Delivering Difficult News and End-of-Life Communication

Placeholder Image for GSHP - TO BE REPLACED

Sharing difficult information is one of the most challenging responsibilities in healthcare. How the news is delivered can shape a patient’s understanding, trust, and ability to cope. Approaching these conversations with clarity, compassion, and sensitivity helps patients and their supporters feel supported, even in moments of great distress.

Allocate As Much Time As Possible

Time can be a premium in healthcare, but it’s important to allocate as much time as possible for conversations that involve difficult news.

Studies show that physicians often move on too quickly, interrupting patients after only a few seconds. In one classic analysis, doctors interrupted their patients in just around 18 seconds on average.

In the context of a challenging conversation, this tendency to push through can leave patients feeling unheard and emotionally unsupported. Offering even just a moment of silent presence, pausing before responding, can create vital space for patients to process the news and begin to respond in their own time.

“I Wish”: A Helpful Phrase

Anne Chiang, MD, PhD, Associate Professor of Medicine in the Section of Medical Oncology, shares a phrase that she has found helpful when delivering difficult news.

The phrase “I wish” allows providers to balance honesty with compassion when a patient or supporter is holding onto hope that no longer aligns with the medical reality.

Rather than shutting down optimism, it gently reframes the situation: “I wish things were different. I wish the treatments were still working.” From there, you can acknowledge the change (“We are in a different place now”) and connect it to concrete examples that match the patient’s or family’s frame of reference (“In my 20 years of experience with what I’ve seen, I believe that you are there”).

This approach validates their hopes while helping them recalibrate to what is possible in the current stage of illness.

Being Nice vs. Being Kind: The Importance of Honesty

In healthcare, “being nice” can sometimes mean avoiding hard truths to spare immediate discomfort. While well-intentioned, this approach can leave patients unprepared and unsupported. “Being kind,” by contrast, means delivering information with honesty and compassion, even when it is difficult to hear. Clear, truthful communication respects the patient’s dignity and fosters trust in the care relationship.

That's also kind of a role that we play in the medical field...delivering hard truths so that people can calibrate their expectations and not continue a false expectation and then have to deal with it later

Elizabeth Peacock-Chambers, MD / Assistant Professor of Pediatrics at the University of Massachusetts Chan Medical School Baystate

Am I dying?

Research shows that physicians tend to frame prognostic information as good or bad news, which can lead to optimistic bias and selective disclosure. This is especially well-documented in palliative care and oncology.

When it comes to prognosis, honesty is not cruelty, it's kindness. This chart illustrates how physicians’ estimates and what they communicated often painted a far more hopeful picture than reality, leaving patients and families unprepared for what was ahead.

Life Expectancy Estimates: A Survey of Research on the Reliability of Prognosis

Source

Median Survival Estimate

Physicians’ own (formulated) estimate

75 days

Physicians’ communicated estimate

90 days

Observed actual survival

26 days

Center for Public Representation. (2020, June 30). Life expectancy estimates: A survey of research on the reliability of prognosis. Retrieved from https://www.centerforpublicrep.org/wp-content/uploads/Life-Expectancy-Studies-Crisis-Std-of-Care-for-Covid-19-6.30.20.pdf

While end-of-life prognosis can be difficult to deliver and receive, honesty allows patients and their supporters to better plan for medical, emotional, and practical needs. Clear communication also builds trust, reduces uncertainty, and affirms the patient’s dignity by respecting their right to know what lies ahead.

Motivations for Hastening Death

Patients facing the end of life often express complex motivations when discussing the desire for hastened death. Research from the Netherlands found that requests for euthanasia were most often tied to loss of dignity (57%), feelings of an “unworthy dying” (46%), pain (46%), and dependence on others (33%). Other factors included tiredness of life (23%), while pain alone accounted for only 5%.

Depression and the Desire to Hasten Death

Research shows that when patients express a wish to hasten death, it often signals underlying emotional distress, most commonly depression and hopelessness. One study found that nearly 60% of patients with a strong desire for death met criteria for major depression, compared with less than 10% of patients without this wish.

Clinical Implication: Expressions of wanting to die should not be dismissed as an inevitable part of serious illness. Instead, they are often a red flag for treatable depression or hopelessness. Sensitive inquiry, mental health screening, and supportive interventions can help alleviate suffering and restore meaning at the end of life.

These findings underscore an important reality: requests for assisted dying or expressions of wanting life to end are rarely driven by physical pain alone. More often, they reflect concerns about dignity, identity, autonomy, and the strain of dependence. For healthcare professionals, this means that palliative care and grief support should extend beyond symptom management to include compassionate attention to psychosocial, spiritual, and relational dimensions of suffering. Honest communication, validation of emotional distress, and thoughtful inclusion of families and caregivers can help patients feel supported, even when cure is no longer possible.

Responding to Expressions of Wanting to Die

Hearing a patient express a wish to die can be painful and unsettling, even for experienced healthcare professionals. It’s normal to feel unsure about what to say in the moment. What matters most is responding with compassion, presence, and a willingness to listen. The following scripts offer examples of grief-sensitive language that can help you acknowledge suffering, provide validation, and open the door to additional support.

Patient: “I just don’t want to keep going like this. Sometimes I wish it would all just end.”

Provider to Patient: “Thank you for sharing that with me. It takes courage to say those words. When people feel this way, it’s often connected to very real emotional pain, like sadness, fear, or even depression. These feelings matter just as much as your physical symptoms. I’d like us to explore this together, and I can also bring in team members who specialize in emotional and spiritual support. You don’t have to carry this alone.”

