Elsevier

The Lancet

Volume 363, Issue 9405, 24 January 2004, Pages 312-319
The Lancet

Review
Communicating sad, bad, and difficult news in medicine

https://doi.org/10.1016/S0140-6736(03)15392-5Get rights and content

Summary

In every medical specialty bad, sad, and difficult information must be given to patients and their families. An insensitive approach increases the distress of recipients of bad news, may exert a lasting impact on their ability to adapt and adjust, and can lead to anger and an increased risk of litigation. Many doctors also find these interactions stressful, and in the absence of much effective training they may adopt inappropriate ways of delivering bad news and coping with the emotional fall-out. Recognition of these difficulties has led to many initiatives, ranging from increased communication skills training to the development of guidelines and protocols. We review some of the research on the impact that giving sad, bad, and difficult news has on doctors and patients, and assess whether interventions are helping. We focus mainly on difficulties encountered involving parents in an obstetric or paediatric setting, people in acute trauma situations such as accident and emergency departments, and patients with cancer.

Section snippets

What is bad news in medicine?

Any information that produces a negative alteration to a person's expectations about their present and future could be deemed bad news.20 Ptacek and Eberhardt21 define bad news as information that “… results in a cognitive, behavioural or emotional deficit in the person receiving the news that persists for some time after the news is received”. Bad news does, of course, have gradations, which to a certain extent are subjective, dependent on an individual's life experiences, personality,

Difficulties faced by health-care professionals

Table 1 shows several studies of health-care professionals' views on breaking bad news from 1993 onwards.3, 13, 22, 23, 24, 25 The disparity between physicians in opinion about truthful disclosure, the stress experienced when giving bad news, and the desire for more training is notable. Talking about distressing subjects is unpleasant, but responsibility for giving sad, bad, and difficult news may come early in training and with little experience. Few doctors receive adequate guidance and help

Patients' and families' needs

A summary of some of the research eliciting patients' and relatives' views on receiving bad news is shown in Table 2.31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42 How bad, sad, or difficult information is received depends on many factors, including expectations, previous experiences, and general personality disposition. Shock, horror, anger, stoic acceptance, disbelief, and denial are all possible reactions and anyone charged with breaking bad news needs to be able to cope with these emotions.

Obstetrics and paediatrics

When parents conceive a wanted child they generally experience several months of excitement and nervous anticipation, hoping for an uneventful pregnancy, a safe delivery, and a normal, healthy baby. For most parents there is a happy outcome, and health-care professionals have the pleasurable experience of confirming that all is well. When things do not follow the anticipated pattern and a baby is born damaged or dead, it is therefore extremely distressing to all concerned. Sometimes everything

Guidelines

There are many guidelines and recommendations as to how doctors should prepare themselves before imparting bad news, about what constitutes an optimum supportive environment, and how difficult information should be given. Examples of such guidelines are summarised in Table 3.6, 12, 50, 66 The empirical basis for guideline development is important, in particular checking that guidelines have some face validity, are ethical, practical, and address patients' needs. A good example can be seen in

Conclusion

The delivery of sad, bad, and difficult news will always be an unpleasant but necessary part of medicine. In the past decade recognition has grown of the need to integrate appropriate communication skills teaching into undergraduate and postgraduate education. Research has shown that if bad news is communicated badly it can cause confusion, long lasting distress, and resentment; if done well, it can assist understanding, acceptance, and adjustment. Training health-care professionals how to do

Search strategy

We identified relevant studies for possible inclusion by searching standard computer databases, including MEDLINE, EMBASE, and CINAHL (1993–February, 2003), and The Cochrane Library. Searches were restricted to papers published in English. Keywords used were: “receiving bad news”, “breaking bad news”, “breaking bad news effect on patients”, “breaking bad news effects on doctors”, “communcation skills”. “training guidelines”. “truth disclosure”, “physician/patient”, “doctor/patient”.

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