Breaking Bad News: What to Actually Say

Breaking bad news is the conversation interns most fear and are least prepared for, partly because it is taught as a framework of letters rather than as sentences you could actually say. The framework matters, but what helps at three in the afternoon in a side room is knowing what words come out of your mouth.

At a glance

Before you go in

Know the facts, including what you do not yet know and when you will know it — “I do not know yet, and the scan on Thursday will tell us” is a usable answer; vagueness is not. Find somewhere private. Sit down, at eye level, without a desk between you if you can manage it. Ask whether they want someone with them, and wait for that person if they do. Silence your phone.

If this conversation is above your level, say so and get the person whose conversation it is. An intern is often the right person to be present and the wrong person to lead.

Finding out what they already know

Start here, always. It tells you where to begin, and it frequently reveals that the patient has already worked it out.

Usable openings: “What have you been told so far?” or “What is your understanding of why we did the scan?” or “What have you been thinking this might be?”

Then ask how much they want to know: “Some people want every detail, others prefer the broad picture and to talk about what happens next. Which are you?” That question is a courtesy and it also protects you from delivering more than they can hold.

The warning shot

A short sentence that signals what is coming, followed by a pause. It gives the person a few seconds to brace, which measurably changes how much of what follows they retain.

Usable phrasings: “I am afraid the results are not what we hoped.” Or “I have some difficult news to tell you.” Then stop. Let them look up. Let them say “go on” if they want to.

The news itself

One or two sentences, plain words, no euphemism. Say cancer if it is cancer. Say died if they died. Softened language — “we lost him”, “a growth”, “a shadow” — is kindly meant and routinely misunderstood, and a family that leaves the room not knowing what happened will find out later in a worse way.

Then stop talking.

The silence

This is the part interns find hardest and the part that helps most. After the news, say nothing. Do not explain the staging. Do not describe the treatment options. Do not reassure. Almost nothing said in the first minute after bad news is retained, so information given then is wasted, and filling the silence serves your discomfort rather than theirs.

Wait. If they cry, wait. If they say nothing, wait. Offer tissues without commentary. When they speak, that tells you what they need next, and it is often not what you had prepared.

What to say when…

They ask “how long?” Acknowledge the question rather than deflecting it, be honest about uncertainty, and give a range if one is genuinely known. “I cannot give you an exact answer, and anyone who does is guessing. What I can tell you is the general picture, if that would help.”

They ask “is it my fault?” Answer directly. Do not lecture about risk factors at this moment, whatever the history.

They become angry. Do not defend. “I can see how angry you are, and that makes complete sense.” Anger at this news is not usually anger at you, and treating it as an attack escalates it.

They ask something you cannot answer. Say so, then say what you will do. “I do not know. I will find out and come back to you today.” Then actually come back, even if the answer is still not available.

A relative asks you not to tell the patient. Do not agree on the spot and do not dismiss them. Explore why they are worried, and be clear that a patient with capacity who asks a direct question is entitled to an honest answer. Escalate — this needs a senior.

What not to say

• “I understand how you feel.” You do not, and it invites the reply that you could not possibly.
• “At least…” Anything beginning this way minimises what they have just been told.
• “There is nothing more we can do.” Almost never true. There is always symptom control, support and presence. Say what you can do.
• “Everything will be fine.” A promise you cannot keep, and the one that destroys trust fastest.
• “How are you?” immediately afterwards. They have just been told terrible news.

Ending it

Summarise briefly, check what they have understood rather than asking whether they understood, and say clearly what happens next and when. Offer written information and tell them who to contact. Say that you will come back — and then do.

Documenting it

Record who was present, what was said in plain terms, what the patient understood, the questions asked and how you answered, and what was agreed. The next clinician needs to know exactly what this person has already been told, because nothing damages trust faster than two different accounts.

Last-minute checklist

• Private space, sitting down, phone silent, right people present
• Ask what they know and how much they want to know
• Warning shot, then pause
• Plain words, one or two sentences, no euphemism
• Then silence — do not fill it
• Answer what they ask, not what you prepared
• Never promise an outcome; never say you understand how they feel
• Check understanding, state what happens next, come back
• Document what was actually said

References

• Standard texts on clinical communication and breaking bad news protocols
• Your hospital’s guidance on communication with patients and families