Why is it so hard to break bad news?

Breaking bad news using Neighbour's 5-stage model of the consultation

Step 1: Connect

Try to see the world through the patient's eyes, and discover his agenda or priorities.
Useful phrases include

Be alert for unspoken as well as spoken answers. Feelings perceptible at the edge of the discussion will probably indicate the the real state of affairs better than the facts actually discussed.

Step 2: Summarise

Reflect back to the patient the impression that you have gained of the situation. This shows that you have understood his/her feelings and gives the patient a chance to correct, refine and expand on them.

Step 3: Hand over

If you answer the questions to the best of your ability and admit any uncertainties, the knowledge that forms bad news is handed over in a way that empowers the patient to keep control of his/her life. To withhold information is also to withhold control and demeans the patient.

Step 4: Safety net

Safety netting is the doctor checking where the patient is, often acknowledging his/her pain, grief or bewilderment - "this must come as an awful shock to you". It is recognising the feelings that lie behind the stunned silence.
If you recognise a grief reaction, in particular the various emotional components of fear, anxiety, denial and so on, this can provide valuable insight into how much further information the patient wants and in what way it can be usefully expressed. If the patient's feelings are "allowed", he/she is more likely to pass through them and acheive some acceptance of the situation.
Give the patient the opportunity to ask for further help. Initially, the patient may be too bewildered to take anything further and should not be swamped with too many details. So leave the door open for further discussion.

Step 5: Housekeeping

The doctor reviews his/her own feelings. Dealing with death or dying is a major cause of stress for medical staff. Never has a patient complained because a doctor shed a tear with him: it seems that patients gain support in dealing with bad news when they perceive their informant is also distressed.
The professional dictum of "not to get involved" has encouraged emotional supression within the profession that prevents the doctor showing distress.


Areas to discuss

An example:

Doctor:  Warning shot           I'm afraid the news isn't very good.

Patient:                        What do you mean?

Doctor:  Staging                The bone marrow is not making the right type of blood cells.

Patient remains silent but looks at doctor enquiringly.

Doctor:  Staging                There are underlying problems with the bone marrow

Patient:                        So what is it?

Doctor:  Breaking the bad news  It's a type of leukaemia.

Points in breaking bad news

Achieving understanding
Pacing and shared control
Responding to emotions


  1. Medical education 1995,29,430-435.
  2. Update July 1996
  3. Breaking bad news - BMJ