Breaking Bad News, NHS Management & Structure

Giving bad news is not just an exercise in dissemination of knowledge, it is vital for those involved that this is done compassionately and sensitively.

CC 13 – Breaking Bad News

EM Curriculum: (click to view)

Breaking Bad News

Breaking bad news is an essential part of medical practice. While no doctor likes doing it, the skill of giving a patient or relatives unwelcome news is very important. Giving bad news is not just an exercise in dissemination of knowledge, it is vital for those involved that this is done compassionately and sensitively. This is particularly important in the ED setting as we often have to break bad news to a patient or family we have never met before, this news is often very sudden and unexpected and given at what is already an acutely stressful time.

There may be unique time pressures such as when a patient has suddenly developed a life-threatening condition and decisions regarding their management including end-of-life care need to be taken quickly and the information conveyed to relatives in a sensitive but timely manner.

NHS Management and Structure

Understanding the structure of the NHS and where you fit in it as a clinician becomes increasingly important as you progress in your career. It will allow you to where ideas for change come from and how you can influence them. It also includes where funding comes from and how services are commissioned.

Learning Outcomes from completing the tasks

  • Recognise the fundamental importance of breaking bad news.

  • Recall the common frameworks used in clinical practice to break bad news.

  • Demonstrate good practice in breaking bad news.

  • Discuss life threatening conditions with a patient and/or relatives and the likely management steps and outcomes.

  • Understand the principles of the NHS structure both locally and nationally.

Learning Outcome from face-to-face teaching

  • Understand the importance of clinical coding.

  • Recall some of the health regulatory agencies.

  • Practice breaking bad news in a simulated scenario.


Complete the following before the face to face session:

Task 1: Breaking Bad News

Duration: 30 mins

Listen to this St. Emlyn's Podcast on breaking bad news. It gives some points to consider when communicating bad news, but tries to avoid giving an outright structure (consider reading the spikes document in the additional resources for this). It also briefly discusses breaking bad news to children. As ever the excellent Liz Crowe gives some good insights from outside the ED and outside medicine. Well worth a listen, but also worth seeking out some of her SMACC talks too.

Task 2: DNAR

Duration: 60 mins

This 37 page document from the BMA, Resus Council and the Royal College of Nursing may seem like a rather laborious task, however DNAR decisions are an area under scrutiny and when they are made in the ED it can be in challenging circumstances. Therefore it is vital that those working in the ED have a thorough understanding of the required process and legal grounding.


Duration: 30 mins

This podcast, via the RCEMFoamed Network covers some of the basic steps to be taken after the death of a patient. It covers:

  • Confirming death

  • Last orders

  • Contacting family to come in

  • The language that should be used for breaking bad news

  • Taking more than one encounter to discuss things with family (an approach also mentioned in Task 1)

  • Tissue donation

  • How at times staff may need support too

Task 4: Organ Donation

Duration: 30 mins

This page from RCEM FOAMed contains both a podcast and written summary, depending on how you prefer to learn. It covers organ donation, but with a focus on how it is relevant to the ED.

Task 5: NHS Structure

Duration: 15 mins

This website covers the current structure of the NHS and it is worth taking the time to read through the page with the use of the diagram to understand how all the relevant bodies fit together.


We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

You have just started your late shift in Resus and have taken handover. One of the patients is Mr Young a 79 year old man who came in with sudden headache and falling GCS.

Additional Resources

Here are some extra resources to review if you want more information:


This document was produced by the East Midlands cancer network, based at the LOROS hospice. In essence this is a revision tool for the modified SPIKES protocol discussing the process of and reasons for the importance each step in the breaking bad news scenario. This is excellent revision on this topic.


Module on communication skills, including: 

  • How the physical environment affects a consultation.

  • An appreciation of the asymmetrical power relationship between doctor and patient.

  • Looks at HEADSS guidelines for communication with young people.

  • How to discuss problem behaviours.

  • Motivational interview techniques.

  • Stages of change model.


This is a useful BMJ module that covers the principles of a good consultation in detail and summarises the evidence base surrounding communication skills in the medical setting. It is well worth the time it takes to read it and will give you some specific pointers on history taking you will find useful in the ED.


An approach to breaking bad news, which in this article is covered with relevance to oncology patients. However it is still relevant and can be adapted to other conditions. Well worth a read.


A blog post about DNAR decisions and why attempts should always be made to discuss with families. Also touches on how this is reflected in the law.


Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form: