Breaking bad news, and news of a death

Why this matters on day one

You will do this, sometimes at night and often by phone, sometimes about a patient you met once. Structure protects both of you — and the phone call about a death has particular rules that nobody warns you about.

The sequence

1. 1Setting and perception. Private space, sit down, no interruptions, ask who they would like present. Then find out what they already understand — this determines everything that follows.
2. 2Invitation and knowledge. Ask how much detail they want. Give a warning shot, pause, then the information in plain language and small pieces. Use the words "cancer" and "died" — euphemism creates confusion that has to be undone later.
3. 3Emotion and silence. Name what you see ("I can see this is a shock"). Then be quiet. Silence is the intervention; filling it with more information is the commonest error.
4. 4Strategy and summary. What happens next, who will be in touch, and when. Check understanding by asking what they will tell the person waiting outside. Offer written information and a specialist nurse.
5. 5Telling a family by telephone. Confirm who you are speaking to and that they are the right person, and that they are somewhere they can talk. Say who you are and that you have difficult news. Do not deliver a death over the phone to someone driving — ask. Use "died", not "passed" or "we lost". Invite them in, and say what will happen when they arrive. Document the call, the time, and who you spoke to.

What goes wrong

• Delivering the information before establishing what they know and want.
• Euphemism — "passed away", "a shadow on the scan".
• Filling silence with facts.
• False reassurance in answer to a direct question about prognosis.
• Breaking news of a death by phone without checking the person is able to receive it.