Breaking Bad News
Nobody teaches you how to do this at medical school. Which is unfortunate, because you'll do it hundreds of times before you retire.
📥Downloads
Handouts, frameworks, and teaching resources — ready when you are. SPIKES, BREAKS, Kaye's model, Carl Rogers, grief frameworks, scenarios, and more.
path: BREAKING BAD NEWS
- 10 ways to help the bereaved and mourning.pdf
- breaking bad news - 4 tasks of mourning.pdf
- breaking bad news - A KISS.ppt
- breaking bad news - abcde method.docx
- breaking bad news - breaks method.docx
- breaking bad news - carl rogers.docx
- breaking bad news - kayes 10 step model.doc
- breaking bad news - kayes model.ppt
- breaking bad news - silvermann kurtz draper.pdf
- breaking bad news - SPIKES.pdf
- breaking bad news - SPIKES.rtf
- breaking bad news patient scenarios.doc
- breaking bad news scenarios.doc
- cancer communication toolkit by NW London Cancer Network.pdf
- communicating bad news.ppt
- death and dying conversations - and looking after ourselves.ppsx
- how do i break bad news.pdf
- ReSPECT - communication tips.docx
- tear model of grief.docx
🌐Web Resources
A hand-picked mix of official guidance and real-world GP training resources. Because sometimes the most valuable insights are the ones hiding outside the official documents.
Patient-facing resource; understand what your patient experiences.
Comprehensive clinical overview including SPIKES and emotional support.
The updated edition of Peter Kaye's foundational text on BBN.
Practical framework for delivering bad news in the 12-minute SCA format.
Peer-reviewed overview comparing SPIKES, ABCDE, BREAKS and others.
Step-by-step SPIKES breakdown with practical example questions.
Detailed walkthrough of the ABCDE mnemonic; highly readable.
Core professional standards including communication with patients.
⚡Quick Summary
Five minutes before a tutorial? Read this first.
If You Only Read One Thing — Read This
- Bad news in GP is not just cancer — it includes diabetes, COPD, dementia, a driving ban, a miscarriage, and any diagnosis that changes a patient's life
- Prepare first — check your facts, confirm the diagnosis, ensure privacy, allow time, and consider who the patient wants with them
- The warning shot is essential — never jump straight to the diagnosis; prepare the patient's mind for what's coming
- Elicit what the patient already knows (perception) before launching into your explanation
- Use silence deliberately — after delivering news, stop talking; let the patient process; resist the urge to fill every second
- Respond to emotion before information — if someone is crying, they cannot hear your management plan
- Avoid euphemisms — say "cancer" or "tumour", not "a little something"; vagueness causes anxiety
- Shared decision-making still applies — involve the patient in what happens next, even in the hardest conversations
- Always safety-net and follow up — offer another appointment, give written information, signpost support
- Look after yourself — these consultations are emotionally draining; debrief with a colleague when needed
- In the SCA: the warning shot, allowing silence, and emotional response are the three skills most commonly missed
- In the AKT: know the key models — SPIKES, Kaye's 10-step, ABCDE, BREAKS — including what each letter stands for
💡Why This Matters in GP
You break bad news more often than you think
Most people picture a cancer diagnosis when they hear "breaking bad news." In reality, as a GP you deliver difficult information many times every single week — often without even labelling it as bad news.
Think about it: telling a patient they have Type 2 diabetes means they must change their diet, may need tablets for life, and are now at elevated risk of heart disease, stroke, and kidney failure. That is genuinely bad news. The same applies to hypertension, COPD, a new diagnosis of atrial fibrillation, a first seizure, early dementia, or a failed smear test requiring colposcopy.
Breaking bad news is not a rare, set-piece event. It is a daily microskill for every GP.
- Delivering news too bluntly without preparation
- Focusing on facts before acknowledging emotion
- Rushing on to the management plan
- Using medical jargon the patient doesn't understand
- Avoiding the word "cancer" to soften the blow — it usually just creates confusion and more anxiety
- Not checking what the patient already knows or suspects
- To be told honestly, clearly, and kindly
- Time to process — not to be rushed
- To feel heard and not alone
- A clear explanation of what happens next
- Written information to take away
- Permission to come back with questions
- Signposting to support (e.g. Macmillan, Age UK, MIND)
💬 A note on language: Research consistently shows that patients who receive clear, honest communication — even when the news is terrible — report greater satisfaction and better psychological outcomes than those who receive vague or softened information. Honesty, delivered with compassion, is not unkind. It is the most respectful thing you can do.
