Michael W Rabow and Stephen J McPhee take you through a difficult task

Expert advice

Despite the fact that clinicians are responsible for delivering bad news, this skill is rarely taught in medical schools or residencies in the United States, and clinicians are generally poor at it.^1-4 Experienced clinicians who have offered recommendations for delivering bad news will agree on many points.^5-8 Box 2 lists the clinician's most important goals for the initial breaking of bad news, as cited in the medical literature.

Box 3 summarises specific recommendations offered in the literature for delivering bad news, organised into a simple mnemonic ("ABCDE"). Experts also point out that clinicians invariably respond with their own feelings about the bad news.⁹

Breaking bad news is sometimes seen as a skill that clinicians can master with attention to the words, setting, and attitude with which they deliver upsetting information. Beyond this however, clinicians also are called on to help manage its consequences. This requires not just expert advice and training, but also attention to patients' existential and spiritual issues.

Suffering and meaning

For patients, bad news often threatens their identity and challenges their sense of transpersonal meaning. Thus bad news can raise profound spiritual issues.

Clinicians focus often on relieving patients' bodily pain, less often on their emotional distress, and seldom on their suffering. Indeed, clinicians may view suffering as beyond their professional responsibilities. But by concentrating on physical or emotional pain, clinicians may be ignoring important elements of meaning to the patient as a person, thereby intensifying suffering.

If clinicians feel unable to, or simply do not want to, address the powerful issue of patient suffering, it is appropriate to refer the patient to another professional on the healthcare team who is more comfortable in this arena. Physicians, nurses, psychologists, social workers, and chaplains all have a role in helping patients who suffer and can support each other in providing care to the patient.

Throughout the process of dealing with suffering, the core task of the clinician must be to understand the patient's response to the bad news and the meaning ascribed to it. This understanding can only come from a detailed and tolerant exploration of the patient's unique experience of suffering.^5,10 The clinician's commitment to non-abandonment and to listening openly to the patient is necessary to being able to accompany the patient through the profound challenges of bad news, especially at the end of life.¹¹ Indeed, it is the trust possible in the patient clinician relationship that allows clinicians to discover what may be of service to the patient.^12,13

Clinicians can help simply by listening with compassion. Secondly, clinicians can provide emotional reflection and validation. Importantly, clinicians also may offer a number of specific responses to patients to help ameliorate suffering. These responses are divided into "inquiries" and "prescriptions" that can be offered to help catalyse patients' thinking and gather resources for facing suffering (box 4).

Finding strength

Patients may be able to bear bad news through personal strength - for example, from previous life experience - or with the strength of others (for example, in bereavement groups). Strength can help hold together the parts of a person threatened with dissolution by bad news.¹⁰

Clinicians may begin an inquiry into the patient's resources by asking, "When bad things have happened to you before, how did you cope?" Simply asking "What are your sources of strength or support?" will help the clinician identify the patient's need for additional resources. Asking patients "To whom will you turn for support?" may encourage patients to mobilise their own resources.

On the basis of an understanding of the patient's inner strengths and social supports, clinicians might "prescribe" educational reading material, support groups, and referrals to other professionals, to lend strength to the suffering patient.

Enhancing growth

The challenge of bad news or illness may be met with personal growth by the patient. The integrity of the whole person may be maintained if the person can compensate for what is lost.¹⁰ Many involved in hospice work report the end of life to be an opportunity for personal growth by patients.¹⁴

Clinicians might ask, "Even though there are some things you can no longer do, what activities can you still enjoy?" With some patients, the clinician may have to search for an opening: "What about you as a person does this disease not affect?"

Reviewing earlier experiences of growth in a patient's life may assist the patient in identifying the processes by which he or she best learns and develops. Research into what has been possible for others at the end of life may challenge the patient's sense of limitation. Volunteer work can help some patients regain a sense of purpose and value.

Embracing the moment

Bad news often represents a threat to the future, but the resultant suffering may be preempted by embracing the present moment. For example, a patient may say, "Although I know I will get very sick from my illness in the days ahead, today I feel well enough to enjoy time with my grandchildren." A patient focused on current feelings, experiences, and meaning may avoid the pain caused by considering a future darkly circumscribed by a bad prognosis. This focus may help dissolve barriers and bring about a sense of intimacy and wholeness.¹⁵

Clinicians might inquire about patients' desires and current feelings, asking such things as "What do you feel like doing right now?" Alternatively, asking patients about their hopes and dreams may reveal a desire that the patient might fulfil earlier rather than later: "Is there something you've always wished you could do?" and "What's stopping you from doing it now?"

