Bad News Consultations Research Articles

The influence of "bad news" and "neutral/good news" on patients' perception of physician empathy during oncology consultations.

Being met with empathy increases information sharing, treatment coherence, and helps patients to recover faster. However, we do not know how the content of the conversation about disease progression, new treatments, or other issues concerning serious illness affects patients' perceptions of the physician's empathy, and thus, the quality of the conversation. This study aimed to test the hypothesis that patients will rate their physician lower following a "bad news" consultation using the consultation and relational empathy (CARE) measure. A total of 186 outpatients from the Department of Oncology were recruited for this study. After meeting with a patient, the physician filled out a form, placing the patient in either the "bad news" group, or the "neutral/good news" group along with information about the patient and the consultation. The patient was given the CARE measure after the visit. The patients who had received bad news rated their physicians a significantly lower score on the CARE measure, even though the effect size was small, than those who had neutral/good news. On average, bad news consultations were 11 min longer. Physicians need to be aware of the patients' need to be known and understood, in addition to having skills to attend to emotional cues and concerns, since the current study's finding could be a sign either of the content being projected onto the physician or that the physician is focused on the message rather than on the patient.

An Investigation of Patients’ and Doctors’ Autonomic Nervous System Responses Throughout News-Focused Medical Consultations

ABSTRACT Although it is clear that people experience physiological arousal in anticipation of news-focused medical consultations, our knowledge of people’s experiences during and throughout these consultations is scarce. We examine interbeat interval responses (IBI) of patients and doctors during real-life medical consultations to understand how the experiences of both parties change throughout these encounters and whether they differ from each other. We also examine how the type of news delivered affects responses. We measured the IBI responses of patients and their oncologists throughout 102 consultations in which providers delivered news (classified as good, bad, or status quo) to patients about a recent computerized tomography scan. We observed two distinct phases of consultations: an initial “news” delivery phase and a subsequent “information” phase. During the news phase, on average, patients’ IBI responses rapidly increased–indicating less autonomic arousal over time – whereas doctors’ responses did not change over time. In contrast, throughout the information phase, on average, both patients’ and doctors’ responses remained steady. During the information phase, responses differed based on news type: on average, status quo consultations involved an increase in autonomic arousal, whereas good and bad news consultations involved no changes. Lastly, we observed significant variability in patients’ responses during both phases. In sum, on average, patients (but not doctors) experience decreases in autonomic arousal while news is being delivered, suggesting that anticipatory distress regarding these consultations wanes quickly. However, our results also indicate that patients’ experiences vary from one another, and future research should focus on factors explaining this variability.

The association of physician empathy with cancer patient outcomes: A meta-analysis.

In oncology, research remains unclear as to whether physician empathy is associated with patient outcomes. Our goal was to answer this question and explore potential moderators of the association. In this meta-analysis on adult cancer care, we excluded randomised controlled trials, and studies of survivors without active disease or involving analogue patients. Eight databases were searched, in addition to reference lists of relevant articles and grey literature. Two reviewers independently screened citations, extracted data, assessed risk of bias and graded quality of evidence by using the AXIS tool. Effect size correlations (ESr) were chosen and pooled by using a random effect model. Subgroup analyses were performed, and statistically significant variables were introduced in a meta-regression. Several methods were used to explore heterogeneity and publication biases. We included 55 articles, yielding 55 ESr (n = 12,976 patients). Physician empathy was associated with favourable patient outcomes: ESr= 0.23, 95% confidence interval (CI) (0.18to0.27), z = 9.58, p<0.001. However, heterogeneity was high, as reflected by a large prediction interval, 95% (-0.07to0.49) and I2 = 94.5%. The meta-regression explained 53% of variance. Prospective designs and physician empathy assessed by researchers, compared with patient-reported empathy, decreased ESr. Bad-news consultations, compared with all other types of clinical encounters, tended to increase ESr. Patient-reported physician empathy is significantly associated with cancer patient outcomes. However, the high heterogeneity warrants further longitudinal studies to disentangle the conditions under which physician empathy can help patients. Recommendations are proposed for future research.

'Bad news consultations' with oncology nurses: Impact on perceived stress and patient experience.