📊The Spectrum of Bad News in General Practice
Not all bad news carries the same weight — but all of it deserves to be delivered with care. This spectrum runs from common, manageable diagnoses through to the most serious and life-altering conversations a GP will have.
changing
diagnoses
altering
cancer news
bereavement
The approach is the same across the spectrum — only the emotional depth and time required vary.
📋 Common BBN scenarios in everyday GP
- New diagnosis: diabetes, hypertension, COPD
- Positive HIV or STI result
- Miscarriage or fetal abnormality
- Abnormal cervical smear — colposcopy referral
- Urgent cancer referral (2-week wait letter)
- Confirmed malignancy following biopsy
- Dementia diagnosis
- DVLA driving cessation advice
- Infertility — investigation results
- Mental health diagnosis (e.g. bipolar disorder)
- Unexpected death notification to a family
- Learning disability confirmed in a child
Breaking Bad News — It Is Not Just Cancer
Approximate distribution of BBN encounters in everyday UK general practice
Diabetes, hypertension, COPD, heart failure
2WW referrals, confirmed malignancy, staging
Dementia, HIV, driving ban, serious cardiac
Miscarriage, infertility, abnormal smear
Unexpected death, end-of-life discussions
Illustrative estimates based on UK primary care patterns. Cancer-related conversations represent only a minority of BBN encounters in general practice.
✅Before You Begin — The Pre-Consultation Checklist
No experienced GP launches into a bad news conversation without preparation. Taking two minutes before the consultation can prevent serious harm — clinical, emotional, and medico-legal.
🧩Models of Breaking Bad News
Several structured frameworks exist to guide the BBN conversation. Each was developed in a specific clinical setting — mostly oncology or palliative care — but the principles translate directly into general practice. You don't need to memorise them all; you need to internalise the underlying logic. The framework is a scaffold, not a script.
🎓 AKT note: These models can appear in the AKT examination. You may be asked to identify what a specific letter in a model stands for, or to match a model to its description. See the AKT Tips section at the bottom of the page.
At a Glance: Model Comparison
| Model | Steps | Origin | GP Applicability |
|---|---|---|---|
| SPIKES | 6 steps | Oncology (2000) | ⭐⭐⭐⭐⭐ Most widely taught |
| Kaye's | 10 steps | Palliative care (1996) | ⭐⭐⭐⭐ Nuanced; allows denial |
| ABCDE | 5 steps | Primary care (1996) | ⭐⭐⭐⭐ Simple & memorable |
| BREAKS | 6 steps | Palliative care (2010) | ⭐⭐⭐ Includes hope-maintenance (K) |
| AKEFS | 5 steps | GP-specific | ⭐⭐⭐⭐⭐ Starts with patient, highly GP-relevant |
What All BBN Models Share — The Three-Layer Foundation
Every framework rests on the same pyramid. Master all three layers — not just the middle one.
Without preparation, communication skills cannot function. Without both, emotional intelligence has nothing to stand on.
🩺The Consultation — What Actually Happens
No model replaces the lived reality of actually having this conversation. Below is a practical, step-by-step guide to what a skilled GP does — blending the frameworks above into a single, human, effective consultation.
☕ The cup of tea: Offering a patient a cup of tea after breaking bad news might feel small — but it is a powerful act of care. It signals that there is no rush. It gives the patient time and space. And it communicates that you see them as a human being, not the next item on the list. Consider offering a private room if your surgery has one. These small gestures are remembered for years.
Why Written Information & Follow-Up Are Not Optional
Information retention drops sharply when emotional shock is present. This is a normal neurological response — not a failure of intelligence.
Clinical implication: After a shock diagnosis, a patient retains only a fraction of what is said. Written summaries, follow-up appointments, and chunked information are therefore patient safety essentials — not optional extras.
💔Understanding Grief Reactions
After breaking bad news, patients enter a process of psychological adjustment. Understanding the models of grief helps you respond to different reactions with compassion rather than alarm — and helps you support your patient over multiple consultations.
