The way in which bad news is broken can either increase the heartache or soften the blow, writes Áine Kerr.
The sight of a garda at the front door or a consultant pulling the bedside curtain to speak in hushed tones can conjure up the most feared emotions.
It is what happens next in those life-changing moments that can exacerbate the heartache and trauma or provide some hope and reassurance.
Breaking bad news is described as the single greatest challenge for doctors. Difficult to relay and difficult to accept, that prolonged moment in time can become the most surreal experience for both the receiver and deliverer of bad news.
Stories of people being told bad news in a store room or being mistaken for a different person and relayed incorrect news feature on a new DVD produced by the Irish Hospice Foundation which aims to provide guidelines on how best to break bad news.
The launch of the DVD follows frequent complaints from patient groups about the failure of doctors to relay factual information with emotion and care, and to also give appropriate time to the patient.
Some 230 junior doctors in Northern Ireland, who are in their first two years after graduation, will begin viewing Breaking bad news: communicating in difficult circumstances as part of their compulsory medical training from early next year.
The subject of breaking bad news and ethical issues will be taught by Dr Max Watson who contends that communicating bad news to patients and their families is one of the single biggest challenges facing healthcare personnel.
Training medical students about how to break bad news across cultural and language barriers, over the phone, after an ultrasound scan, and to a member of the travelling community will encompass much of the course.
"If bad news is itself communicated in an insensitive and inappropriate manner, it can cause long-term trauma to individuals," he says.
"In the process of telling bad news to a patient, any trauma caused should be related to the news imparted and not the manner in which the information was relayed."
As society has changed from being paternalistic and caring to one which is fearful of litigation and lawsuits, the patient has suffered, according to Watson.
Ensuring that sufficient information is relayed, while not being excessive in detail, is a key priority for doctors whose training in communication is now perceived as important as the training in surgical skills.
"Breaking bad news badly can have a detrimental effect on families for a very long time after the bad news is delivered . . . we as doctors have to recognise that the news we deliver will have implications and that it is every bit as important as learning to prescribe drugs," he says.
Preparing the setting, compiling patient information and cross- checking the identity of family relatives must first be completed before bad news is broken, according to Watson.
"If you compare it to farming, you would never go out and sow a field without first harrowing the ground and ploughing the field. Otherwise, the seeds will just bounce back off the ground.
"Likewise, you have to prepare your patient and know where your patient is at."
Michael Egan, of the Living Links organisation, a support organisation for the suicide bereaved, says fewer complaints are being received regarding the manner in which bad news is broken to families. As a former Garda sergeant who set up a training programme for gardaí in the protocol and best practices for breaking bad news, Egan contends that distressful news should never be given by phone.
"One of the most important things is for medical professionals and gardaí to provide accurate information.
"Where a sudden death occurs, as much information as possible should be given on the first meeting," he says.
"A lot of people like to know who was the first person on the scene . . . people like to know especially about items, money and personal belongings the person may have had in their possession."
Jeanette Byrne of Patients Together noted that patients have frequently been told bad news in accident and emergency wards within earshot of dozens of other patients. In some cases, patients were relayed upsetting news without a family member present and in one recent instance, a family member was asked to leave the room on the orders of a doctor before bad news was broken, according to Byrne.
"Often by pulling a curtain around a bed, we think we have obtained some privacy. We forget, however, that a curtain is just a material curtain and provides no confidentiality really," she says.
"Having a designated room in a hospital which provides privacy for patient and doctor would be ideal but because we are so short on space in hospitals, it's not realistic."
According to hospitals' patient charters, however, patients are entitled to privacy and confidentiality when in the care of a hospital, according to Byrne, who contends that privacy is an "entitlement" which is now overlooked given the strain on hospital resources.