Breaking Bad News to Patients and Caregivers: A Critical Narrative Review of Standardised Communication Approaches, Evidence and Ethical Adaptation
Emem Samuel Edung
Emergency Department, Basildon and Thurock University Hospital, London NHS Trust Foundation, United Kingdom.
Jacques Forwah Ndeh *
Department of Hematology and Blood Transfusion Sciences, Faculty of Clinical Sciences, University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria.
Blessing Festus Arimie
Department of Psychiatry, NES Healthcare / Priory Group, Peterborough, United Kingdom.
Okafor Emmanuel Ifeanyi
Department of General Medicine, Marigold Hospital and Critical Care Centre, Lagos,Lagos Stste, Nigera.
Olabimpe Oluwabusayo Oyinloye
Department of Obstetric and Gynaecology, Federal Teaching Hospital, Ido-Ekiti, Ekiti State, Nigera.
Ilevbare Martina Olohirere
Department of Psychiatry, Medimax Hospital, Abuja, Nigeria.
Jane Ulifo Falade
Department of General Medicine, Mashi Hospital and Specialist Clinics, Kaduna, Nigeria.
Adetoun Olubusola Adekanmbi
Department of General Outpatients, Affil Onikan General Hospital, Lagos, Lagos State, Nigeria.
Monioluwa Fasola
Department of Acute and General Medicine, Samron Specialist Hospital, Ibadan, Oyo State, Nigeria.
Chukwudiebere Ekuma Oko
Department of Obstetrics and Gynaecology, Hospital Management Board, FCTA, Abuja, Nigeria.
Mary Ajayi
Department of Obstetrics and Gynaecology, University of Medical Sciences Teaching Hospitals Complex, Ondo, Nigeria.
Adeboye Ayomide Adeola
Department General Practice/ Obstetrics and Gynecology (mixed Practice), Olu-Ola Specialist Hospital Ijebu-Ode, Ogun State, Nigeria.
Olukayode O. Mabogunje
Department of Family Medicine, Safehands Medical Centre, Lagos, Lagos State, Nigeria.
Godwin Adakole Otebe
Department of Paediatrics, Federal Teaching Hospital, Katsina, Katsina State, Nigeria.
Naheemat Mofolasayo Salimon
Department of Psychiatry, Teesside, Middlesbrough University, United Kingdom.
Funsho Jacob Akande
Department of ENT/HNS, Federal Medical Centre, Bida, Nigeria.
Isu-Egwu Stella Nnenna
Department of Internal Medicine, FCTA, Federal Capital Territory Administration, Abuja, Nigeria.
Ahaiwe Chinagozi Chibuike
Department of Social Science, Heriot-Watt University, Edinburgh, Edinburgh, United Kingdom.
Michael Iheanyi Madubuko
Emergency Department, Countess of Chester NHS Foundation Chester, United Kingdom.
Oluwatobiloba Akinwale
Department of Acute Medicine, East Cheshire NHS Trust, Macclesfield, United Kingdom.
Habiba Abdulkadir
Department, Primary Health Care, Lagos, Lagos State, Nigeria.
Faruq Olushola Balogun
Department of General Medicine, Ministry of Defence, Nigeria.
Benjamin Essien
Department of Hematology and Blood Transfusion Sciences, Faculty of Clinical Sciences, University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria.
Bassey Okon Bassey
Department of Hematology and Blood Transfusion Sciences, Faculty of Clinical Sciences, University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria.
Ewa Anthony Obi
Department of Family Medicine, University of Calabar Teaching Hospital Calabar, Cross River State, Nigeria.
Idiege Idiege Omang
Department of Surgery, University of Calabar Teaching Hospital Calabar, Cross River State Nigeria.
Akaba Kingsley Onoridea
Department of Hematology and Blood Transfusion Sciences, Faculty of Clinical Sciences, University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria.
Nnaji Chimuanya Joseph
Department of Surgery, Nnandi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria.
Immaculate Ihuoma Ekeagba
WORCACCCE UNION GROUP Integrated Healthcare Sciences, Technological Development and Training and Innovative Research Foundation (WUGIHSTTAIRF), P.O Box 45 Bamenda, North West Region, Cameroon.
Abeshi Sylvester Etenikang
Department of Obstetrics and Gynecology, University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria.
*Author to whom correspondence should be addressed.
Abstract
Delivering information that threatens a patient's anticipated future is a recurring clinical task with consequences for understanding, trust, decision-making and the wellbeing of family caregivers. Structured approaches such as SPIKES (Setting, Perception, Invitation, Knowledge, Emotions, Strategy and summary), BREAKS (Background, Rapport, Explore, Announce, Kindle and Summarise) and the Serious Illness Care communication guide seek to make difficult conversations more coherent and teachable. Yet widespread adoption of a mnemonic does not, by itself, establish patient benefit, and conventional dyadic models can overlook caregiver participation, cultural negotiation and continuity after disclosure. This critical narrative review examines the conceptual rationale, empirical evaluation and implementation of standardised bad-news communication for adult patients and families, while drawing on paediatric and serious-illness evidence where it illuminates the role of caregivers. Peer-reviewed original studies, qualitative syntheses, randomised trials and methodological reviews were identified through targeted searches of accessible scholarly sources and critically interpreted according to design, outcome relevance, contextual transferability and risk of bias. The literature supports structured preparation, elicitation of information preferences, comprehensible disclosure, acknowledgement of emotion and collaborative follow-up as defensible communication functions. Training frequently improves observable clinician behaviour in simulations, although effects on patient understanding, psychological adjustment, caregiver outcomes and long-term care remain less consistently demonstrated. Patient preference studies reveal discordance between what clinicians deliver and what recipients value, especially concerning the pace of information, opportunities for questions, family inclusion and post-consultation support. Family members can facilitate understanding and practical decisions but may also become unexamined gatekeepers of disclosure. Across health systems, feasibility depends on interpreter access, privacy, staffing, leadership and longitudinal support. The review advances a patient-authorised, family-aware interpretation of standardisation: standardise safeguards and communicative functions, while individualising wording, timing, involvement and information depth. Future comparative effectiveness research should evaluate patient–caregiver dyads, validated relational outcomes, unequal access and the sustainability of training in routine services rather than relying predominantly on checklist adherence.
Keywords: Truth disclosure, clinical communication, serious illness conversations, patient autonomy, family caregivers, communication skills training, SPIKES protocol, compassionate care