Kübler-Ross: The 5 Stages of Grief
Originally described in On Death and Dying (1969). Now understood as non-linear — patients move between stages, skip some, and revisit others. This is a framework for understanding, not a predictable sequence.
⚠️ Important: These stages are not universal, not sequential, and not a checklist. Many patients never reach "acceptance." Some cycle between stages for years. Your role is not to push patients through the stages — it is to accompany them wherever they are.
Grief Is Not a Journey — It Is a Landscape
Patients move freely between stages, skip stages, revisit them, or remain in one for years. The dashed ring shows possible paths — none are mandatory.
Patients are not moving through stages towards acceptance. They are navigating complex emotional terrain — and they need a doctor who can meet them wherever they are.
Worden's 4 Tasks of Mourning
J.W. Worden (1982) — describes grief as active work rather than passive stages
- Accept the reality of the loss
- Work through the pain of grief
- Adjust to the world without the loved one
- Emotionally relocate — find a new place for the person in one's emotional life
Useful for follow-up: ask which task the patient feels they are working on. It opens productive conversations.
The TEAR Model
An accessible framework based on Worden's tasks
| T | To accept the reality of the loss |
| E | Experience the pain of grief |
| A | Adjust to a new environment |
| R | Reinvest in a new life |
How grief reactions present in the GP surgery
Bereaved or grieving patients often present with physical symptoms — fatigue, poor sleep, weight loss, palpitations, low mood. The consultation may seem to be about a headache when it is really about a broken heart. Looking for the grief underneath the symptom is a hallmark of excellent GP consulting.
- Repeated attendances with vague or medically unexplained symptoms
- Emotional flatness or withdrawal at odds with the clinical picture
- Bereaved patients requesting certificates, paperwork, or medication at an unusually early return
- Anger directed at the practice following a death (even when care was appropriate)
- The anniversary effect — worsening symptoms around the anniversary of a bereavement
⚖️Medico-Legal Considerations
Breaking bad news poorly is not just emotionally difficult — it can have serious medico-legal consequences. The MDU, MPS, and GMC all provide clear guidance on what constitutes good professional practice. These are the points every GP must know.
- Duty of candour — the professional obligation to be honest with patients when something has gone wrong (GMC Good Medical Practice; CQC Duty of Candour regulation)
- Informed consent — patients cannot meaningfully consent to treatment if they have not understood their diagnosis. Bad news delivery and consent are directly linked.
- Capacity after shock — significant emotional shock can temporarily impair capacity. Do not seek consent to major treatment steps in the immediate aftermath of difficult news without first allowing time to process.
- Confidentiality — even next of kin have no automatic right to know a patient's diagnosis without consent. Check before disclosing.
- Document the date and time of the BBN consultation
- Record who was present (patient, relative, interpreter)
- Note what information was given — specifically what was said about diagnosis, prognosis, and next steps
- Record the patient's initial response and apparent understanding
- Note any follow-up arranged or offered
- Document if the patient declined information or wished information given to a family member instead
- If an interpreter was used, record this — and that it was a professional interpreter, not a family member
When the Patient Does Not Want to Know
Some patients exercise their right not to receive full information. This is a legally valid choice under the principle of patient autonomy. However, it must be handled carefully:
- Clarify what the patient does want to know — it may be that they want the facts but not prognosis, or want their relative told first
- Document the patient's stated preference clearly — date, what was said, and that the patient had capacity to make this choice
- Ensure the patient knows they can change their mind at any future appointment
- Consider whether withholding information could impair their safety or consent to treatment — if so, the balance of duties must be discussed sensitively
- In the SCA, if a patient says "I'd rather not know the details," acknowledge this with empathy, confirm what they would like, and proceed accordingly — examiners reward candidates who respect this without abandoning the patient
The MDT Meeting — Explaining the Process
GPs frequently need to explain the MDT (multidisciplinary team) process to patients who are waiting for a decision. This is a source of significant anxiety for patients — and an area where GPs can genuinely add value.
- Explain that the MDT brings together all the relevant specialists to agree the best plan — it is not a delay, it is thoroughness
- Give a realistic timescale: "The team usually meets on [day of week], so you should hear within about two weeks"
- Reassure the patient that they are not "waiting in a queue" but actively being discussed by a team of experts
- Offer to be the person they contact if they have questions before the MDT outcome arrives — this continuity is deeply reassuring and is excellent UK GP practice
Patients often ask for survival rates or prognosis data after receiving a serious diagnosis. This requires careful handling:
- As a GP, you may not have the full staging information needed to give meaningful statistics — it is entirely appropriate to say: "I don't have enough detail yet to give you a meaningful figure — that's something the specialist team will be able to discuss with you properly."
