Communicating Bad News in Healthcare Professions

Original Editor - Habimana Sixbert Top Contributors - Habimana Sixbert, Candace Goh and Ines Musabyemariya

Introduction[edit | edit source]

Bad news is defined as “any information that adversely and negatively affects the patients’ view of future”[1]. Breaking bad news is a sensitive, complex yet important communication skill that all healthcare professionals must be able to execute well and avoid a drastic effect on the patient experience. There are many benefits of communicating sad news, not only for the patient, but also for the medical team managing the patient. This empowers and informs the patient and allows them to plan ahead.

It is thought that many health professionals aren’t well skilled or haven’t learned the best, most compassionate techniques for delivering bad news to patients. They may assume that that particular skill is more necessary for other health professionals like an oncologist, palliative and end-of-life care etc. Yet, health professionals in almost every specialty will one day find themselves in a position of giving an unpleasant diagnosis or prognosis.

Why is it really necessary?[edit | edit source]

Breaking bad news has psychological effects on both patient and a professional[2]. Studies have shown that there is a need and interest for patients to know the truth about their conditions[3]. If they feel that their health professional is not honest, it makes them more anxious and damages their trust which may increase risk situations, such as the probability of suicide or harm to others[4][5]. The reasons that prevents the professionals from telling the truth about a bad news include fear of being blamed, unexpected evoking reactions by the patients and their family, and expressing piteous emotions and questions[6][7]. Instead of the benefits of being truthful, if bad news is not delivered appropriately, it will have negative consequences. It is therefore relevant to tell the truth which has several benefits, such as strengthening the professional-patient relationship, less complains against him/her and better decision making for the treatment process[8].

Approaches To Break Bad News[edit | edit source]

Being a health professional can be exhilarating and fulfilling when you are able to help patients recover from life threatening illnesses. But there are going to be times when you will need to tell a patient some negative information about their prognosis. Are you prepared to be the bearer of bad news? No one likes to be the bearer of bad news but in health care, it’s part of the job. Fortunately, there are ways to equip yourself to do your best in this difficult situation and get through it.

  • What to consider

Clear and empathic communication is particularly important when breaking bad news. The following are key things to be taken into consideration as they may be among possible barriers to effectively breaking bad news (BBN) as well:

  1. Culture: healthcare professionals work with persons from different background. Patients’ cultural background is often very different from that of the health facility where they seek healthcare services. Therefore, there is a need to use a client-centred approach when providing such services. This includes providing culturally sensitive care. As these differences may create certain challenges, health workers should consider client's culture, as well as their own.
  2. Professional attitudes (Body language): Non-verbal behaviour or body language such as gestures, facial expressions, movements and tone of voice can convey receptivity, interest, comprehension, hostility, disinterest, anxiety or discomfort. Interestingly, in cases where verbal and non-verbal messages contradict each other, non-verbal communication tends to outweigh the verbal message. This means that non-verbal communication is an integral, but often overlooked part of the medical interview. Empathy is expressed by being warm, friendly and reassuring. It has been linked with better patient satisfaction and recovery rates, and subsequently better health outcomes. Take an inventory of your body language and consider what expressions or gestures of the person you are communicating with suggest. Do they fit the accompanying words or does the person’s body language convey a different message[9]?
  • Effective tips

To effectively deliver an unpleasant news to patients requires particular skills and techniques in order to avoid or minimise frustration and damages to the patients. In this regard, Edward Leigh, an health care communication expert and director of the Center for Healthcare Communication in Cleveland gives his opinions about strategies to use both before, during and after breaking bad news[10].