Provider To Supporters: “When a loved one expresses a wish to die, it can be frightening to hear. It doesn’t necessarily mean they truly want their life to end. It often means they’re suffering and need more support. We’ll work together to address both physical comfort and emotional well-being so they feel less overwhelmed.”

You don’t need to have all the answers in the moment. What matters most is that you stay present, listen without judgment, and affirm that the patient’s suffering is real. Even a simple acknowledgment can reduce isolation. When needed, connect patients and families with palliative care, mental health, or spiritual support to ensure no one carries the weight of these feelings alone.

End of-Life and Feelings of Failure

Caring for patients at the end of life requires both clinical skill and compassionate presence. This stage is often marked by complex emotions, changing goals of care, and heightened needs for comfort and dignity. Clear communication, symptom management, and emotional support for both patients and those close to them are central to quality end-of-life care. When providers approach these moments with sensitivity, they can ease suffering and foster trust in the healthcare experience.

Every time a patient dies, a part of me feels like I failed.

Anne Chiang, MD, PhD / Thoracic Medical Oncologist

For many healthcare professionals, a patient’s transition to end-of-life care can stir feelings of failure. Medicine is often framed around curing, fixing, and prolonging life, so when those goals are no longer possible, clinicians may question whether they’ve let their patients or the families of their patients down.

These emotions are real and can be compounded by the weight of witnessing suffering. Recognizing that shifting from cure to comfort is not failure, but an essential expression of care, can help reframe these moments as opportunities to preserve dignity, ease distress, and walk alongside patients in their final chapter.

Permission to Grieve: Lessons from Dignity Therapy

Dignity therapy is a structured intervention most often used in palliative care and life-limiting illnesses or conditions to help individuals s reflect on their lives and leave a record of meaning for loved ones. While GSHP participants are not expected to deliver dignity therapy, its principles can guide everyday care.

At its core, dignity-conserving care is about treating the person, not just the patient. Research by Dr. Harvey Chochinov highlights the ABCDs of dignity in healthcare:

Attitude – approaching each patient with respect and openness.
Behavior – demonstrating consistency, reliability, and care in small actions.
Compassion – recognizing suffering without judgment.
Dialogue – listening in ways that affirm voice and agency.

For patients and families facing loss, these simple practices can make the difference between feeling invisible and feeling valued. Even brief comments that validate grief ( “It makes sense this news is weighing on you”) can provide what some describe as permission to grieve.

While full dignity therapy requires training and time, the mindset behind it is accessible to all healthcare professionals. Every interaction is an opportunity to conserve dignity, affirm identity, and reduce isolation for patients and their loved ones.

Discussing Palliative Care and Hospice

Conversations about palliative care and hospice can feel challenging, but clear communication helps patients and their supporters understand these important services. When providers explain the goals and differences in plain language, they reduce confusion and ease fear. These discussions also open the door for timely support that improves quality of life.

Clarify: Hospice is Palliative Care But Palliative Care is Not Hospice

Most people who have heard of palliative care recognize its core goals: managing pain and symptoms, supporting emotional well-being, and helping families cope.

Still, important gaps remain. Roughly one in three people believe palliative care is the same as hospice, and many are unsure about when or how it can be used. Because patients and their supporters often take their cues from healthcare providers, clear communication from clinicians is critical in correcting misconceptions and ensuring timely access to supportive care.

Given that palliative care has only been formally recognized as a medical sub-specialty in the U.S. since 2006, it makes sense that there are lingering misconceptions

Clear, consistent communication can dispel myths, normalize the use of palliative care alongside curative treatments, and reinforce that it is appropriate at any stage of serious illness. When providers frame palliative care as an added layer of support,rather than as “giving up,” they help patients and families feel more comfortable accessing services that improve quality of life.

Misconceptions

ADD TABLE

Including a palliative care provider early in the process benefits both patients and the care team. It gives patients more time to build rapport with the specialist and helps the provider develop a fuller understanding of the patient’s needs.

Similarities and Differences

Palliative care is an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminal illnesses.

ADD TABLE

From Clarifying to Conversation

Once patients and their supporters understand that palliative care and hospice are not the same, it becomes easier to talk about when hospice might be appropriate. From there, you can open a conversation that emphasizes support, dignity, and patient-centered goals: hospice as an added layer of care, not the removal of care.

What you might say to patients:
"Hospice care focuses on comfort and quality of life when treatments are no longer helping in the way we hoped. It allows us to center on what matters most to you, whether that’s being at home, being comfortable, or spending meaningful time with loved ones. You’re still in charge of your care, and hospice is here to support you and your family through this stage."

What you might say to family/supporters: "I know this is incredibly difficult news to take in. Hospice doesn’t mean giving up, it means shifting the focus to comfort, dignity, and support. The team is here not just for your loved one, but for you as well, helping with medical care, emotional support, and practical needs too."

Grief-Sensitive Phrases to Use Throughout EOL Care Discussions

“It’s normal to feel grief and worry while making these decisions.”
“You don’t have to go through this alone. Support is built into these programs.”
“We’ll walk with you and adjust care as your needs change.”
“Your feelings, hopes, concerns, and preferences all matter here.”

Bringing hospice into the conversation is about helping patients and their supporters feel supported, so they do not feel abandoned. Clear, compassionate language can reduce fear and highlight the ongoing presence of care. By framing hospice as a continuation of support that centers dignity, comfort, and connection, you reinforce trust and create space for patients and families to focus on what matters most in this stage of life.