- Patients consistently misinterpret survival statistics. A 90% 5-year survival sounds reassuring, but a patient may hear "10% of people die." Explain what the numbers actually mean, not just the numbers themselves.
- Research shows that a 95% cure rate is sometimes interpreted as "definitely cured" and an 80% mortality as "definitely going to die." Neither is true. Help patients understand probability — gently and without a statistics lecture.
- Never give statistics without context. Never round up statistics to be more comforting. And never say "most people do fine" as a way of closing the conversation about prognosis — the patient in front of you needs to know about their situation, not averages.
⚠️Common Pitfalls & Trainee Traps
These are the patterns that experienced GP trainers see time and again — in real clinics, in video reviews, and in the SCA. Most are fixable once you know to watch for them.
- No warning shot — jumping straight from "I've got your results" to the diagnosis without any preparation. The patient is blindsided.
- Rushing to the management plan before the patient has had time to process the headline. They haven't heard anything you've said.
- Filling silence with information — the silence after bad news serves a clinical purpose. Do not fill it.
- Using euphemisms — "a little shadow," "a few changes," "something we need to look at." These create anxiety and confusion. Be clear.
- Not checking what the patient knows beforehand — they may already know, or may have a completely different understanding of the situation.
- Information overload — giving the full treatment pathway, survival statistics, and clinical detail in one go. Most of it will not be retained.
- Maintaining false hope to avoid distress — this erodes trust and makes later conversations harder
- Being overly clinical when the patient just needs human connection
- Not exploring ICE — the patient's ideas, concerns, and expectations transform the conversation
- Breaking bad news on the phone when a face-to-face could have been arranged — unless truly unavoidable
- Not following up — a brief call or appointment a week later costs minutes and means the world to the patient
- Assuming the patient knows what the next steps are without being told explicitly
- Using a family member as interpreter — particularly problematic for diagnoses the patient may want to keep private
- Always fire a warning shot — one sentence is enough
- After the news: stop, breathe, wait
- Name the emotion you can see — "I can see this is distressing"
- Check what the patient wants to know before you tell them everything
- Offer written information — people retain very little after a shock
- Say "I don't know all the details yet" when you don't — it builds trust
- Close with a follow-up offer, not just "come back if worried"
- Always document the conversation — date, content, who was present
💎Insider Pearls & Real-World Wisdom
- The warning shot feels unnatural at first — practice saying it out loud until it stops feeling that way
- In the SCA, candidates who passed consistently said: the silence was the hardest thing to do, and the most important
- Real patients often already know — or strongly suspect — something is wrong. Your job is often to confirm what they fear, not to deliver a bolt from the blue
- Never assume the patient's support network. Ask: "Is there someone at home you can talk to after this?"
- Patients often don't cry during the consultation — the emotion comes later, in the car park, at home. Prepare them for that: "You might feel a wave of emotion later on. That's completely normal."
- Writing a brief summary note to the patient after the consultation is remembered for years by patients and their families
- Demonstrating genuine curiosity about the patient's experience — not performing empathy
- Showing that you are comfortable with uncertainty — not pretending to know things you don't
- Treating the consultation as a conversation, not a delivery of information
- Checking in repeatedly: "How are you feeling right now? Is this making sense?"
- Letting the patient set the pace — some want all the details; others need to stop after the headline
- Remembering that patients are watching how you react as much as what you say. Calm, warm, and steady is what they need to see.
The single most important insight for BBN in the SCA: The examiner is not testing whether you can deliver information — they are testing whether you can stay present with a patient who is suffering. Silence, acknowledgement, and patience are skills. Use them.
On filling silence: The urge to fill silence is almost universal among trainees. In the SCA, filling silence with clinical information immediately after delivering bad news is one of the clearest markers of an underprepared candidate. Practice silence until it feels normal.
On bad news that is not cancer: Many BBN cases in the SCA involve life-altering but non-cancer diagnoses — dementia, diabetes, driving cessation. Trainees who approach these as "minor" bad news consistently score lower. Treat every bad news case with the same care, regardless of severity.
