Ruth Parry, PhD, still remembers a conversation she mishandled as a junior National Health Service stroke rehabilitation physiotherapist many years ago.

“I was treating a man whose stroke had severely affected his right arm,” recalled Parry, now emeritus professor of human communication and interaction at Loughborough University, Loughborough, and honorary professor in the Treetops Hospice Education Department in Derbyshire, England.

“He was very unlikely to get its movement back. I launched straight into telling him this prognosis — it was really shocking to him….If I could go back in time, I would have first tried to suss out if he suspected his arm would not get better. I would have supported him as he gradually recognized this very difficult prognosis himself, helping him to get into a place of understanding,” she told Medscape News Europe.

Since then, Parry has analyzed nearly 100 video consultations between practitioners and patients with poor prognoses in stroke and head injury and with terminal diagnoses. Her research explores a critical clinical dilemma: How do doctors navigate the delicate balance of providing fair, accurate information about dire prognoses while respecting a patient’s feelings and personal choices?

What Makes These Conversations Difficult

The challenges start with patient awareness or lack thereof. Patients with serious illness need prognostic awareness to have realistic expectations of treatment limitations.

A 2025 Italian study found that only 52% of patients entering palliative care knew their full prognosis, even though 75% of the patients in the study reported that they had wanted to be fully informed about their condition. What’s more, a 2025 cross-national study found that awareness of palliative care as an available healthcare service varied considerably across Central Europe, ranging from 9.7% who had never heard of it in Croatia to nearly 30% in Austria.

Families add another layer of complexity. While they are crucial for caregiving during difficult times, cultures vary in their thoughts and behaviors around disease, and death and how to handle them. In many cultures, relatives feel very strongly about not disclosing their full diagnosis with the aim of giving them hope.

Then there’s the emotional toll on physicians themselves. A 2024 multinational study found that some oncologists emotionally distance themselves from their patients when they must have difficult discussions with them because they feel guilt, a sense of failure, and moral uncertainty as to how to break the news. The study also found that having to deal with this kind of challenge can leave doctors with self-doubt and deep grief experienced repeatedly during their careers.

A 2024 Swiss study found that self-awareness and self-reflection are two important points that healthcare providers need to utilize when talking about dying with patients and their families. Yet this can be very hard for many doctors to do.

A Structured Approach to Difficult Conversations

Having a clear, step-by-step plan is imperative in informing a patient about treatment limitation or discontinuation. Research from the Department of Lung Cancer and Thoracic Tumors at the Maria Sklodowska-Curie National Research Institute of Oncology in Warsaw, Poland, points out that respecting patient values and preferences while maintaining hope without false expectations is among the important goals a doctor should have in mind.

“When a patient and/or their family have a limited understanding of the patient’s deteriorating condition, a team-based approach becomes essential,” first study author Aleksandra Piórek, MD, PhD, told Medscape News Europe.

“Joint conversations involving both the physician and a psychologist allow us to combine accurate medical information with psychological support. While the doctor explains the clinical situation, the psychologist can help address emotional reactions and assist patients and families in navigating the acceptance process. This collaboration reduces misunderstandings and helps maintain trust and emotional safety during even the most difficult discussions.”

Before breaking bad news, physicians need to understand what patients already suspect or know. Parry outlines the following steps in first gauging a patient’s prognostic awareness:

• Retell the patient’s medical story of what’s happened to date. Let the patient add details, agree, or correct points.
• Mention conversations and tests that point toward the patient’s prognosis. Ask them what others have said to them about their condition. Quite often, the patient will fill in information that shows they do indeed have an awareness of their prognosis.
• With terminal patients, ask questions that encourage them to raise end-of-life concerns. Examples could be, “When you’re coughing really badly and panicking, what goes through your mind?” or “Have you thought about why your pain might be getting much worse?”
• Give examples of other patient scenarios, which can make difficult topics feel less confronting. You can say, “Sometimes people who have been diagnosed with advanced cancer find it really hard to think about the future, but at the same time, people in your position often find it a bit of a relief to talk just a little bit about what’s coming next, and what is important to them.”
• Use hypotheticals, which can get a patient to engage without exposing them to information too harshly. You can say, “At some point in the future, if you had a really bad chest infection and antibiotics weren’t working, do you have a feel for whether you would want to be at home or would want to go into hospital?”

When breaking bad news must happen next, clinically clear yet compassionate talking points provide both clinical and psychological benefit.

This may include using a framework such as the six-step protocol for breaking bad news, SPIKES, said Carrie L. Cormack, DNP, APRN, associate professor at the Medical University of South Carolina, Charleston, South Carolina, and lead palliative care faculty in the Doctor of Nursing Practice program, who also teaches palliative care education in Europe to international healthcare providers.

She told Medscape News Europe that this can help ensure that medical information is conveyed clearly while also addressing and responding to emotional responses, ultimately creating a supportive environment for difficult conversations.

Working With Families

“The main strategy we use in hospice is the family conference, which consists of a multidisciplinary team meeting with the family,” said Tommaso Filippini, MD, DrPH, PhD, associate professor of epidemiology and public health at the Medical School of the University of Modena and Reggio Emilia, Modena, Italy.

“The meeting is always attended by the physician responsible for the patient’s treatment, the primary nurse, the psychologist, and other individuals who are significant to the patient. The purpose of the meeting is to discuss the patient’s situation and care pathway, as well as the psychosocial issues faced by both the patient and the family,” he told Medscape News Europe.

The conversation should be repeated if necessary. “In complex or problematic situations, we schedule several family conferences throughout the patient's stay in hospice,” Filippini continued. Using an individualized and integrated care plan, teams can outline each patient’s main problems along with the corresponding goals and interventions. Gradual, targeted communicative and relational interventions can also address issues of awareness.

In terms of an interpersonal approach to family members, Parry said, use empathy. “Help the family members come toward a gradual recognition of, and engagement, with the situation,” she said. “It’s important not to claim you fully understand their feelings because only they can fully know how they feel.” She added that it is important to give very clear assurances that their loved one will continue to receive the best possible care and support.

Doctors Need Support Too

Physicians themselves should not hesitate to take advantage of therapeutic care.

A 2024 Norwegian study stressed the importance of providing a safety net through organizational support and collaborating with colleagues, with a focus on experience in end-of-life discussions. Equally important is physician debriefing after delivering a terminal diagnosis.

“At our institution, we are fortunate to work with an outstanding psycho-oncology team,” said Piórek. “Our psychologists not only support patients and their families in coping with the illness and processing medical information, but they also provide valuable support to us, the physicians.” Talking through the experience is an important tool that can make the process easier in the future.

Parry, Piórek, Cormack, and Filippini reported having no relevant financial relationships.