Breaking bad news

Good practice guidelines

Breaking bad news may be one of the most difficult tasks faced by health care professionals. It is hard to predict how a person will react when receiving bad news. The way in which we present bad news is an important factor in how it is received, understood and dealt with. Breaking bad news is a complex skill, requiring us to impart the information clearly and sensitively, as well as recognising and responding to emotions. You may not be involved in breaking bad news regularly and may not feel confident, even with years of experience. We advise people to always seek support from others if necessary.

Ideally, news regarding the death of a loved one should be delivered in person and not over the telephone. However, for guidance if news does have to be given by telephone, see page 4.

Breaking bad news face to face

• Choose a suitable environment and ensure that the room is free from interruptions.

• Ensure you have protected time. This may mean turning off bleeps or mobile phones.

• Identify who the family members are and what relationship they have to the patient. They may wish to call other family members to support them.

• Speak simply and honestly and try to avoid jargon and euphemisms, e.g. passed away, departed. Although difficult, it is best to say the person has died.

• Avoid overwhelming the family with too much information.

• Be aware of your own body language and reactions.

Ensure the family knows what will happen next.

• Be sure to offer support and treat people with empathy and sensitivity.

Breaking bad news by phone

It may be necessary to deliver bad news over the telephone, where this absolutely cannot be avoided, please see the guidance below.

Step 1: Prepare

• Take a moment to compose yourself. A few slow deep breaths will help you focus.

• Check patient’s information: name, relevant background and current status. Check the name of the person you are ringing and their connection to the patient. Ensure you have the patient’s permission to speak to the person, or are acting in their best interests when discussing clinical information.

• Consider rehearsing or discussing what you are going to say with a colleague.

• Find a space where you won’t be interrupted. Pass your bleep or phone to a colleague.

Step 2: Starting off

• Introduce yourself by name. Clearly explain which team and hospital you are calling from.

• Establish who you are speaking to. Check they are free to talk and can talk privately. Ask if there is anyone else they want to be in on the call too.

• Speak slowly with pauses between sentences. Counting to 3 in your head can help slow you down, particularly if you’re feeling nervous.

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If the person does not answer the phone, don’t divulge any details about the patient’s condition, but leave a message asking them to call the ward back.

Step 3: Setting up the conversation

• Set the context e.g. ‘I’m calling about your dad who has been with us on X Ward for a few days now’.

• Check their understanding of the situation e.g. ‘What was the last update you had from the medical team?’ or ‘Would you mind telling me what you have been told about their condition?’

• Give them a warning shot e.g. ‘I’m afraid that things are changing with your dad and I need to update you about what is happening. I am sorry that we have to have this conversation on the phone, but I want to make sure you know what is happening’.

Step 4: Giving knowledge & information

• Talk VERY slowly, honestly and realistically. If the patient is sick enough that they might die or that they have died, explain this.

• Avoid euphemisms and technical jargon. You may need to talk about de-escalation from ICU or respiratory support, stopping all active management, or you may have to break the news of someone’s death.

• Listen for reactions to gauge when they are ready for more information. Remember pauses are important as you can’t see the other person’s reaction to what you are saying.

• Check they are following e.g. ‘This must be very difficult to hear. Would you like me to repeat anything?’

Step 5: Managing the response

• Distress may limit the person’s capacity to absorb information. Acknowledge how upsetting this is e.g. ‘I can only imagine how hard this is for you. I am so sorry.’

• Silences can feel uncomfortable and longer than they actually are on the telephone. It is difficult to know how a person is reacting when you can’t see them; there may be other people in earshot including children.

• Using sounds and words, e.g. ‘uh-huh’, ‘mmm’, ‘take your time, I’m still here’ replaces eye contact or touch, and confirms your presence.

Step 6: Make a plan

• Finish by explaining what will happen next: either the management plan, or, if the patient has died, practical steps.

• Reassure the person that all patients are regularly reviewed and cared for, and that there are always staff around to ensure the patient is not in distress, and to provide human contact.

• Check their understanding: ‘I realise this has been an extremely difficult conversation. There has been such a lot to take in; is there anything you would like me to go over?’

• Establish a plan for further phone conversations if needed. Leave contact details in case the person has more questions or concerns.

• Record the conversation in the notes.

These are emotionally exhausting conversations. Take a 5 minute break and have a cup of tea. Talk to your team.