- In UK GP, patient autonomy is paramount — patients have the right to receive (or decline) information about their own health. This may differ from systems where family involvement in decision-making is the norm.
- Using family members as interpreters for bad news is not acceptable in UK practice — always arrange a professional interpreter
- Patients in the UK often want frank, direct communication — more so than in many other healthcare cultures. Euphemism is not kindness here; it creates confusion.
- The GMC's Good Medical Practice requires you to be honest and open with patients, including when things have gone wrong
- Consent and information disclosure are closely linked — patients cannot consent to treatment without understanding their diagnosis
🪖From the Trenches — What Trainees Actually Say
Distilled from trainee accounts, GP training scheme forums, and educator resources across the UK. Validated against RCGP and GMC guidance — these are the insights that don't always make it into the textbooks.
🔥 The Things People Wish They'd Known Earlier
- Spending too long on history at the start. In a BBN consultation, the news is the priority. Trainees who spend five minutes taking a detailed history before getting to the results leave themselves no time to manage the emotional response — and rush the most important part.
- Using jargon as a shield. "The CT has revealed a lesion with irregular margins" may feel gentler — but it protects the doctor, not the patient. Jargon creates distance and confusion. Plain language, delivered kindly, is kinder.
- Conflating reassurance with empathy. "It'll be fine," "lots of people get through this," "try not to worry" — these close down emotional expression rather than opening it. Empathy sits with the feeling: "This is a lot to take in."
- Not returning to ICE after the news. Many trainees explore ICE early then forget it entirely. The patient's concerns after the news may be completely different from their concerns before it. Come back to them: "Now that you've heard this, what's worrying you most?"
- Underestimating "smaller" bad news. Trainees who treat a new diabetes diagnosis or a driving ban as routine bad news — rather than as life-changing information — consistently score lower. Every piece of bad news deserves the same thoughtful approach.
- Practising back-to-back cases without feedback. SCA candidates who improved most consistently trained themselves to stay focused and consistent across multiple cases without mid-session correction. Build that stamina before the exam.
- Being "awkward" as the simulated patient in study groups. The Bristol GP Training Scheme explicitly advises study groups to make simulated patients challenging — patients who push back, ask difficult questions, or become upset. This builds the skills the exam actually tests.
- Using the 3-minute reading time well. Before each SCA case, use the reading time to identify whether it might involve bad news. If the notes show a recent test result, plan your warning shot before the consultation begins.
- Showing genuine curiosity about the patient's experience. Examiners consistently reward candidates who ask follow-up questions about the patient's life context — "How does this affect your work?" "Who do you have at home?" — rather than staying purely clinical.
- Explicitly verbalising your safety-net. Don't just imply the follow-up — say it clearly: "I'm going to book you a follow-up appointment for next week. I want you to come back and tell me how you're feeling."
- Sometimes your role is to re-explain someone else's bad news. Increasingly, GPs are the first point of contact after a hospital team has given a diagnosis that the patient didn't fully absorb. Your job is not to re-deliver the shock — it's to help the patient make sense of what they've already been told. Start with: "Can you tell me what the hospital explained to you?"
- The patient's reaction in clinic is not their final reaction. Some patients appear calm and composed in the consultation — and fall apart later at home. This is normal. Warn them it may happen: "Some people feel numb at first. The emotions often come later, and that's completely normal."
- Bereavement notifications in general practice. GPs are sometimes asked to notify a family of a death — particularly of a patient who dies at home or before ambulance arrival. This requires the same principles as any BBN, plus specific attention to: confirming identity, using the word "died" or "death," allowing the family time before moving to practical next steps, and documenting the conversation carefully.
- The "please don't tell" request from a family member. Occasionally, family members contact the surgery before a consultation to request that the patient not be told their diagnosis. In UK practice, this is ethically complex. A competent patient has the right to their own health information. You cannot withhold a diagnosis from a patient at the request of their family — though you can take time to explore the reasons behind the request. If in doubt, seek advice from your MDU or MPS.
- When the patient already knows. Many patients arrive knowing exactly what you're about to tell them. They've read their hospital letter, consulted Dr Google, or spoken to a relative who's a nurse. The consultation becomes less about delivery and more about acknowledgement, meaning-making, and planning. Checking what they know first is never wasted time.
