Medicine has specific cures for only a small fraction of the diseases affecting mankind. Many children that come to us have incurable disorders. Some children with otherwise treatable conditions come in an advanced stage of the illness, when a cure is no longer possible. Lifelong problems, mental retardation, and the news of the impending death of a child, are some of the situations where a pediatrician has to give bad news to parents.

Bad news has been defined as "any news that drastically and negatively alters the patient’s view of her or his future"(1). Giving bad news is an important skill, but one in which formal training is rarely available, even though such training has been shown to be helpful and effective(2). How well a bad news is handled by a doctor influences parental anxiety, hope, decision making, coping with the child’s illness, and depression.

All parents have hopes of a healthy and happy life for their children. When the news of a long term illness or lifelong affliction is received, they react with shock or dismay. Some parents also feel guilt, disbelief, anger or hopelessness. Coupled with it, the treating doctor may have his own feelings of inadequacy and guilt despite which he is expected to give the news in a calm, compassionate and culturally sensitive manner.

Another difficulty faced by the doctor is judging parents’ needs. Many parents may ask for full disclosure but be emotionally shattered on hearing the news. However, a few parents prefer not to know all the details, but only the basic information, and the future plan of treatment. Added to all these difficulties is the fact that most of us have never received any training in how to give bad news to parents. Exposure to such strong emotions has a wearying effect on the doctor, which may persist for weeks(3). Giving bad news is always going to be difficult, but it is possible to improve our performance and avoid the worst mistakes (Table I).

Except in acute care, bad news does not come suddenly. A distressing diagnosis usually is made after several consultations, laboratory tests, and other investigations. This gives us time to prepare for the breaking of bad news. A useful approach to this preparation is the ABCDE approach(4,5). This approach consists of: Advance Preparation; Building a therapeutic relationship; Communicating well; Dealing with the patient and family reactions; and Encouraging and validating emotions.

These steps are simply a guide to organise the difficult task of giving bad news to parents and should be used to help in achieving the goals of a bad news consultation (Table II).

Giving bad news to parents of a child is a difficult and delicate task, and should be taken seriously. Whenever possible, advance preparation should be done. A mental rehearsal of the planned conversation can be of help.

Arrange time and place. A serious discussion should not be carried out in the noise and bustle of a ward, or even a patient room. Arrange an office where everyone can sit down, hear each other clearly, and privacy is available. Choose a time that suits everyone involved, and ensure that there are no interruptions. If possible, phones should be switched off. Both the parents and the doctor should come to the discussion with enough time in hand. Hurrying through such meetings is a major source of parent dissatisfaction.

Ensure adequate presence. It is best to have both parents present at such times(6). If this is not possible, grandparents or other relatives should be included. A single parent being given bad news might feel shocked and overcome. The presence of other family members is a great support. This also saves repetition of the same information at a later time.

Be prepared. Review the case papers and investigations, and look up information about the disease. Have the case papers ready to hand, and be prepared to answer questions related to the course of the disease, the prognosis, and the treatment plan. Going unprepared to such a serious meeting is unacceptable. Without accurate and up to date information, a doctor cannot perform well the task of counsellor. Also, most parents base their decisions on the information given by their doctor. Therefore if given incorrect information, parents will be horrified and angry and lose faith in the treating doctor(7).

At the beginning of the consultation, introduce everyone and know the relationships. If other physicians are present as specialists, introduce them and describe their specialty. Parents prefer, however, that they are told by a single person who knows their child, rather than by multiple experts(6). Begin the consultation by asking the parents what they already know about their child’s condition, giving them adequate time to speak. This will elicit not only the information they have, but also their concerns and beliefs. Try to assess also how much the parents want to know about the child’s condition. Touch can be important. Holding the affected child has a positive effect(6), but the doctor should not get too involved in playing with the child.

The bad news must be conveyed to the parents in clear and unambiguous language while remaining sensitive to parents’ distress and grief. Hiding any information is unacceptable, but it can be given in an empathetic way, and split up over two or more sessions, if necessary. It is also important to avoid being too pessimistic and avoid saying things like "this child will never go to school or have a normal life"(6). Being honest, but not taking away hope, has been rated the most difficult aspect of giving bad news(8).

Speak frankly, but compassionately. Humour and flippancy should be avoided. It is important that the parents get the message. We often use words like "slow" and "developmental delay" to avoid saying a harsh and distressing term like "mental retardation". However, such euphemisms hinder understanding by the parents, and often prevent them from grasping the full significance of the condition(9).

Once the news has been understood and absorbed, we can move on to further discussion of the child’s condition. Prognostic information, if available, should be shared at this time. Life expectancy, disability, and other problems to be anticipated in the future, should be talked about. The treatment plan, if one has been formulated, should be explained to them. A clear plan for the future reduces anxiety and uncertainty. On the other hand, giving the parents some choice and say in the future of their child empowers them and gives them a feeling of being somewhat in control of the situation. The approach for each family must be individualised, based on an assessment of their particular needs.

Bad news often has a shocking and disorienting effect on parents. They are likely to find it hard to absorb, or retain, what is told to them. We must go slowly, allowing enough time, and repeat essential information.

Also it is important to not criticise the care provided by colleagues or blame them for the situation. You should emphathise with the parents and let them know that you understand their feelings and concern.

It is wrong to offer unrealistic hope, but we should offer some encouragement. Treatment options should be talked about, and the effect on the child should be discussed. In particular, parents like to know about relief of symptoms, freedom from pain and suffering, and life expectancy. Other things that can be discussed are the effect on the family, support and specialist services available. If the parents seem to be blaming themselves for the child’s condition, an effort should be made to relieve them of guilt. The parents must be assured that their pediatrician will be available for care or consultation. This is required even if the child is being referred to a specialty center for management.

When ending the consultation, summarise the matter, and ask if it has all been understood. This is also the time to encourage questions from the parents. Offer them another appointment, if they wish to discuss the matter again. After the consultation is ended, enter it in the patient’s records.

Giving bad news about a child is one of the most difficult and challenging tasks facing pediatricians. Learning how to do it well is important for all of us. No matter how skilful we are at communication, we will never enjoy such interactions, because there are often feelings of guilt and failure, and the parents’ distress affects us too. However, if bad news is given skilfully, it can reduce parents’ distress as well dissatisfaction with the medical establishment.