Searching for meaning in suffering The psychiatrist Viktor Frankl wrote: "Man is not destroyed by suffering; he is destroyed by suffering without meaning."Searching to understand the meaning underlying bad news or at the end of life can provide solace. "In some way," Frankl wrote, "suffering ceases to be suffering at the moment it finds a meaning."¹⁶

Clinicians must understand the model of disease employed by the patient, as well as the patient's understanding of the meaning of the illness. Asking a patient "Where do you think your illness came from?" might uncover the patient's beliefs regarding the cause of disease and his or her sense of responsibility for it. Patients often find comfort in learning from their clinicians that the bad news is not their fault. Asking patients "How are you doing within yourself ?" or "What does this news mean to you?" may lead to discussions that help patients begin to grapple with the meaning of their illness, giving them a sense of control.

The sufferer's question, "Why me?," is a potent one to which clinicians must respond-although not necessarily answer. Clinicians can facilitate the patient's own search for meaning by encouraging the patient to undertake an examination of his or her life and memories. The clinician might offer a prescription to keep a journal, practice meditation, or look through photograph albums.^17,18

Seeking acceptance and reconciliation

The philosopher and priest Henri Nouwen wrote about "befriending" one's suffering as the first step towards healing.¹⁹ In accepting suffering, a patient can claim it, become familiar with it, and, potentially, overcome it by embracing it. Consideration of the end of life sometimes prompts patients to forgive or seek forgiveness from loved ones. This forgiveness can provide the patient with an unexpected positive outcome from the experience of illness and has even led some patients to describe their cancer as a gift.²⁰

Regret, guilt, and shame act as barriers to self acceptance. A clinician may gently explore a patient's regrets or personal dissatisfaction with questions such as "Where are you hardest on yourself ?" Asking directly about painful or estranged current or past relationships is appropriate for some patients ("Is there someone you really want to talk to before you die?"). Clinicians can offer to assist patients contemplating a reconciliation with an estranged loved one.

An acceptance of bad news allows patients to focus on the tasks of adjusting to their illness or on the tasks of dying, rather than fighting fruitlessly against inevitable death. Advance care planning encourages patients to make personal and legal arrangements for the time when they become sicker or die. Some patients at the end of life gain a sense of joy and completeness in distributing their possessions to loved ones.

Achieving transformation

Sometimes, illness, and loss may be transformative. Patients can respond to bad news by growing not merely stronger but fundamentally different. In a powerful paradox, such transformation allows patients to discover a passion for life in the face of impending death.¹⁴

Clinicians can ask "Are you a spiritual person?" More direct questions include "Has illness ever changed you in a fundamental way in the past? If so, how?" and "Do you know anyone who was transformed in a positive way by his or her illness?"

Although transformation through suffering is an intensely personal event, the clinician has an appropriate role in searching creatively with the patient for how good can come from bad. Clinicians may encourage religious patients to pray or may help them to seek out a spiritual mentor. Sitting with, talking with, or writing letters to loved ones often helps focus patients at the end of life on transcendent issues such as the soul, the meaning of life, and the nature of love.

Reviving the messenger

In ancient times, the bearer of the news that a battle had been lost was often killed. In a similar fashion, reacting to bad news, some patients blame their clinicians. This desire to "kill the messenger" seems understandable if clinicians appear merely to deliver prognoses without compassion and to be locked in battle with death as an adversary rather than acknowledging death as an essential part of life.²¹

Clinicians can deliver bad news well and manage its consequences. Clinicians are not responsible for knowing the answers to patients' deeply personal and existential questions; they are called on to be present as witnesses to their patients' suffering and to respect the vulnerability created by the news they bear. Whether simply being present for a patient in shock after the delivery of bad news or accompanying a patient undergoing a spiritual transformation, clinicians can help meet the patient's existential needs. In working to relieve suffering, in helping patients to discover not just how to live but why, clinicians fulfil an obligation and enjoy a privilege deeply rooted in the healing tradition and sanctified by society at large.

To manage bad news well, the clinician must place his or her relationship with the patient, the strength and reality of their human bond, over the insecurity of disease, the threat of dissolution, and the fear of death. Breaking bad news is not as much a delivery as it is a dialogue between two people, both striving to discover in each other a simple faith in the future and an understanding of meaning beyond themselves.⁵