Key Takeaways
- Breaking bad news requires preparation, clear language, empathy and time for the patient to respond.
- Find out what the patient already understands before giving new information.
- Give a brief warning that difficult news is coming.
- Avoid jargon, vague language and false reassurance.
- Pause after sharing the news and respond to the patient’s emotions.
- Confirm the next steps and check what the patient has understood.
Introduction
Breaking bad news is one of the most challenging responsibilities in healthcare. Even experienced professionals may worry about finding the right words.
For International Medical Graduates, these conversations can feel especially difficult when they take place in a second language or within an unfamiliar healthcare culture. The challenge is not only explaining the medical information accurately, but also responding to emotion, uncertainty and silence.
There is no perfect script that will remove the patient’s distress. However, a clear structure and a selection of natural English phrases can help you communicate with compassion and confidence.
The widely used SPIKES framework organises breaking bad news into six areas: setting up the conversation, understanding the patient’s perception, asking how much they wish to know, sharing knowledge, responding with empathy and agreeing on a strategy or summary (Baile et al., 2000).
The phrases below can be adapted to the patient, the clinical situation and your professional role.
1. Prepare for Breaking Bad News
Whenever possible, choose a private setting and reduce avoidable interruptions. Review the clinical information beforehand and decide who should lead the conversation.
Check whether the patient would like someone with them:
- “Would you like a family member or friend to be here?”
- “Is there anyone you would like us to contact?”
- “Would you prefer to have this conversation on your own?”
If the patient needs language support, arrange a professional interpreter according to local policy. Sensitive news should not be made less clear because of a language barrier.
Begin by introducing yourself and explaining the purpose of the conversation:
“Thank you for meeting with me. I’d like to talk about the results of your tests and what they mean.”
This prepares the patient without giving the news abruptly.
2. Find Out What the Patient Already Understands
Before explaining the results, ask what the patient already knows.
Useful questions include:
- “What have you been told so far?”
- “What is your understanding of the situation?”
- “How do you feel things have been going?”
- “What were you expecting the results to show?”
The patient’s answer helps you understand their expectations and identify any misunderstandings.
For example, if the patient already suspects that the condition is serious, the conversation may begin differently from one in which the result is completely unexpected.
Listen carefully and avoid correcting every detail immediately. First, try to understand the patient’s perspective.
3. Give a Warning That Difficult News Is Coming
A brief warning statement gives the patient a moment to prepare emotionally.
You might say:
- “I’m afraid the results are not what we had hoped for.”
- “I’m sorry, but I have some difficult news.”
- “Unfortunately, the scan has shown something concerning.”
- “I wish I had better news to give you.”
This is sometimes called a warning shot.
Avoid making the warning too long or vague. Once you have prepared the patient, give the main information clearly.
4. Explain the News Clearly
Use direct but compassionate language. Begin with the essential information and then pause.
For example:
“I’m sorry, but the biopsy shows that you have cancer.”
Or:
“The scan shows that the cancer has spread to the liver.”
Avoid surrounding the main message with a long medical explanation. If the patient has to work out what you mean, the conversation may become more confusing and distressing.
Use plain English wherever possible:
- Instead of “malignant,” say “cancerous.”
- Instead of “the treatment was unsuccessful,” say “the treatment has not stopped the cancer from growing.”
- Instead of “the patient has passed,” use “died” when clarity is essential.
The words should be honest without being unnecessarily blunt.
Give information in small sections:
“The scan shows a growth in the lung. We are concerned that it may be cancer. We’ll need a biopsy to know for certain.”
This separates what is known from what remains uncertain.
5. Pause and Allow the Patient to Respond
After giving the news, stop speaking.
The patient may cry, remain silent, ask several questions or appear not to react at all. Silence does not mean that you have communicated badly. The patient may need time to process what they have heard.
You can acknowledge the silence gently:
- “I can see that this is a lot to take in.”
- “Please take your time.”
- “We don’t have to discuss everything at once.”
- “What is going through your mind at the moment?”
Avoid filling every pause with more medical information. Continuing too quickly may overwhelm the patient.
6. Respond to Emotion with Empathy
Empathy involves recognising and responding to what the patient is experiencing.
Useful phrases include:
- “I’m sorry. I know this is difficult news.”
- “I can see how upsetting this is.”
- “I can understand why you feel frightened.”
- “This must be a great deal to take in.”
- “I wish the situation were different.”