- The next patient in the waiting room. After a difficult BBN consultation, you may be running late. The next patient may be frustrated. This is part of the reality of GP — and it is perfectly reasonable to ask reception to offer an apology and an explanation. You cannot be fully present in one room while mentally rushing to the next.
Breaking bad news is one of the most practised scenario types in SCA study groups — but many trainees practise it poorly. These are the techniques that make study group BBN practice genuinely useful:
- The person playing the patient should be emotionally realistic — not artificially easy. Cry. Go silent. Ask the same question twice. Get angry. These are normal responses and you need to have experienced them before the exam.
- The observer's job is to time the silence specifically. After the news is delivered, measure how long the candidate waits before speaking. Candidates are often shocked at how little silence they actually allow.
- Practise back-to-back without break or feedback — just as the SCA requires. This builds the mental stamina to reset between cases.
- After each case, the person playing the patient should feed back first: "As the patient, I felt..." This is often more valuable than clinical feedback.
- Use the RCGP North West Consultation Toolkit RAG tool (endorsed by the RCGP) to rate performance across all three domains. It's free and specifically calibrated for the SCA.
- Vary the type of bad news — don't just practise cancer diagnoses. Include diabetes, driving bans, dementia, HIV results, and miscarriage. Each has its own emotional texture.
🧑🤝🧑From the Trainee Community
Patterns, insights, and lessons that emerge time and again from GP trainees' real experiences — distilled into clean educational teaching points.
These patterns emerge consistently in training discussions with internationally trained doctors who are adjusting to UK GP consulting norms:
- Protecting the patient from the truth — in some systems, softening or withholding a diagnosis is considered compassionate. In UK GP, it creates anxiety and erodes trust. Honesty is the compassionate choice.
- Involving the family before the patient — UK law and GMC guidance is clear: competent adults receive their own information first, full stop. Family can be involved at the patient's request.
- Moving quickly to solutions — in many systems, rapid problem-solving after bad news is considered reassuring. In UK GP, it signals to the examiner that you haven't sat with the patient's emotion.
- Deferring information to senior colleagues — "The consultant will explain" is not acceptable. As the GP, you are responsible for ensuring the patient understands their situation at the primary care stage.
- Watching video examples of UK GP consultations — not to copy them, but to calibrate the expected pace and tone
- Practising the warning shot in low-stakes conversations first — then moving to study group mock cases
- Having an explicit conversation with their trainer about which of their communication habits to keep and which to modify for UK GP
- Reading UK patient experience accounts — understanding what patients in the UK say they value helps calibrate the entire approach
- Recognising that silence in a UK GP consultation is interpreted as respect and presence — not discomfort or incompetence
How to Practise BBN in Your Study Group
BBN cases benefit from very deliberate study group practice. A group of 3–5 people works well. Here is how to make the most of it:
- One person plays the doctor, one plays the patient, one observes. The observer's job is to time the silence after news delivery and watch for emotional cues that are missed.
- Give the "patient" permission to cry, go silent, or become angry — this is what the exam actually looks like
- After each case, the observer gives feedback specifically on: (a) was a warning shot used? (b) how long was the silence? (c) what emotion did the doctor name?
- Video your practice cases if possible — it is uncomfortable, but watching yourself is the fastest route to improvement
- Deliberately practise silence — the observer can count silently and tell the "doctor" how long they actually waited vs how long it felt
- Practise a wide range of BBN scenarios: not just cancer, but dementia diagnosis, diabetes, DVLA restriction, smear result, miscarriage — these are more commonly tested
- Ask your trainer to sit in on a BBN role-play and give specific feedback on the emotional response phase
- After each session, each person reflects: what one thing would they do differently?
👩🏫For Trainers — Teaching This Topic
Common Trainee Blind Spots
- Not realising they've already broken bad news hundreds of times — "I don't know how to do it" is rarely true
- Thinking the framework IS the skill — knowing SPIKES ≠ being able to have this conversation
- Avoiding the word "cancer" or "death" because it feels unkind
- Not knowing what to do with silence — treat it as failure rather than as a tool
- Conflating empathy with reassurance — "it'll be fine" is not empathy
- Not following up after a difficult conversation — the continuity element is often missed
Tutorial Ideas
- Role-play: Give the trainee a result to deliver — watch for the warning shot (or lack of it)
- COT/audioCOT review: Listen back specifically for the moment of delivery and the response to emotion
- Reflect on a real case: "Tell me about the last time you broke bad news. How did you feel afterwards?"