The below attached video summarises 5 tips for breaking bad news to patients:

  • Protocols and techniques

Singh and Agarwal in a systematic review they carried out, they found that Six-step SPIKES & BREAK & ABCDE protocols are important protocols commonly used by health professionals for delivering bad news to patients and their families[11]. The above acronyms of the protocols are explained as follows:


The protocol (SPIKES) consists of six steps. The goal is to enable the clinician to fulfil the four most important objectives of the interview disclosing bad news: gathering information from the patient, transmitting the medical information, providing support to the patient, and eliciting the patient's collaboration in developing a strategy or treatment plan for the future. It can be used in numerous situations to deliver bad news, from a new diagnosis to a medical error. It provides a structured, easy way to enter a conversation and allow the other person, whether it is a patient or one of their family members, to have whatever reaction they need to have in that moment. It was developed by three doctors in the ontological field: Dr. Robert Buckman of Toronto-Sunnybrook Regional Cancer Centre, Dr. Michael Levy of the Fox Chase Cancer Center, and Dr. Watler Baile of the MD Anderson Cancer Center[12].

Step 1: S—Setting up the interview

Step 2: P—Assessing the patient's perception

Step 3: I—Obtaining the patient's invitation

Step 4: K—Giving knowledge and information to the patient

Step 5: E—Addressing the patient's emotions with empathic responses

Step 6: S—Strategy

For more details about these steps, click here.


The BREAKS protocol is a systematic and easy communication strategy for breaking bad news developed by Doctors Narayanan, Bista, and Koshy from India and Nepal in 2010. They emphasise that the way you share bad news can have either a positive or negative therapeutic effect. BREAKS is a professionally satisfying one and was designed to ensure the best outcome for the patient while supporting the doctor through a difficult situation[13].

The following are the 6 steps of BREAKS protocol and you can read breakdown here.

B –Background, R-Rapport, E – Explore, A –Announce-; K-Kindling and S –Summarise.

Rabow and McPhee also proposed a model for delivering bad news called ABCDE which is a practical and comprehensive model, synthesised from multiple sources, that uses the simple catchword: A, advance preparation; B, build a therapeutic environment/relationship; C, communicate well; D, deal with patient and family reactions; and E, encourage and validate emotions[14] Additionally, numerous other published articles deal with communication skills relating to delivering bad news to patients.

Delivering bad news in Physiotherapy[edit | edit source]

Announcing unfortunate news to patients may be part of interventions provided to patients attending physiotherapy. While challenging, it may be critical to the retention of optimism and participation in rehabilitation. Physiotherapist or any other rehabilitation professional have to be well skilled and knowledgeable as well to deliver a bad or sad news in a proper way that will not bring about negative impact on his overall expectations. Some of the patient received in physiotherapy services for physical rehabilitation are neurological conditions such as spinal cord injury and stroke patients. These patients are experiencing or facing mental or emotional issues due to the conditions they have which sometimes they are not aware of. They are wondering if they will regain the functional capability and maximise their participation in the communities. This brings about mainly a state of stress and anxiety.

They are eager to know their diagnosis and condition prognosis; some want to compare with what other health professionals told them about their conditions. And some of these professionals say nothing about the prognosis and prefer to say: “go to physiotherapy they will tell you everything you want to know”. Therefore, a physiotherapist needs to be well prepared to go about the above mentioned issues mainly regarding the prognosis of patient’s condition. When breaking bad news (BBN) regarding independence and mobility, for example, skill is required to communicate clear, realistic, and hopeful information[15][16]. A consultation done with stroke rehabilitation team showed that many of them are not confident enough to break a bad news to patients and suggested a training in this regard[17]. If we take an example of stroke and its uncertain trajectory of  recovery, announcing the prognosis can be a challenging and critical task. This is likely to affect negatively the qualities of hope and optimism of the survivors toward optimal participation in rehabilitation programs[18]. A physiotherapist needs to understand and master SPIKES which stands for Setting, Perception/Perspective, Invitation, Knowledge, Empathy/Emotion and Summary/Strategy. He/she must familiarise with Depression Anxiety Stress Scale (DASS-21) which will help to deliver sad news to patients in concise way.

Interdisciplinary collaboration[edit | edit source]

Breaking Bad News is perceived as a way not only to inform but also to educate patients, encourage them to make decisions and prepare for the future. It is a wider process that involves primarily healthcare professionals and on the other hand the non-healthcare professionals as this should ideally be an interdisciplinary exercise. Professionals integrating knowledge and methods from different disciplines, using a real synthesis of approaches to come up with a better way or strategy to announcing an unpleasant information. A study exploring an interdisciplinary breaking bad news role-play in a palliative care revealed that the role-play led to increased understanding of and changes in attitudes towards key palliative care principles, interdisciplinary teamwork, and communication of bad news[19].

