Delivering difficult diagnoses or poor prognoses remains one of medicine’s most challenging responsibilities. It seems even more difficult when it happens just before holidays. How physicians communicate bad news profoundly affects how patients process information, make decisions, and cope with their circumstances.
My sister-in-law was told by phone days before Christmas that she had metastatic breast cancer. Her family physician’s office was closed. Family were travelling and not easily reached. She still had to make Christmas happen for her young daughter. And she felt guilty about telling people such difficult news just before the holidays. Six years later, again just before Christmas she was told (again by phone) that the cancer had returned for a third time and it was Stage IV. It would be for weeks before she was able to see an oncologist to get some answers.
As health professionals and patients, and friends and family, we need a strategy to not only deliver difficult medical news, but options to help support the person hearing the news.
Suggest they bring a family member or friend with them to the appointment. Offer to let them make notes and offer to review them with them before they leave. My husband and I often hear conflicting information at medical appointments. So I take notes and do a checkback with the healthcare provider.
The SPIKES Protocol
Many physicians find success with the SPIKES framework, a six-step approach developed specifically for delivering bad news:
Setting up the conversation involves choosing a private, quiet space and ensuring adequate time without interruptions. Invite family members if the patient wishes, and sit down at eye level to signal your full attention and respect.
Perception means assessing what the patient already knows or suspects. Ask open-ended questions like “What have you been told about your condition so far?” or “What’s your understanding of why we did these tests?” This reveals misunderstandings you’ll need to address and gives insight into the patient’s emotional state.
Invitation requires determining how much information the patient wants. While most patients want full disclosure, some prefer limited details or want family members to receive information first. A simple “Would you like me to explain what we found?” respects patient autonomy.
Knowledge is the actual delivery of information. Use clear, plain language without medical jargon. Give information in small chunks, pausing frequently to check understanding. Be direct but compassionate. Instead of euphemisms that obscure meaning, say clearly “The biopsy shows cancer” rather than “The results weren’t what we hoped.”
Emotions will emerge, and your response matters deeply. Expect and allow silence, tears, or anger. Acknowledge feelings with empathetic statements like “I can see this is very difficult news” or “I wish the results were different.” Resist the urge to immediately problem-solve or offer false hope. Simply being present in someone’s pain is itself therapeutic.
Strategy and Summary involves outlining next steps while the patient is still processing. Patients typically retain little information from the conversation after hearing bad news, so provide written materials and schedule a follow-up soon. Discuss treatment options, support services, and what will happen next, but keep it brief and concrete.
Additional Considerations for Physicians
Timing matters. When possible, avoid delivering bad news late on Friday afternoons when support services are unavailable over the weekend. Ensure you have sufficient time for the conversation without rushing to your next appointment.
Bring a colleague or nurse who knows the patient. They can provide continuity, help clarify information later, and offer additional support.
Be prepared for varied reactions. Some patients become very quiet, others ask detailed questions immediately, and some may seem inappropriately cheerful due to shock or denial. All reactions are valid.
Address hope realistically. Rather than false reassurances, help patients identify realistic hopes—hoping for quality time with family, hoping to attend a grandchild’s wedding, hoping for dignity and comfort.
Follow up consistently. Check in within days, not weeks. Patients think of questions after the initial shock fades, and your continued presence signals commitment to their care throughout their journey.
For Patients: Sharing Your News with Loved Ones
After receiving difficult medical news, patients face another daunting task—telling family and friends. This burden shouldn’t fall entirely on you, but having some strategies can help.
Take Time to Process
You don’t need to tell everyone immediately. Give yourself time to absorb the information, cry, rage, or simply sit with it. There’s no deadline for disclosure except what feels right for you.
Start with Your Inner Circle
Tell your closest person or people first—your partner, parent, adult child, or best friend. These are the people who will help you tell others and support you through what’s ahead. Practice saying the words out loud with someone safe before broader announcements.
