When breaking bad news to a patient, it is important to strike the right balance between providing information and overwhelming a patient with details, by tailoring information to the individual situation. Physicians sometimes feel an obligation to complete a predetermined script and mentally check off boxes as each piece of information is provided. This can leave patients feeling overwhelmed and confused. It is important to realize that many details may need to be repeated later after the initial shock has worn off. The most important aspects of the initial encounter are to make sure the patient feels supported and that there’s a clear plan and direction about what the immediate next steps will be, whether it is further testing, hospitalization, or other treatments and when the next contact with the provider will be. -Amy L Fothergill, MD, Internal Medicine, Associated Physicians, Madison, WI.

Historically, some medical professionals, especially doctors, are seen as aloof, abrupt and lacking empathy. Below are simple ways one can break bad news to patients:

It is easy to tell your patients that you see their perspective, but going through the motions of having heard yourself what you have just told them can really open your eyes. It was not until I tried to schedule my life as a dialysis patient that I realized what I had been telling my patients. To integrate 4 hour treatments three times a week opened my eyes to the independence, travel, work, privacy and freedom that were at stake. I now ask my patients about the rest of their lives and what is most important for them. This lets them know that they are seen as more than a disease, and that we are working with them to make their lives work, not just their kidneys. -R. Allan Jhagroo MD, Division of Nephrology, University of Wisconsin, Madison.

Death comes to all, yet the fore-warning in medical illness does not seem to allay the fear, shock or uncertainties about prognosis, extent of suffering, and end of life decisions . The best antidote for patients’ uncertainties is effective communication [36]. Discussing death may be difficult for physicians due to a sense of personal failure, fear of how the family will react, or personal insecurities about mortality. For clinicians to be thorough and compassionate, their care must extend beyond the physical realm to the spiritual [37, 38]. Some patients want to discuss beliefs about the soul after death with their health care providers [39, 40]. Always offer patients spiritual care according to their religious affiliation, [41] as spiritual beliefs vary with each religious sect. Regardless of religious inclinations or lack thereof, there is a universal belief in love and compassion shared by all human beings, especially when in need of healing of physical or emotional pain .

Sometimes, words are unnecessary in times of grief or delivery of bad news; and a presence, quiet empathy, tears, touch or a hug is equally effective. People express grief in various ways, like apathy, anger, denial, sadness, or a smile. This individual right of expression should be respected, not judged. Understanding and compassion is all patients and families need from their health care providers.

It can be extremely difficult for families of patients in the intensive care unit (ICU) to cope emotionally as they transition from thinking there may be a cure to, the next time, facing ­palliative care or imminent death [36, 42]. Although a physician has no obligation to provide futile care, patient care continues compassionately through helping the family cope with the loss. “Do not resuscitate orders” must be clear and ­unambiguous. Withdrawal life support should be done after open and honest discussions with the family and medical team. Health care professionals should provide the highest quality of terminal and palliative care for dying babies just as in adults [43]. Respecting families’ end of life wishes , allowing them at the bedside during terminal procedures, providing time to gather other loved ones for support, and compassionate care of the patient and family help bring closure, peace and acceptance to the grieving family, and reassure them that “everything was done”.

With advances in neonatal and obstetric care, premature infants are surviving at younger gestational ages, bringing a unique set of clinical, moral and ethical challenges. Extremely premature infants have severe neurodevelopmental disability, [44] including cognitive deficits, hearing loss , cerebral palsy, and blindness that can affect them up to adolescence [45] and beyond. The ethical principles of autonomy, beneficence, non-maleficence, and justice, [46] apply to fetuses or infants facing a life-limiting diagnosis as well as their mothers. Caring for infants in neonatal intensive care units requires extraordinary sensitivity, extreme responsibility, and heroic compassion [47]. Physicians should present facts in an honest and unbiased way, avoiding grossly grim or falsely optimistic information . Find out what the family knows, before giving information in simple language devoid of excessive medical jargon, remaining supportive of the family’s decision. Parents and medical staff are both advocates in considering the ‘best interest’ of the child. In complex ethical situations or when conflicts arise between parents’ and physicians’ desires for the child, a referral should be made to the hospital ethics committee for a formal consensus . Good palliative care entails a systematic multidisciplinary coordination of services to avoid communication breakdowns, [48–50] provide direction for clinicians and appropriate follow-up [51].