'Bad News Consultations' (BNC), conducted by nurses who are specialists in cancer, have been institutionally implemented in all French anti-cancer centres, to support the patient facing announcement-related stress. This study aimed to 1/describe the impact of the BNC on the patient's perceived stress and 2/determine the patient's benefits from the BNC. This monocentric study, cross-sectional evaluation, used a mixed method, both quantitative and qualitative. During 8 months, 336 eligible participants who underwent a BNC were recruited by nurses. Perceived stress was self-assessed with a validated Visual Analogic Scale (VAS), at the beginning and at the end of the BNC. Stress resilience was self-assessed once using the CD-RISC2. Qualitative experiences were explored after the BNC, using a 25-item questionnaire. Multivariate analyses were conducted on perceived stress measures (on the VAS) to test mixed-effects models, including initial predispositions (e.g., stress resilience) and organisational constraints (e.g, interval between the medical consultation and the BNC). Analyses on the perceived stress measures revealed a significant and negative effect of Time (B=-1.91; p<.001), Gender (B=0.72; p=.03), and Resilience score (B=-0.43; p<.001), without any significant effect of the other incorporated random effects (i.e., Type of cancer/treatment) nor fixed effects (i.e., Age, Organisational constraints). Patients mostly reported having received necessary information, having their addressed emotions with empathetic responses and respect, perceived benefits in the healthcare pathway, and heard of some supportive cares. Perceived stress was reduced after BNCs. According to the patients, the BNCs allowed a better patient-centered communication and a better care pathway.

Methodological choices in experimental research on medical communication using vignettes: The impact of gender congruence and vignette modality

ObjectiveExperimental vignette designs are used to systematically test the effects of medical communication. We tested the impact of two methodological choices –gender congruence and vignette modality– on analogue patient reported outcomes. MethodsIn an online experiment using a vignette portraying an oncological bad news consultation, we manipulated (1) gender congruence between the analogue and the vignette patient, and (2) vignette modality, i.e., text, audio, or video. Cancer-naïve students acting as analogue patients (N = 209, 22 ± 3 years old, 75% F) were assigned one randomly-selected vignette variant and completed questionnaires. Using 3 × 2 (repeated-measures) ANOVAs, we tested main and interaction effects of gender congruence and modality on self-reported engagement, recall, trust, satisfaction and anxiety. ResultsWe found no main effects of gender congruence or modality on any of the outcomes, nor any interaction effects between modality and congruence. ConclusionOur results indicate that researchers may needlessly create gender-congruent vignettes at considerable cost and effort. Also, the currently assumed superiority of videos over other modalities for experimental vignette-based research may be inaccurate. Practice implicationsAlthough further testing in an offline format and among different populations is warranted, decisions regarding gender congruence and modality for future vignette-based studies should be based primarily on their specific aims.

Mindfulness Improves Otolaryngology Residents’ Performance in a Simulated Bad-News Consultation: A Pilot Study

Delivering bad news is a stressful moment for both patient and clinician. As poor bad-news consultation quality may lead to misunderstandings, lack of treatment adherence, acute or even post-traumatic stress in patients, training interventions to improve communication skills and stress-management are necessary. Mindfulness is a recognised stress-management strategy that has shown its efficacy in reducing stress in both health professionals and students. We then supposed that a short mindfulness meditation session performed just before a simulated breaking bad-news consultation to patients with laryngeal cancer may help ear, nose and throat (ENT) residents to master their stress and improve their management of this consultation. This study aims at showing how a short mindfulness meditation performed before a simulated bad-news consultation may improve performance in its realisation by ENT residents. We enrolled 53 ENT residents, randomised in 2 groups. The first group completed a 5-minute mindfulness session while the other group listened to a control track. Thereafter, every resident completed an 8-minute simulated bad-news consultation with a standardised patient. Two blinded expert assessors evaluated their performance on a 25-point grid (BNC-OSAS). Residents self-assessed their stress before and after the intervention and simulated patients rated their perception of physician's empathy. The performance was significantly better in the mindfulness group than in the control group (m = 19.8, sd = 3.2 and m = 17.4, sd = 3.7 respectively, F(1,45)=5.27, p = 0.026, d = 0.67), especially in the communication and knowledge subdomains. There was no significant difference in perceived stress between the 2 groups. Empathy perceived by simulated patients was positively correlated to residents' performance. A short mindfulness meditation is effective for improving ENT residents' performance in a simulated bad-news consultation. These results encourage further assessments of this method with objective measures of physiological stress. More research is required concerning the feasibility and efficacy of mindfulness before daily clinical activities such as stressing bad-news consultation.