Decide Your Approach
Consider whether you want to tell people individually, in small groups, or through a written message. Each has merits. Individual conversations allow for personal connection but require repeated emotional labour. Group settings (like a family dinner) let you control the narrative and say things once. Written messages (email, text, or platforms like CaringBridge) give you time to craft your words and avoid repeating yourself, though they feel less personal.
Control the Narrative
Decide what information you want to share and what you’d prefer to keep private. You’re not obligated to share every medical detail. A simple statement like “I’ve been diagnosed with cancer, and we’re developing a treatment plan” is sufficient if that’s all you want to reveal. Above all, make sure there’s time after you share the bad news for people to ask questions, take time to process and allow them to be there for you.
Prepare for Reactions
People will respond differently. Some will cry, others will immediately offer solutions, and some may seem to make the conversation about themselves. Try to remember that most reactions come from love and fear, even if they’re not helpful. It’s okay to say “I need you to just listen right now” or “I’m not ready to discuss treatment options yet.”
Designate a Point Person
Choose someone who can field questions, provide updates, and coordinate help. This person can tell extended family, coworkers, or community members, sparing you from repetitive conversations. They can also manage the well-meaning but overwhelming offers of help.
Be Specific About Needs
Instead of vague offers like “Let me know if you need anything,” people appreciate specific requests: “Could you drive me to appointments on Thursdays?” or “Would you organize a meal train for the weeks I’m in treatment?” Concrete tasks help others feel useful and ensure you get the support you actually need.
Set Boundaries
You may not want to discuss your health at work, with certain relatives, or in public spaces. It’s completely appropriate to say “I appreciate your concern, but I’d prefer not to discuss my health right now.” You can also authorize your point person to say “They’re doing as well as can be expected and prefer privacy at this time.”
Manage Social Media Carefully
Decide early whether you want your health information on social media. If you post, set clear expectations about what others can share. If you don’t want it public, explicitly tell family members not to post about your condition. Once information is online, you can’t control it.
Tell Children Age-Appropriately
If you have children or grandchildren, tell them sooner rather than later. Children sense when something is wrong and imagine scenarios often worse than reality. Use clear, simple language without euphemisms. Young children need basic facts and reassurance about their daily life. Adolescents may need more information and space to process their feelings separately.
Talk to your local librarian who may be able to suggest resources for children getting bad news, such as in story books.
Accept Imperfect Responses
Some people will say awkward things. Others will disappear because they don’t know how to help. A few will be absolutely perfect. Try to focus on the support you do receive rather than disappointments, though it’s normal to feel hurt by those who fail to show up.
Give Yourself Grace
However you choose to share your news is the right way. There’s no perfect script, no ideal timeline, and no obligation to manage everyone else’s emotions. Your priority is your own health and wellbeing. The people who truly care will understand.
Both delivering and receiving difficult medical news are profoundly human experiences that test our capacity for compassion, honesty, and courage. For physicians, the goal is clear communication wrapped in genuine empathy. For patients, the goal is finding a path forward that honors your needs while accepting the support of those who care. In both cases, there’s no perfect approach—only the genuine effort to navigate these difficult moments with as much grace and humanity as possible.
Proudly Canadian! 2Ascribe Inc. is a medical and dental transcription services agency located in Toronto, Ontario Canada, providing medical transcription services to physicians, specialists (including psychiatry, pain and IMEs), dentists, dental specialties, clinics and other healthcare providers across Canada. Our medical and dental transcriptionists take pride in the quality of your transcribed documents. WEBshuttle is our client interface portal for document management. 2Ascribe continues to implement and develop technology to assist and improve the transcription process for physicians, dentists and other healthcare providers, including AUTOfax. AUTOfax works within WEBshuttle to automatically send faxes to referring physicians and dentists when a document is e-signed by the healthcare professional. As a service to our clients and the healthcare industry, 2Ascribe offers articles of interest to physicians, dentists and other healthcare professionals, medical transcriptionists, dental transcriptionists and office staff, as well as of general interest. Additional articles may be found at http://www.2ascribe.com. For more information on Canadian transcription services, dental transcription, medical transcription work or dictation options, please contact us at info@2ascribe.com. 866-503-4003
