Challenging conversations

Key messages

Effectively communicating bad news with respect, empathy and compassion is a skill that is rarely taught but often necessary in health care
Clinicians need to prepare themselves to feel upset or uncomfortable about delivering bad news
A person-centred approach to challenging conversations results in a better experience for the patient and their family.

Why is it important?

Communicating bad, sad or difficult news can be one of the most challenging tasks of a clinician. The way that health professionals deliver bad news can have a profound effect on a patient’s psychological adjustment and functioning. Minimising the potential harm to patients, families and health professionals is essential when communicating bad news.

Clinicians need to develop expert communication skills, especially when delivering bad news to patients and families. Patients and families differ in their needs for levels of information, interpretation of information delivered to them, and responses to unfavourable news. When bad news is delivered in a sensitive and caring manner, morale can be maintained, and the process of coming to terms with illness or death is possible through realistic expectations and hope. It is valuable for nurses and doctors to elicit patients' or family members' understanding of what is happening, and consideration of their needs and responding to their feelings is vital to the process of communicating in a crisis time.

Communication skills

Open disclosure is an honest, open discussion with a patient about an incident(s) that resulted in harm to that patient while they were receiving health care. The elements of open disclosure are:

An apology or expression of regret (including the word ‘sorry’)
A factual explanation of what happened
An opportunity for the patient to relate their experience
A discussion of the potential consequences of the adverse event
An explanation of the steps being taken to manage the event and prevent recurrence.

Open disclosure is a discussion and an exchange of information that may take place over several meetings. While disclosure is required when harm has occurred, it may be appropriate to disclose even when no harm is immediately apparent. This is a matter of judgement by the healthcare team.

Guides and tools

Open Disclosure checklist template (4 pages)
Open Disclosure principles, elements and process (11 pages)
Implementing the Australian Open Disclosure Framework in small practices (39 pages)
Open Disclosure resources for consumers
Open Disclosure templates and tools for clinicians and health service organisations
Open Disclosure information for clinicians and health service organisations
Open disclosure: ethical, professional and legal obligations, and the way forward for regulation – Medical Journal of Australia article

For Patients and families

Most patients want to discuss end of life care and believe the doctor should initiate the discussion. End of life care discussions should be raised by clinicians in a timely manner and address a wide range of physical and psychosocial concerns, and not focus on resuscitation alone. Patients should be encouraged to speak openly about their concerns, feelings and wishes. Direct, compassionate communication, and including family members in the discussions, improves end of life care and can minimise pain and suffering and allay the fears of the dying patient.

Guides and tools

End of Life care resources webpage
Patient-centred communication in palliative care – Department of Health End of Life Essentials
End of life Essentials for Acute Hospitals website - education modules and resources - Department of Health End of Life Essentials
Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers – Medical Journal of Australia
End-of-Life Care: Guidelines for Patient-Centered Communication - American Cancer Society
Ethical hub - suite of practical resources for clinicians from the UK’s General Medical Council
Sad news sorry business - guidelines for caring for Aboriginal and Torres Strait Islander people through death and dying (20 pages) - Queensland Health
Last days of life toolkit - Guidance for Recognising Dying; Management Planning; and Care after Death – Adult Patients (12 pages) – NSW Clinical Excellence Commission
Advance care planning training resource – 9 modules - AMA Victoria
Planning ahead resources - Dementia Australia

Guides and tools

SPIKES - 6 step protocol for delivering bad news – The Oncologist (webpage)
Breaking bad news - practical guide from UK (webpage)
Breaking bad news - Buckman’s 6 step protocol - University of Washington’s School of Medicine
The art of communication – Australian Family Physician article (webpage)
Communication skills training - resources from Cancer Australia (webpage)
Breaking bad news – communications skills training initiative (3 pages) National Breast and Ovarian Cancer Centre checklist

National Safety and Quality Health Service Standards

There is a National Safety and Quality Health Service (NSQHS) Standard dedicated to Partnering with Consumers. This Standard describes the systems and strategies to create a consumer-centred health system by including patients in shared decision making, to ensure that patients are partners in their own care, and that consumers are involved in the development and design of quality health care.

Each of the NSQHS Standards (2nd ed.) includes a partnering with consumers action that requires clinicians to actively involve patients in their own care, meet the patient’s information needs, and share decision making.