Breaking bad news: tackling cultural dilemmas

Requesting that serious diagnoses be concealed from patients, a widespread phenomenon in many cultures, presents a professional dilemma. Practical and sensitive communication strategies are needed.

In this paper, we use analysis of the existing literature to develop a communication tool for practitioners facing requests for diagnostic non-disclosure. Our approach builds on existing strategies, in providing a mnemonic communication tool, permitting more than one outcome, and focusing on the need for mutual understanding and cooperation.

Existing work on this dilemma highlights the need to appreciate the family's standpoint, affirm their benevolent intentions and correct misperceptions. To this end, we have developed a mnemonic tool, 'ARCHES', to be used in situations where the family has requested diagnostic non-disclosure. The model has six stages: acknowledge the request for non-disclosure, build the relationship, find common ground, honour the patient's preferences and outline the harm of non-disclosure, provide emotional support and devise a supportive solution.

Facing requests for diagnostic non-disclosure is a challenge of communication. The dilemma is particularly marked when practising across cultures. Our model gives a structure for building rapport with the family and realigning their misperceptions while upholding the patient's right to knowledge.