Additional Resources[edit | edit source]

References[edit | edit source]

  1. Buckman RJBmj. Breaking bad news: why is it still so difficult? Br Med J (Clin Res Ed) 1984;288(6430):1597–9.
  2. Gorniewicz J, Floyd M, Krishnan K, Bishop TW, Tudiver F, Lang FJPe, et al. Breaking bad news to patients with cancer: a randomized control trial of a brief communication skills training module incorporating the stories and preferences of actual patients. Patient Educ Couns. 2017;100(4):655–666.
  3. Rozveh AK, Amjad RN, Rozveh JK, Rasouli DJIjoh-o, research sc. Attitudes toward Telling the Truth to Cancer Patients in Iran: A Review Article. Int J Hematol Oncol Stem Cell Res. 2017;11(3):178–184.
  4. Goebel S, Mehdorn HMJWn. Breaking Bad News to Patients with Intracranial Tumors: The Patients' Perspective. World Neurosurg. 2018;118:e254–e262.
  5. Hafidz MIA, Zainudin LDJMJM. Breaking Bad News: An essential skill for doctors. Med J Malaysia. 2016;71(1):26–7.
  6. Rising MLJJoTN. Truth telling as an element of culturally competent care at end of life. J Transcult Nurs. 2017;28(1):48–55.
  7. Craxì L, Di Marco V. Breaking bad news: How to cope. Digestive and Liver Disease. 2018.
  8. C Cardona M, Kellett J, Lewis E, Brabrand M, Ní Chróinín D. Truth disclosure on prognosis: Is it ethical not to communicate personalised risk of death? Int J Clin Pract. 2018:e13222.
  9. UN High Commissioner for Refugees (UNHCR), Community-Based Protection in Action - Effective & Respectful Communication in Forced Displacement, 2016, available at: [accessed 25 April 2023]         
  10. How to break bad news to patients: Experts offer best practices. Available from: (Accessed 24th April 2023)
  11. Singh, Madhav Madhusudan, and Raijiv Kumar Agarwal. 2017. “Breaking Bad News In Clinical Setting: A Systematic Review.” Indian Journal of Applied Research 7(12).
  12. SPIKES, a Six-Point Protocol, Helps Physicians ‘Break the Bad News’ to Cancer Patients Available from : (accessed 24th April 2023)
  13. Narayanan V, Bista B, Koshy C. 'BREAKS' Protocol for Breaking Bad News. Indian J Palliat Care. 2010 May;16(2):61-5.
  14. Monden KR, Gentry L, Cox TR. Delivering bad news to patients. Proc (Bayl Univ Med Cent). 2016 Jan;29(1):101-2
  15. Gorniewicz J, Floyd M, Krishnan K, Bishop TW, Tudiver F, Lang F. Breaking bad news to patients with cancer: A randomized control trial of a brief communication skills training module incorporating the stories and preferences of actual patients. Patient Educ Couns. 2017 Apr;100(4):655-666.
  16. Axboe MK, Christensen KS, Kofoed PE, Ammentorp J. Development and validation of a self-efficacy questionnaire (SE-12) measuring the clinical communication skills of health care professionals. BMC Med Educ. 2016 Oct 18;16(1):272.
  17. Phillips J, Kneebone II, Taverner B. Breaking bad news in stroke rehabilitation: a consultation with a community stroke team. Disabil Rehabil. 2013;35(8):694–701.
  18. Bonnie B. Y. Cheng, Brooke J. Ryan, David A. Copland, Sarah J. Wallace. (2022) Prognostication in Poststroke Aphasia: Perspectives of Significant Others of People With Aphasia on Receiving Information About Recovery. American Journal of Speech-Language Pathology 31:2, pages 896-911.
  19. Sween, Catherine et al. "Keeping it real: Exploring an interdisciplinary breaking bad news role-play as an integrative learning opportunity." Journal of teaching and learning 15 (2015): 14-32