis of
liver abscess because he or she 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 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 consider the preferences of patients and families
regarding what information is disclosed, how the information is delivered, and who delivers it.

Most patients prefer to be informed of their diagnoses, with studies demonstrating this
preference in more than 95 percent of patients [5]. However, there is some variation in what
specific types of information patients want to know, particularly among those who are receiving
a cancer diagnosis [5,6]. For patients with newly diagnosed cancer, the vast majority want to
know about their chances for cure and the effectiveness of cancer-directed treatments [6,7], but
a lower percentage wants to know their specific prognosis [7]. 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'.)

Cross-cultural differences in patient/family preferences deserve special mention, particularly


when the disease is cancer. In many Western countries, oncologists usually inform patients of
their diagnosis, and the vast majority of patients want to know their diagnosis and prognosis [8].
However, in many non-Western 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 Western studies wanted to discuss life expectancy, but that figure
decreased to 30 percent or fewer of patients in Asian studies [7]. There is some evidence that
things may be changing in some Asian populations. A year 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 [9].

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 [10-13]. In other cases,
particularly in Asian countries where there is a family-centered model of decision-making,
families ask physicians not to reveal the diagnosis and prognosis to patients [11]. 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 [13,14], although there is no evidence
to suggest that this occurs. Practical strategies to deal with families 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 [15].

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, in an atmosphere that welcomes questions, using
clear and direct language (without euphemisms or medical jargon), honestly, with optimism
rather than pessimism and with adequate time, privacy, reassurance of an ongoing plan, and
appropriate support (having a trusted companion attend the meeting) are all important aspects
[7,16,17].

However, patients differ in what information they want and how they want to receive it. In a
study of 100 women with early breast cancer attending 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
[16]. Most wanted their cancer specialist 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
approach to 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 [18].
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 to one with a better prognosis
[19]. Other studies have shown similar patterns of censoring how much information is disclosed
when discussing serious news [20]. Factors that influence clinicians' behavior include lack of
control (over time or setting), feelings of failure or inadequacy, fear of the patients emotions as
well as ones own emotions, and lack of knowledge to answer anticipated questions [21].
(See "Communication of prognosis in palliative care", section on 'Rationale for discussing
prognosis'.)

Information disclosure is also affected by geographic and cultural factors [22,23]. 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 [22]. (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 [24]. 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 [23,25,26]. Physicians can and should promote hopefulness
without endorsing unrealistic optimism [27]. (See 'Approaches to breaking serious news:
existing models and key elements' below.)

Strategies to deal with situations where families 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
perceptions of the way in which doctors 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 [28].
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 [29].
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) [30].
(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.

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 [27]. 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 patient/family emotions including shock, horror, feeling
upset, disbelief, anger, and feeling depressed [31-34].

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 [35]. 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 [33]. 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 [36].

In particular, communications about prognosis in patients with metastatic disease can be


emotionally difficult. In one study based upon interviews of 17 patients and 13 health
professionals working in oncology, seven primary themes emerged as important in this setting:
communication within a caring, trusting, long-term relationship; open and repeated discussions
about patient preferences for information; clear, straightforward presentation of prognosis where
desired; strategies to ensure patient understanding; encouragement of hope and a sense of
control; consistency of communication within the multi-disciplinary team; and communication
with other members of the family [37]. In another review of 40 studies involving >600
oncologists from 12 countries, communicating serious news to oncology patients was described
as a balancing act requiring oncologists to necessarily and constantly adapt to different factors
for each patient, including their individual relationships to the patient, the patients family, the
institutional and systemic environment, and the cultural milieu [15]. Individualized adaptive
communication skills that are required for this sort of interaction differ significantly from the
stereotypical way in which oncologists are currently trained in communication skills. (See 'Can
communication skills be taught and learned?' below.)

Communicating serious news can also negatively impact the clinician. Multiple clinician surveys
demonstrate that clinicians find discussing serious news stressful [38,39]. 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 [38]. Oncologists highlight this type of communication as a contributing factor to
burnout [40-42]. Inadequate training in communication skills has been cited as a reason why
breaking serious news contributes to clinician stress and burden [43-46]. Balint groups or
training in mindfulness have been suggested as ways to improve oncology trainees self-
reflective skills, and emotional resiliency, as well as reducing burnout [47].

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 physician, and physical health outcomes [35,48-50]. However, there
have been relatively few high-quality studies examining how enhanced communication skills to
deliver serious news directly impact patient/family outcomes [51,52]. 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 [51].
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 [53].
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
[54].
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 [55].
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 [56].
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 [57].
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 [58].
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 [59].
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 [60]. 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 physician empathy scale scores [61,62]

Can communication skills be taught and learned? While there are no consistent findings
from randomized interventional studies that [63] 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 [4,23,52,64-70]. As examples:

Back and colleagues showed improvements and acquisition of communication skills in


oncology fellows after four-day intensive retreats that emphasized skills practice,
simulation, and small group work [64]. 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 patients perception of their
illness, asking permission to give the serious news, the act of sharing the news itself, and
attending to the patients 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 [65-67].
The benefit of attending a communication skills course for attending physicians 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) [71]. 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
[72]. 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 year 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) [73].
Alternatively, several web-based tools (eg, VitalTalk, DocCom) 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 between health
care providers and their patients are that the amount of information is adequate, and that it is
understood, believed, remembered, and hopefully, acted upon. (See "Approach to the patient".)

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".)

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) [74]. 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 [4,23]. Since then, there have been several other models created, including ABCDE,
GUIDE, and BREAKS (table 1) [74-77]. 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. A medical
interpreter should be scheduled for patients with limited English proficiency. 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 advance conversations with consultants or other
clinicians who may be involved in the patients care so that the patient receives consistent
information.

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 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 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]. In delivering the information itself, utilize simple and direct language
with attention to keeping the news brief. 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) [78]. After giving the information,
pause and allow the patient/family 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 cant get a liver transplant anymore.

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/family 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 the patient/family 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 [79,80].

I can see this is very upsetting (Naming the emotion)

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
emotion, identifying the emotion behind the question, and then responding to the emotion.
Patients and families 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 ones 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 patients/familys 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 [3]. This does not necessarily mean that the patient/family needs to
make decisions on treatment plans immediately. It may mean discussing follow-up
appointments and upcoming tests. 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 dont have to
make any decisions today. Im going to refer you to our surgeon, Dr. X, to discuss the
surgical optionand I will set up a follow-up appointment to see you again next week.

Approach to patients with intellectual disabilities The task of delivering serious news can
be particularly challenging for patients with intellectual disabilities. Reasons for non-disclosure
include: wanting to prevent distress; an inability to understand the concepts of illness,
treatments, and death; a lack of sense 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 [81]. 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 [82-84]. Patients with intellectual disabilities do 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 [81,85]. Delivering serious news is seen as a process, rather than a linear series of
events. Some have proposed use of a single guiding question in consultation with the range of
stakeholders, including family, 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 persons 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).

A simpler model has been proposed that was based upon a study involving focus groups and
interviews of patients with intellectual disabilities, family carers, as well as medical providers
[81].

SUMMARY

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 patients 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, 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 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 year 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) [73].
Alternatively, several web-based tools (eg,VitalTalk, DocCom) are available to assist in
improving communication skills for discussing serious news. (See 'Can communication
skills be taught and learned?' above.)