Patients’ Needs In Breaking Bad News For Cancers Diagnosis: Preliminary Result

Introduction: How to perform a breaking bad news consultation properly with the present circumstances and especially it fits the local people. The way to deliver bad news to cancer patients was studied and practiced widely in the world. Some studies were conducted in Vietnam but not yet in central Vietnam. The people here are quite different in thinking and personality. Hence, they may need and expect consultation differently. The study was performed to note the needs of patients in the breaking bad news of cancer and to explore their own experience of giving bad news. Methods: A cross-sectional study was conducted on 44 cancer patients undergoing treatment at the Hue University of Medicine and Pharmacy hospital in July 2020. Results: Of 44 patients, The age average was 56.73. Male was more prevalent in the study with 61.4%. About 45.5% of patients expected to be explained in a private room and most of them desired to hear the truth at the same time with their family (68.2%), only 4.5% of patients wanted the bad news to be delivered only to their families. One hundred percent of patients preferred their oncologists to explain the bad news. More than 80% of patients wanted you received all at once. Patients were interested in getting information about the diagnosis of cancer, stage of cancer, cost of the treatment, treatment option to be selected and results of clinical studies were less important to them. They mostly wanted the truth to be delivered to them than to the family for most of the information contents given by the researchers. Conclusions: Patients in the study wanted to know the truth but some information was more important than others according to them. They mostly satisfied with the breaking bad news that has been done.

Simulation haute-fidélité à la consultation d’annonce en oncologie médicale

Medical oncology bad news consultation is a particularly stressful situation for both the patient and the physician. High-fidelity simulation is a learning option that has never been evaluated in France in this field. This is a feedback from simulated announcement consultations carried out from January 2018 to May 2019. Residents from the medical oncology and radiotherapy departments performed high-fidelity simulations at the announcement consultation with an announcement nurse, a psychologist, a certified coach and an oncologist. A competency assessment was completed in pre-test, immediate post-test and after 5 months. Fourteen of the 16 eligible interns participated. The pre-test competency assessment showed that interns over 5 semesters reported being more comfortable at the consultation (P=0.04) and thought they were clearly explaining the disease (P=0.03). However, all residents, regardless of the semester, felt stressed before a consultation. The evolution of parameters skills after the simulation was positive for all criteria, particularly for adaptation to patient reactions, use of appropriate vocabulary and reduction of stress (P<0.05). This evolution was independent of the gender, curriculum, semester, or previous completion of a medical oncology internship. More than 80% of the students were ready to repeat this type of training. This training demonstrates the value of simulation training for medical oncology advertising consultation.

Physician Empathy Interacts with Breaking Bad News in Predicting Lung Cancer and Pleural Mesothelioma Patient Survival: Timing May Be Crucial.

This study is the first to examine the prognostic role of physician empathy in interaction with the type of consultation (TC) (TC, bad news versus follow-up consultations) in cancer patient survival. Between January 2015 and March 2016, 179 outpatients with thoracic cancer and a Karnofsky performance status ≥60 assessed their oncologist’s empathy using the CARE questionnaire, which provides a general score and two sub-dimensions: listening/compassion and active/positive empathy. Survival was recorded until April 2018. Usual medical, social and psychological confounders were included in the Cox regression. The median follow-up time was 3.1 years. There was a statistical interaction between listening/compassion empathy and TC (p = 0.016) such that in bad news consultations, higher listening/compassion predicted a higher risk of death (hazard ratio (HR) = 1.13; 95% confidence interval (CI): 1.03–1.23; p = 0.008). In follow-up consultations, listening/compassion did not predict survival (HR = 0.94; 95% CI: 0.85–1.05; p = 0.30). The same results were found with the general score of empathy, but not with active/positive empathy. In bad news consultations, high patient-perceived physician compassion could worry patients by conveying the idea that there is no longer any hope, which could hasten death. Further studies are warranted to confirm these results and find out the determinants of patient perception of physician empathy.