- “We will continue to support you through this.”
Try to respond to the patient’s specific emotion rather than relying on a memorised phrase.
For example:
Patient:
“I’m worried about what will happen to my children.”
Healthcare professional:
“Your children are clearly very important to you. Let’s talk about your concerns and the support available to your family.”
Avoid saying “I know exactly how you feel.” You may understand why the patient is distressed, but you cannot know their experience completely.
7. Address Questions and Uncertainty Honestly
Patients may ask questions that cannot be answered immediately:
- “How long do I have?”
- “Will the treatment work?”
- “Am I going to die?”
- “Why has this happened to me?”
Avoid guessing or giving false reassurance.
You could say:
- “I understand why you’re asking. I cannot give you an exact answer, but I can explain what we know.”
- “We need some more information before we can answer that properly.”
- “The treatment may help, but I cannot promise that it will work.”
- “I’m sorry; we do not always know why this happens.”
- “Would it be helpful if I explained what we expect over the coming weeks?”
It is possible to maintain hope without making unrealistic promises. Hope may focus on treatment, symptom control, time with family or support through the next stage.
Instead of:
“There is nothing more we can do.”
Try:
“Although we cannot cure the illness, there is still a great deal we can do to control your symptoms and support you.”
8. Explain the Next Steps
After receiving bad news, patients may remember very little of the conversation. Keep the initial plan simple.
You might say:
- “The next step is to arrange an appointment with the specialist team.”
- “You do not have to make every decision today.”
- “We’ll give you written information to take home.”
- “We can arrange another meeting after you’ve had time to think.”
- “Here is the number to call if you have questions before your next appointment.”
Check what the patient would like to discuss now:
“Would you like me to explain the treatment options today, or would you prefer some time before we continue?”
Where appropriate, involve specialist nurses, interpreters, palliative care teams or other support services.
9. Check Understanding
Do not assume that the patient has understood or remembered everything.
Rather than asking only “Do you understand?”, try:
- “Could you tell me what you understand from our conversation?”
- “What will you tell your family about the results?”
- “What questions do you have at this point?”
- “Is there anything you would like me to explain again?”
Correct misunderstandings sensitively:
“I’m sorry if I wasn’t clear. The treatment may slow the illness down, but we do not expect it to cure it.”
Checking understanding protects the patient from leaving with an inaccurate impression of the diagnosis or plan.
10. Close the Conversation with Support
Before ending, summarise the main points and make sure the patient knows what will happen next.
For example:
“We’ve discussed that the biopsy shows cancer. The next step is to meet the specialist team to discuss treatment. You do not need to make any decisions today, and our nurse will give you contact details in case questions come up.”
You can then ask:
- “Is there anyone you would like us to contact?”
- “Would you like some time here before you leave?”
- “Do you feel able to travel home safely?”
- “Is there anything else you need from us today?”
Follow local requirements for documenting the conversation, including who was present, what information was shared and the agreed plan.
Phrases to Use Carefully
“Everything will be fine.”
This may provide false reassurance.
Try:
“We will support you and explain each step as clearly as we can.”
“At least…”
Beginning a response with “at least” may minimise the patient’s distress.
Try:
“I can see how difficult this is for you.”
“There’s nothing more we can do.”
This may make the patient feel abandoned.
Try:
“We cannot cure the condition, but we can continue treating your symptoms and supporting you.”
“I understand.”
This can sound automatic if it is not followed by anything specific.
Try:
“I can understand why the uncertainty is frightening.”
Final Thoughts
Breaking bad news is not about finding one perfect sentence.
It requires preparation, honest language, careful listening and the confidence to allow silence. Patients may not remember every medical detail, but the way they are treated during the conversation can have a lasting effect.
Clinical communication phrases can provide a helpful structure, but they should never become a rigid script. Adapt your language to the patient’s understanding, emotions and preferences.
For healthcare professionals communicating in a second language, practising realistic scenarios can make difficult conversations feel more manageable. It can also help empathetic language become more natural when it is needed most.
Book a consultation to discuss your goals and see how I can help.
Reference
Baile, W.F., Buckman, R., Lenzi, R., Glober, G., Beale, E.A. and Kudelka, A.P. (2000) ‘SPIKES—A six-step protocol for delivering bad news: application to the patient with cancer’, The Oncologist, 5(4), pp. 302–311. doi: 10.1634/theoncologist.5-4-302.