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Breaking Bad News

1 Jun 2024

Tags: Communication | Difficult Circumstances

Breaking Bad News

Breaking bad news in a prehospital setting is a challenging and delicate task that requires planning and careful considerations. Emergency medical professionals often find themselves in situations where they need to deliver distressing information to patients or their families, and doing so with empathy and clarity is crucial.

Here’s a comprehensive guide on how you may approach braking bad news in the prehospital setting.

Principles Of Breaking Bad News


Know the Details: Ensure you have all the necessary information about the patient’s condition and the situation.

Anticipate Reactions: Be prepared for a range of emotional responses, from shock and disbelief to anger and grief.

Self-Preparation: Mentally prepare yourself for the task. Being composed and empathetic is crucial.

Setting The Scene

Privacy: Find the most private setting possible. While this can be challenging in a prehospital environment, even small steps to ensure some level of privacy can help, such as using alternative rooms and closing doors.

Minimise Distractions: Try to limit external noise and interruptions.

Clear Communication

Simple Language: Use clear, straightforward language. Avoid medical jargon that can confuse the patient or family members.

Direct but Compassionate: Be honest about the situation but deliver the news with empathy and compassion.

Delivering The News

Introduce Yourself: Ensure that the patient or family members know who you are and your role.

Give a Warning Shot: A phrase like “I’m afraid I have some difficult news” can prepare them for what is coming.

State the Facts: Clearly and calmly explain the situation.

Pause for Reaction: Allow time for the information to be acknowledged and for the person to process the news.

Providing Support

Empathy and Compassion: Show that you care. Use body language and words that convey empathy.

Answer Questions: Be prepared to answer questions, even if you don’t have all the answers. It’s okay to say “I don’t know, but I’ll find out.”

Next Steps: Explain what will happen next, whether it’s further treatment, transport to the hospital, or other actions.


The SPIKES acronym, originally designed for clinical settings, can be adapted effectively for the prehospital setting.

S - Setting

It’s important to break bad news in an appropriate setting:

Privacy and Comfort: Aim to have the discussion in a comfortable, quiet, and private area. If a private room is not available, ensure you find a place with at least some privacy where the patient and family can sit. Avoid breaking bad news in public/outdoor area.

Seating: Offer both you and the patient/relatives to sit down as this may promote open communication, avoiding physical barriers like tables etc.

Uninterrupted Time: Ensure you have uninterrupted time during the discussion, possibly by leaving radios outside or turned down and turning off mobile phones/equipment.

Other people may be useful to include in this discussion such as family or friends, asking if they would prefer to have anyone present.

P - Perception

Assess Understanding by starting to discuss what has led to the current situation (e.g., the incident or symptoms) and assess the patient’s or family’s emotional state.

Determine what the patient or family already knows or expects. They may not be aware of the possible diagnoses. If this is the case, you can provide a general explanation: “Symptoms like the ones you’ve described can sometimes be caused by an infection, but they can also be due to more serious underlying conditions.” This also serves as a warning shot.

I - Invitation

Consent to Proceed: Verify if they are ready to hear the information now. In an emergency setting, this step may need to be expedited, but it’s still crucial to gauge readiness.

K - Knowledge

Deliver in Chunks: Provide information in manageable segments, pausing to check for understanding and emotional reaction.

Warning Shot: Use a warning shot to prepare them for bad news. Example could be: “We have carried out the ECG, and I’m afraid it’s not what we were hoping for.”

Clear Language: Use simple, direct language to deliver the diagnosis. Example could be: “I’m sorry to tell you, but the results show you have a serious condition.”

Pausing: Allow pauses for them to process the information and to ask questions. Once the bad news has been delivered pause until the patient/family speaks or seems ready to talk again.

Questions of disbelief, such as “This can’t be happening, can it?” or “But how am I supposed to deal with this?” are common at this stage. Assess whether these questions need a direct response. Sometimes a simple, empathetic statement like “I’m so sorry I had to bring you this news today” is sufficient.

If the patient maintains eye contact and asks questions like “So what will happen next?” it indicates they are likely ready to receive more detailed answers.

E - Emotions & Empathy

Acknowledge Emotions: Recognise and respond to emotional reactions with empathy. Example could be: “I can see this is very upsetting for you, and I’m so sorry to be the one to tell you this.”

Provide Comfort: Validate their feelings and offer support. Avoid giving false hope or lying but be reassuring about the next steps. Example could be: “I understand this is overwhelming. We are here to support you through this.”

S - Summary & Strategy

Summarise: Kindly and gently reiterate key points, as patients in shock or distress may not absorb much information. Ensure you address any questions or concerns that can be answered at this time.

Next Steps: Clearly outline the immediate next steps, whether it’s further treatment, transport to the hospital, or contacting other healthcare providers. Example may be: “We will transport you to the hospital where specialists will be able to take over and provide more detailed care.”

Follow-Up: Inform them of what will happen after the initial care you provide. Example may be: “Once we arrive at the hospital, the emergency team will perform further tests and decide on the best course of action.”

Reassurance: Assure them that they will not be left alone and that a plan is in place. Example may be: “We’ll make sure you are well taken care of and that your family is informed and supported.”

Challenges & Strategies

Emotional Reactions

Patients and families may respond with a range of emotions, including anger, disbelief, or overwhelming sadness. It’s important to remain calm, supportive, and non-defensive. Validating their feelings can help in managing their reactions.

Cultural Sensitivity

Be aware of and respect cultural differences in how bad news is received and processed. Understanding cultural nuances can help in delivering news in a way that is sensitive to the patient’s or family’s background.

Personal Impact on First Responders

Delivering bad news can be emotionally taxing. It’s important to have access to support systems, such as counselling or peer support groups, to manage your own emotional health.

Key Points

  • Using the SPIKES framework can significantly aid in delivering bad news effectively.

  • Approach the situation with empathy, acknowledging the emotional impact of the news on the recipient.

  • Communicate the information in a clear and straightforward manner, avoiding medical jargon or ambiguity.

  • Offer reassurance and support and provide resources or avenues for further assistance or information as needed.


Monden, K. R., Gentry, L., & Cox, T. R. (2016). Delivering Bad News to Patients. Baylor University Medical Center Proceedings, 29(1), 101–102. https://doi.org/10.1080/08998280.2016.11929380

Sarkhel, S., & Kumar, V. (2023). Clinical Practice Guidelines on Breaking Bad News. Indian Journal of Psychiatry, 65(2), 238. https://doi.org/10.4103/indianjpsychiatry.indianjpsychiatry_498_22