Synopsis
Prepare and conduct honest, compassionate conversations about prognosis, uncertainty, values and treatment choices, respond to emotion, make an individual clinical recommendation and leave a clear shared record and follow-up plan.
- Prepare before speaking: clarify the medical facts, decision, likely outcomes, uncertainty, capacity, participants, environment and who will follow up.
- First-line opening is permission plus agenda: ask what the person understands, what they want to know and who they want involved.
- Give a warning phrase before difficult news, use plain language, pause, and check understanding before adding more detail.
- Describe prognosis as a range and pair uncertainty with what is known about function, likely crises and the next review.
- Respond to emotion with recognition, validation, curiosity and presence before returning to facts or solutions.
- Elicit values through abilities, relationships and experiences the person wants to preserve, plus outcomes or burdens they find unacceptable.
- The gold-standard endpoint is not a memorised script: it is shared understanding, a values-linked recommendation, documented decisions and reliable follow-up.
- Ask for teach-back, summarise the agreed plan and explicitly state what remains uncertain or undecided.
- Use a professional interpreter and accessible information; capacity cannot be judged fairly if communication support has not been attempted.
Key red flags
A patient asking whether they are dying must receive a truthful, sensitive response rather than automatic deflection to relatives.
Relatives requesting that prognosis be concealed cannot override a capable patient's stated wish for information and involvement.
Acute confusion, sedative effect, severe hypoxia or shock may impair capacity and demands supported, time-specific assessment.
Threats, coercion, intimidation or fear during a meeting requires attention to safety and private assessment of the patient's wishes.
A language mismatch in a high-stakes decision requires a professional interpreter except where immediate life-saving action genuinely prevents access.
Unresolved disagreement over potentially life-sustaining treatment needs senior review, a second opinion or legal advice rather than pressure for instant consensus.
Different accounts of prior wishes, demands for non-beneficial treatment or exclusion of the patient calls for senior facilitation and a clear decision process.
Investigation priorities
Discover what the person understands, how much information they want now and whom they authorise to participate.
Management branches
A foreseeable treatment or future-care discussion can occur before urgent deterioration.
- Confirm facts and decision scope, arrange privacy and communication support, invite chosen participants and establish what the patient already knows.
- Ask permission, give information in small units with a warning phrase, explain uncertainty and pause to recognise emotional responses.
- Explore goals and unacceptable burdens, offer a values-linked recommendation, use teach-back and document actions, contingencies and follow-up.