Breaking Bad News
Case Vignette: You are an IMT doctor working on the acute medical unit. You are asked to speak to Mr James Carter, a 62-year-old man, who was admitted with weight loss, persistent cough, and haemoptysis.
A CT chest performed earlier today shows a right upper-lobe lung mass with features suspicious for bronchogenic carcinoma.
He has been waiting anxiously for the results and is currently alone in the room.
He has not yet been told the diagnosis.
Your task is to:
Explain the results of the scan
Break the bad news sensitively
Address his concerns
Outline the immediate next steps
Provide appropriate support and safety-netting
What This Station Is Testing?
• Rapport and empathy
• Structure and clarity
• Safe information delivery
• Responding to emotion and offering support
• Appropriate safety netting and guiding next steps
Model Consultation Structure
Introduce + set expectations (role, agenda, confidentiality)
Explore understanding (“Can I check what you understand about what’s been happening so far?”)
Ask permission (“Would it be okay if I explain what the results show?”)
Warning shot (“I’m afraid the results aren’t what we were hoping for…”)
Deliver the news in chunks (simple language)
Pause and allow emotion (silence, tissues, acknowledgement)
Explore concerns (“What worries you most?”)
Outline next steps (immediate next steps + support and referrals)
Check understanding (“Can I check I explained that clearly?”)
Safety net + close (support teams, written info, follow-up)
Opening Framework
Aim: Create safe environment, set agenda, check understanding, get permission.
• Introduce yourself and your role
• Check the patient’s understanding
• Ask permission to continue
• Acknowledge the situation and emotions
Model opening:
“Hello, my name is Dr ___, one of the medical doctors looking after you today. Thank you for coming in. Before we start, I just want to check that you’re comfortable and this feels like a good place to talk? Would you like anyone else here with you?
Before we start, can I check what you understand so far about what’s been going on?”
“Thank you that’s really helpful. You came in with these symptoms and we arranged a few tests, would it be okay if I explain what we’ve found, and then we can talk through what it means and what happens next?”
Empathy (use early):
“I can see this is worrying — we’ll take this one step at a time.”
Core Content - SPIKES Framework
S – Setting and Listening Skills
Although the PACES exam environment is simulated, you should still demonstrate awareness of good clinical practice.
Key points to verbalise or demonstrate:
Acknowledge that you are in a private and appropriate setting
Sit at eye level with the patient
Use open body language (lean forward slightly, avoid crossed arms)
Maintain appropriate eye contact
Demonstrate active listening (nodding, verbal affirmations)
Model phrasing:
“Before we start, I just want to check that you’re comfortable and that this feels like a good place to talk.”
This immediately signals professionalism and situational awareness to the examiner.
P – Patient’s Perception
Before giving any information, establish what the patient already understands.
Aims:
Avoid repeating information the patient already knows
Identify misunderstandings or unrealistic expectations
Tailor the depth of information appropriately
Model phrasing:
“Before I explain the results, can I check what you understand about what’s been happening so far?”
Allow the patient to speak freely and support them if they struggle to explain.
I – Invitation
Not all patients want full details immediately. This step demonstrates respect for patient autonomy, which is highly valued in PACES.
Key points:
Ask how much detail the patient would like
Offer the presence of a support person
Model phrasing:
“Would you like me to explain the results in detail, or would you prefer just a general overview for now?”
“Would you like anyone else to be here with you for this discussion?”
This is high-scoring behaviour in the Communication station.
K – Knowledge (Delivering the News)
How to deliver the information
Give information in small, clear chunks
Avoid medical jargon
Use a story-based approach where helpful
Model structure:
“You came in with these symptoms, so we arranged some tests. Unfortunately, those tests have shown…”
Use a warning shot
Always prepare the patient:
“I’m afraid the results aren’t the news we were hoping for.”
Be clear and explicit
If the diagnosis is cancer, use the word “cancer”.
Do not rely solely on:
“Mass”
“Lesion”
“Tumour”
You may use these as a warning shot, but must then clarify:
“This means you have cancer.”
Clarity is essential — many patients do not understand medical euphemisms.
E – Explore Emotions and Empathise
After delivering the news:
Pause
Allow silence
Give the patient time to process
Then explore and acknowledge emotion.
Model phrasing:
“I know I’ve just given you some very difficult news. How are you feeling right now?”
Respond empathetically:
Validate emotions
Avoid false reassurance
Do not rush into management or planning too early
S – Strategy and Summary
This step is frequently done poorly, but is crucial in PACES.
From the patient’s perspective, the key questions are:
What happens next? Is there treatment? – If you are unsure as to exact treatment options available inform the patient that their case will be discussed in a specialist MDT to determine best care. However, offer immediate symptom control and support.
Am I going to die? How long do I have to live? – Explore what the patient really wants to know (patient agenda) i.e. wants to attend relative wedding. Answer in broad terms avoiding hard timelines.
Immediate Next steps
Explain clearly, even if provisional:
Further tests (biopsy if scan shows tumour growth)
MDT discussion of best care + arrange meeting with patient immediately after meeting
Support you immediately with symptom control, a named contact and written information.
Specialist nurse referral (Macmillan nurses) – “There are specialist nurses and support services who will be there for you throughout this.”
Support groups
If specifics are not provided in the station:
“The next step would usually be for your case to be discussed at a specialist MDT, where doctors from different backgrounds agree on the best treatment plan.”
Support
Explicitly reassure the patient that they are not alone:
Healthcare team – GP, Oncologists, Psychologists
Specialist nurses (e.g. Macmillan nurses)
Support groups
Family and friends – “Would you like a family member or friend to be contacted by me?”
Even if the patient has no social support:
“There are specialist nurses and support services who will be there for you throughout this.”
Offer help with transport getting home, offer ringing relative to collect them.
Key Phrases That Score Marks
“I’m sorry this isn’t the news we were hoping for.”
“Would it be okay if I explain what the results show?”
“I can see this is a shock take your time.”
“We can pause at any point if you need.”
“What’s going through your mind right now?”
“What worries you most?”
“Would you like someone with you for support?”
“Let me explain the next steps clearly, then we’ll check what questions you have.”
“Can I check I’ve explained that in a way that makes sense?”
“You won’t be facing this alone we’ll make sure you’re supported.”
Common Station Pitfalls
Giving too much detail too early (stage, prognosis)
Talking continuously without pausing for emotion
Using jargon (“malignancy”, “lesion”, “metastases”)
Not checking understanding
Not giving a clear next step
Forgetting support systems (family, nurse, GP, written info)
Safetynetting & Close
“What questions do you have right now?”
“Would you like me to summarise what we’ve discussed?”
Summary:
“Today we discussed that the scan shows a growth that looks suspicious for cancer. We’ve talked about the need for further tests to confirm it, and that you’ll be seen urgently by the specialist team to discuss the best treatment options. We also discussed support available to you.”
Safety net:
“If you feel overwhelmed, develop worsening symptoms, or you’re struggling at home, you can contact ___ or attend A&E. We’ll also arrange a follow-up appointment.”
Take-Away Box
Empathy first, structure second — and always finish with clear next steps.