- Video review: Excellent BBN consultations are available — watch and discuss what worked
- Written reflection: Ask trainees to write about a BBN consultation — what they did well, what they would do differently
Reflective Questions for Tutorial Use
- "What do you think the patient was most afraid of before you saw them?"
- "When did you realise the patient had understood what you were telling them?"
- "How did you feel after that consultation? Did you debrief with anyone?"
- "What would you do differently if you had the consultation again?"
- "How did you decide how much information to give?"
- "What role does silence play in that consultation, do you think?"
- "Tell me about a BBN consultation that went well. What made it good?"
- "What supports are in place for you when consultations like this are hard?"
Looking After Yourself — and Your Trainee
Breaking bad news is emotionally taxing. Even experienced GPs feel the weight of these consultations. As a trainer:
- Check in after difficult consultations — "How was that for you?" is a powerful question
- Model appropriate debrief behaviour by sharing your own experience when appropriate
- Normalise emotional responses — feeling upset after a difficult consultation is not weakness, it is humanity
- Be alert for trainees who are over-identifying with patients (becoming too emotionally involved) or under-identifying (appearing detached or robotic)
- Signpost supervision, Balint groups, and coaching as legitimate tools for processing this kind of work
❓FAQ
Q: Do I have to use a specific model?
No. The RCGP and GMC do not mandate any particular framework. Models are scaffolding — they help you structure your thinking. What matters is that you prepare, assess understanding, fire a warning shot, deliver clearly, respond to emotion, and follow up. Any model that helps you do that is the right model for you.
Q: What if I don't have time in a 10-minute appointment?
If you recognise a consultation will require breaking bad news, it is entirely appropriate to double-book or to invite the patient back for a dedicated appointment. Saying "I have your results and I'd like to book a longer appointment to go through them properly" is good practice — not avoidance.
Q: What do I do when the patient cries?
Stop talking. Hand them tissues if available. Say something simple like "Take your time" or "I'm here." Do not attempt to move on until they are ready. Crying is healthy and appropriate — your job is to be present, not to stop it.
Q: What if the patient asks a question I can't answer?
Be honest: "That's a really important question, and I want to make sure you get the right answer — let me find out from the specialist team and get back to you." This is more respectful and safer than guessing. Always follow up as promised.
Q: Can I use a family member to interpret?
No. Using family members as interpreters for breaking bad news is not acceptable in UK practice. Arrange a professional interpreter through your practice. Even if the patient seems happy for a family member to translate, the risks — including distortion, confidentiality issues, and family distress — are significant.
Q: What does "maintaining hope" mean when the prognosis is very poor?
Hope does not have to mean cure. In palliative situations, hope might be: hope for comfort, hope to see a grandchild born, hope to have meaningful time at home, hope to be pain-free. Find out what the patient's goals are, and frame hope around those. The BREAKS model uses the word "Kindle" — a helpful image.
Q: What commonly comes up in the SCA on this topic?
Scenarios include: abnormal chest X-ray result, cancer diagnosis following biopsy, dementia confirmation, driving restriction notification, a 2-week wait referral, abnormal smear, HIV result, or unexpected bereavement notification to a family member. The skill being assessed is always the same: emotional responsiveness, clarity of communication, and a clear plan.
🔥AKT High-Yield Points
The models of breaking bad news can appear in the AKT. Know what each letter stands for — and know the differences between models.
🔥 AKT — Know These Cold
- S — Setting
- P — Perception
- I — Invitation
- K — Knowledge
- E — Emotions
- S — Strategy
- B — Background
- R — Rapport
- E — Explore
- A — Announce
- K — Kindle (maintain hope)
- S — Summarise
- A — Advance preparation
- B — Build therapeutic relationship
- C — Communicate well
- D — Deal with reactions
- E — Encourage and validate emotions
- 1. Preparation
- 2. What is known?
- 3. Is more information wanted?
