Breaking bad news: a clinician's view of the literature

In daily practice, a clinician may have to break bad news to patients and their families. How the patient responds depends largely on the manner in which the messenger conveys the news. The clinician may harbour fears of the patient's unpredictable emotional reactions, his or her own display of emotions, and a revival of bad news that he or she may have received. He or she may also feel ineffectual about an inability to deal with the patient's expectations for cure. He or she may use distancing tactics in discussing emotionally charged topics. The ensuing anxiety fosters an uneasy alliance in such situations. Moreover, the patient may question the information. This should be seen as a need for more information, and not as a challenge to the messenger's integrity or the validity of the news. Denial on the part of patients and families may indicate their inability to accept the news. The paucity of medical education in this area dictates more emphasis in teaching communication skills to medical students and postgraduate trainees. Receiving the news is the start of an adaptation process for a patient. He or she must know that there will be difficulties ahead. The patient and family will face them together with the clinician. The doctor will be available as necessary throughout the process to answer questions and provide support. This entails spending time to listen, hear, acknowledge the patient's emotions, and advocate on the patient's behalf. It is always possible to help the patient frame his or her fears. When the shadow of death approaches, life and time become more precious. Deeper meanings and clearer priorities often emerge for the dying person. He or she is forced to examine what makes a life meaningful. By sharing burdens, insight, and support, patients and professionals can pursue these discoveries together.