Does silence speak louder than words? The impact of oncologists’ emotion-oriented communication on analogue patients’ information recall and emotional stress

ObjectiveThe impact of two types of oncologists’ emotion-oriented communication on participants’ recall of medical information was investigated, and the potential mediation by a reduction in emotional stress. Additionally, moderation effects by personal characteristics were explored. MethodsAn oncologist’s communication in response to a patient’s emotional expressions was manipulated during a videotaped, scripted bad-news consultation. Three conditions were created: 1) standard communication, 2) emotion-oriented silence, and 3) emotion-oriented speech. Participants (N = 217) were randomly allocated to one of the three conditions. Measurements included information recall (free recall and recognition), emotional stress (self-reported and physiological), and personal characteristics. ResultsEmotion-oriented silence (p = .002) and speech (p = .019) enhanced information recognition compared to standard communication. No differences in free recall were found. Emotional stress did not mediate these relations. Poorer functional health literacy predicted poorer recognition, but this was counteracted by emotion-oriented communication. ConclusionsBy means of acknowledging, exploring, empathic and supportive statements, and attentive silence, the oncologist’s communication resulted in better information recognition. How oncologists’ communication impacts patients’ information recall warrants further investigation, as this could not be explained by reducing emotional stress. Practice implicationsThese insights will help educators to validate the relevance of emotion-oriented strategies, and encourage oncologists to adopt them.

Affective communication during bad news consultation. Effect on analogue patients’ heart rate variability and recall

ObjectiveThe aim of the study was to investigate the effect of physicians’ supportive communication on analogue patients’ (APs) heart rate variability (HRV) and recall, while watching a video of palliative treatment being explained to a female patient. MethodsSixty healthy women, acting as APs, were randomly assigned to watch one of two versions (standard vs. affective) of a scripted video-vignette of a bad news consultation to a female patient. The physician’s communication differed only in the delivery of four supportive comments. Empathy, support and engagement perception were assessed by three questions. APs’ HR was recorded during video-observation and recall was assessed immediately after. HRV was determined through measures defined in time and frequency domains. ResultsData of 54 APs (27 + 27) were included. The group with supportive communication perceived the physician as more empathic and supportive. Intra- and Inter-group comparisons suggested a greater sense of stress in the standard communication group. Recall did not differ in the two groups. Conclusion and practice implicationsFindings show that the use of supportive expressions contribute to the perception of the physician as more empathic, potentially buffer patients’ arousal after a bad news announcement, but does not confirm a positive impact on general recall.

In which context is physician empathy associated with cancer patient quality of life?

ObjectiveIn cancer settings, physician empathy is not always linked to a better patient emotional quality of life quality of life (eQoL). We tested two possible moderators of the inconsistent link: type of consultation (bad news versus follow-up) and patient emotional skills (emoSkills, i.e., the way patients process emotional information). MethodsIn a cross-sectional design, 296 thoracic and digestive tract cancer patients completed validated questionnaires to assess their physician empathy, their emoSkills and eQoL. Moderated multiple regressions were performed. ResultsIn follow-up consultations, physician empathy was associated with a better eQoL in patients with low or average emotional skills. Those with high emotional skills did not benefit from physician empathy. Their eQoL was nonetheless very good. In bad news consultations, the pattern was reversed: only patients with average or high emotional skills benefited from physician empathy. Those with low emotional skills were not sensitive to it and presented a poor eQoL. ConclusionMedical empathy is important in all consultations. However, in bad news consultations, patients with low emoSkills are at risk of psychological distress even with an empathetic doctor. Practice implicationsAccordingly, physicians should be trained to detect patients with low emoSkills in order to refer them to supportive care.

‘Just gripping my heart and squeezing’: Naming and explaining the emotional experience of receiving bad news in the paediatric oncology setting

ObjectiveTo explore recipients’ perspectives on the range and origins of their emotional experiences during their ‘bad news’ consultations. MethodsParticipants were four bereaved families of children who had changed from active treatment to palliative care in paediatric oncology. Data was collected using emotional touchpoint storytelling. The names (descriptors) given to the emotional experiences were linguistically classified. Explanations of their perceived origins were examined using applied thematic analysis. Results26 descriptors were given, relating to bodily sensations, affective states, evaluations and cognitive conditions. Three themes were identified in the origins of these experiences – ‘becoming aware’, ‘the changes’ and ‘being in this situation’. Parents described strong emotional displays during the consultation including physical collapse. These related to the internal process of ‘becoming aware’. Three descriptors were given as originating from the clinicians and their delivery of the news – ‘supported’, ‘included’, ‘trusting’. ConclusionsRecipients perceive their emotional experiences as mainly originating from the news itself, and perceived consequences of it, rather than its delivery. Strong emotional reactions during the interaction are not necessarily an indicator of ineffectual delivery. Practice ImplicationsFindings offer a thematic framing that may support and deepen practitioners understanding of recipients’ emotional reactions during bad news consultations.

