A. What is bad news? Sharing bad news involves complex medical communication during critical life events. In every area of medicine, there are times when bad news must be communicated. In pediatrics, bad news can be the diagnosis of a serious chronic illness, a significant developmental disability, or a fatal disease. But bad news is not simply a function of the severity of the disease process. It also refers to the impact of the shared information on the recipients’ sense of quality and meaning in life, their expectations, and their goals.

B. More than a communication of facts. Cassell has written that “the imperative to tell the truth seems an insufficient guide to what you should tell patients.” A more complete perspective requires that the sharing of information reduce uncertainty, provide a basis for action, and strengthen the patient-clinician relationship. This becomes possible when the clinician looks beyond stating facts and prognosis and attempts to appreciate how the receiver of the information will understand the matters in focus. This patient-centered approach involves attempting to grasp how the new reality and options might seem to the patient and family and helping them with first steps in its integration. Information and the way it is conveyed itself can be an important therapeutic tool with direct implications for later management.

Studies document long-lasting consequences of poorly or negatively perceived disclosure affecting the patient-doctor alliance and a parent’s understanding of the clinician’s attitudes toward their child. Conversely, successfully conveyed bad news can establish helpful themes and foci for the parents to use in their efforts to clarify the goals of their child’s care.

C. The clinician’s role. Research has found that clinicians generally project a limited set of personae in communicating bad news. They have been described as the inexperienced messenger, the emotionally burdened, the rough and ready, the benevolent but tactless, the distanced doctor, and the empathic professional. Although each approach can be effective, empathic professionals may be the best because they are able to share bad news in an understanding way that affirms hope and a committed relationship with the patient.

It is important for the clinician to understand his or her personal feelings before attempting to communicate bad news. Understanding that these apprehensions exist and working to minimize their impact helps increase the potential for meaningful communication. It is not uncommon for a clinician’s apprehensions to be based upon fear. Commonly expressed fears include the fear of being at fault and blamed, the fear of unleashing a disagreeable reaction, or the fear of not knowing all the answers during a critical conversation. Many clinicians feel that the skills involved in this communication are untaught or unknown and worry about performing at the level the situation demands. Clinicians may also experience a personal discomfort with illness and death, which can exhibit itself as a discomfort with hopelessness.

Minimizing clinician-based impediments to communication is not simply a matter of acting in the way the clinician believes the recipient desires, but rather one of assuring that this communication does not undermine a parent or dissolve hope. It is important to reinforce the goals the family have for their child. Most of the time, there will be opportunities for further refinements in the future and the sharing of news is the beginning of the process.

D. Difficulties with prognosis. Clinicians should be wary of prognosis. Studies investigating prognosis have found that clinicians are accurate only 20% of the time and tend to be overly optimistic. Although studies have shown that more experienced clinicians tend to have less error, there is also a correlation between the length of a relationship with a patient and a lowered likelihood that the prognosis will be correct. Despite this tendency toward error on the part of clinicians, patients nonetheless seek a clear disclosure of information. They interpret hidden or minimal information as their doctor withholding frightening information. Patients who receive more elements of prognostic disclosure are more likely to report communication-related hope, even when the likelihood of cure is low. To help balance the hazards of sharing prognosis is to tell parents how their child’s clinical treatment condition will be monitored over time.