- 4. Allow denial
- 5. Warning shot
- 6. Explain (if requested)
- 7. Elicit concerns
- 8. Venting of feelings
- 9. Summary & plan
- 10. Offer availability
- Confusing the letters — SPIKES has two S's (Setting AND Strategy)
- BREAKS has K for Kindle — not Knowledge (that's SPIKES)
- Kaye's model is a 10-step model — not 6 steps
- ABCDE was developed for primary care — SPIKES for oncology
- All models share a core: preparation → assess existing knowledge → deliver → emotional response → plan
- "In the SPIKES protocol, what does 'I' stand for?" → Invitation
- "Which model explicitly includes 'Allow denial' as a step?" → Kaye's 10-step
- "In BREAKS, what does 'K' stand for?" → Kindle
- "Which model was developed specifically for oncology?" → SPIKES
- Questions may also test understanding of grief stages (Kübler-Ross)
Kübler-Ross — AKT Ready
Mnemonic: DABDA — "Dad A Bit Depressed Actually"
🎯SCA High-Yield Tips
Breaking bad news is one of the most heavily examined consultation types in the SCA. It tests all three marking domains simultaneously — Data Gathering, Clinical Management, and Relating to Others. The Relating to Others domain carries the most weight in BBN cases.
SCA — BBN in 12 Minutes
- No warning shot — the most common error; examiner notes it immediately
- Spending too long on history-taking when the news is the priority
- Filling silence with clinical information before the patient has processed the headline
- Using vague euphemisms: "a few changes," "something we need to look at"
- Rushing straight to management without acknowledging emotional impact
- Being so empathetic that no management plan is ever reached
- Not safety-netting or arranging follow-up
- Fire the warning shot early — even in the first 60 seconds if the notes indicate a result
- Name the patient's emotion: "I can see this is a shock"
- Use silence as a tool — wait 10–15 seconds after delivering news
- Explicitly invite questions: "What questions do you have?"
- Offer written information or a follow-up appointment
- Acknowledge the limits of your own knowledge honestly
- End with a clear plan — patients leaving without knowing what happens next score you down
- "Before I go through the results, can I check — what's your understanding of why we did this test?"
- "I'm afraid the news isn't what I was hoping for..." [pause]
- "Take your time. There's no rush."
- "I can see this has come as a real shock."
- "We don't need to cover everything today — some of this can wait."
- "I'd like to arrange a follow-up appointment just to check in — would that be OK?"
- "Is there anyone you'd like me to explain this to with you?"
- "What's the most important thing for you right now?"
- Patient cries — this is expected; allow it, don't rush to move on
- Patient asks the same question twice — they are processing; answer again, calmly
- Patient goes quiet — silence is appropriate; wait with them
- You don't know all the answers — "I don't have all the details yet" is a perfect answer
- Patient becomes very distressed — step back, offer to pause, check for safety
- Patient expresses thoughts of self-harm — address directly: "You mentioned not wanting to go on — I want to make sure you're safe"
- Patient is about to leave with no plan — gently redirect before closing
- 7 minutes in and no news delivered yet — pivot
🗣Consultation Phrases — Breaking Bad News
These are natural, human phrases for every stage of a BBN consultation. Read them once. Then use them tomorrow. The goal is not to memorise a script — it is to have language that feels like your own when you need it most.
🔧 Adaptable Templates
These structural patterns can be modified for different patients and presentations.
🏁Final Take-Home Points
The Bits to Remember Tomorrow
- Breaking bad news is a daily skill in GP — not just for cancer diagnoses
- Always prepare before the consultation: correct facts, correct patient, private room, enough time
- Check what the patient already knows before you say anything — you may be surprised
- The warning shot is non-negotiable — one sentence before the diagnosis, every single time
- After delivering the news: stop talking, hold the silence, let the patient process
- Respond to emotion first — information second. A patient who is crying cannot hear your management plan.
- Use honest, plain language — avoid euphemisms; vagueness creates anxiety, not comfort
- Know the key models for the AKT: SPIKES, Kaye's 10-step, ABCDE, BREAKS, AKEFS
- In the SCA: the warning shot, silence, and emotional acknowledgement are where candidates win or lose marks
- Always follow up — a brief appointment next week is one of the most powerful things you can offer
- Look after yourself too — these consultations take something from you. That is not weakness; it is what makes you human and good at this job.
"The most important skill in breaking bad news is not knowing what to say. It is knowing when to stop — and simply being there."