Analogue patients’ self-reported engagement and psychophysiological arousal in a video-vignettes design: Patients versus disease-naïve individuals

ObjectivesThe ecological validity of video-vignettes design investigating patient-provider communication hinges on the engagement of analogue patients (APs) with the vignette. The present study aimed to compare engagement in two commonly utilized groups of APs, patients and disease-naïve individuals. Engagement was assessed by self-report and in the form of physiological arousal. MethodsCancer patients (N=22) and disease-naïve individuals (N=24) were recruited as APs. APs completed the Video Engagement Scale after watching a vignette of a oncologic bad news consultation. Electrodermal and cardiovascular activity were assessed continuously during watching the vignette, and cortisol levels were assessed in four saliva samples. ResultsPatients reported higher engagement with the vignette than disease-naïve individuals (t=2.46, p<0.05) and showed a larger blood pressure response (systolic: F=5.87, p<0.01 and diastolic: F=4.00, p<0.05). However, these differences disappeared after adjusting for age. No group differences were found on other psychophysiological parameters. ConclusionsOur results suggest that patients and disease-naïve individuals are equally engaged when viewing video vignettes. When group differences were found, older age turned out to be a more prominent predictor of engagement. Practice implicationsResearchers may consider other arguments besides APs’ disease history when selecting an AP group.

The impact of delivery style on doctors’ experience of stress during simulated bad news consultations

ObjectiveThe purpose of this study was to investigate the relationship between doctors’ bad news delivery style and their experience of physiological stress during simulated bad news consultations. Methods31 doctors participated in two simulated breaking bad news (BBN) consultations. Delivery style was categorized as either blunt, forecasting or stalling (i.e. avoidant), based on the time to deliver the bad news and qualitative analysis of the interaction content and doctor’s language style. Doctors’ heart rate (HR) and skin conductance (SC) were recorded in consecutive 30s epochs. ResultsDoctors experienced a significant decrease in HR (F(1,36)=44.9, p<.0001) and SC (F(1,48)=5.6, p<.001) between the pre- and post-news delivery phases of the consultation. Between-group comparisons for the three delivery styles did not identify any significant differences in HR (F(2,36)=2.2, p>.05) or SC (F(2,48)=.66, p>.05). Conclusion and practice implicationsDoctors experience heightened stress in the pre-news delivery phase of breaking bad news interactions. Delaying the delivery of bad news exposes doctors to a longer period of increased stress.This suggests that medical students and doctors should be taught to deliver bad news without delay, to help mitigate their response to this stressful encounter.

The power of clinicians’ affective communication: How reassurance about non-abandonment can reduce patients’ physiological arousal and increase information recall in bad news consultations. An experimental study using analogue patients

ObjectiveThe diagnosis of incurable cancer may evoke physiological arousal in patients. Physiological arousal can negatively impact patients’ recall of information provided in the medical consultation. We aim to investigate whether clinicians’ affective communication during a bad news consultation will decrease patients’ physiological arousal and will improve recall. MethodsHealthy women (N=50), acting as analogue patients, were randomly assigned to watch one out of the two versions of a scripted video-vignette of a bad news consultation in which clinician's communication differed: standard vs. affective communication. Participants’ skin conductance levels were obtained during video-watching, and afterwards their recall was assessed. ResultsWhile the diagnosis increased skin conductance levels in all analogue patients, skin conductance levels during the remainder of the consultation decreased more in the affective communication condition than in the standard condition. Analogue patients’ recall was significantly higher in the affective condition. ConclusionBreaking bad news evokes physiological arousal. Affective communication can decrease this evoked physiological arousal and might be partly responsible for analogue patients’ enhanced information recall. Practice implicationsAlthough our findings need to be translated to clinical patients, they suggest that clinicians need to deal with patients’ emotions before providing additional medical information.

Reducing patients' anxiety and uncertainty, and improving recall in bad news consultations.

Patients' recall of provided information during bad news consultations is poor. According to the attentional narrowing hypothesis, the emotional arousal caused by the bad news might be responsible for this hampered information processing. Because affective communication has proven to be effective in tempering patients' emotional reactions, the current study used an experimental design to explore whether physician's affective communication in bad news consultations decreases patients' anxiety and uncertainty and improves information recall. Two scripted video-vignettes of a bad news consultation were used in which the physician's verbal communication was manipulated (standard vs. affective condition). Fifty healthy women (i.e., analogue patients) randomly watched 1 of the 2 videos. The effect of communication on participants' anxiety, uncertainty, and recall was assessed by self-report questionnaires. Additionally, a moderator analysis was performed. Affective communication reduced anxiety (p = .01) and uncertainty (p = .04), and improved recall (p = .05), especially for information about prognosis (p = .04) and, to some extent, for treatment options (p = .07). The moderating effect of (reduced) anxiety and uncertainty on recall could not be confirmed and showed a trend for uncertainty. Physicians' affective communication can temper patients' anxiety and uncertainty during bad news consultations, and enhance their ability to recall medical information. The reduction of anxiety and uncertainty could not explain patients' enhanced recall, which leaves the underlying mechanism unspecified. Our findings underline the importance of addressing patients' emotions and provide empirical support to incorporate this in clinical guidelines and recommendations.

Is it possible to improve the breaking bad news skills of residents when a relative is present? A randomised study

Background:Although patients with cancer are often accompanied by a relative during breaking bad news (BBN) consultations, little is known regarding the efficacy of training programmes designed to teach residents the communication skills needed to break bad news in a triadic consultation.Methods:Residents were randomly assigned to a 40-h dyadic and triadic communication skills training programme (n=48) or a waiting list (n=47). A simulated BBN triadic consultation was audiotaped at baseline, and after training for the training group, and 8 months after baseline for the waiting list group. Transcripts were analysed using content analysis software (LaComm). A coder determined the moment of bad news delivery and the relative's first turn of speech regarding the bad news. A generalised estimating equation was used to evaluate residents' communication skills, BBN timing, and the relative's inclusion in the consultation.Results:Ninety-five residents were included. After training, the duration of the pre-delivery phase was found to be longer for the trained residents (relative risk (RR)=3.04; P<0.001). The simulated relative's first turn of speech about the bad news came more often during the pre-delivery phase (RR=6.68; P=0.008), and was more often initiated by the trained residents (RR=19.17; P<0.001). Trained residents also used more assessment (RR=1.83; P<0.001) and supportive utterances (RR=1.58; P<0.001).Conclusion:This study demonstrates that a training programme that focuses on the practice of dyadic and triadic communication skills can improve the communication skills of the participating residents in a BBN triadic consultation. Such a training should be included in resident curriculum.

Doctors’ experience of stress during simulated bad news consultations

ObjectiveBreaking bad news (BBN) is a core component of medicine. Psychophysiological studies confirm the subjective reports of doctors that BBN is a stressful experience. This study investigated doctors’ physiological stress responses prior to and during two simulated bad news consultations. MethodsThirty-one doctors participated in a speech-interaction task and two simulated BBN consultations. Heart rate (HR) and skin conductance (SC) were recorded using consecutive 30-s epochs during each of the interactions. The simulations were video recorded. ResultsMost doctors showed an early anticipatory increase in HR and SC that peaked during the reading of the case history prior to the BBN consultations. Most doctors then experienced a brief and relatively small stress response. However, about one-third of the doctors showed a significant and sustained stress response. ConclusionsThe results suggest that most doctors were cognitively engaged with the BBN tasks, however, a small proportion of doctors might have focused more on their own internal feelings and less on these contextual features. Practice implicationsIn regards to training medical students and doctors, these results suggest that there is a need to focus more on the impact of these encounters on the doctors, not just their performance during these encounters.

Patient preferences for the delivery of bad news - the experience of a UK Cancer Centre

The primary aim of this study was to assess how patients would prefer to be given their cancer diagnosis in a typical UK cancer centre. Two hundred and forty-four patients attending the oncology outpatient department at the Leicester Royal Infirmary, UK, were recruited. Patients were invited to complete the Measure of Patients' Preferences questionnaire, write comments on their own experience of the breaking bad news consultation and choose their preferred role in decision making. Over 90% of questionnaires were completed. Patients rated the items addressing the message content of the consultation as more important than the facilitative or the supportive aspects. Over 80% of patients wrote a detailed account of their experiences, of which 60% were satisfied with the consultation. Most of the patients who were dissatisfied commented on the unsympathetic or pessimistic manner of the doctor. The majority of patients wanted a collaborative role in decision making. Regarding the cancer diagnosis, the majority of patients have information needs, want to be involved in treatment decisions and know their prognosis. The difficulty for physicians is how to meet individual information needs, give hope, but not deliver unrealistic expectations.