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Close-up photo of hands embracing.

Choosing to tell good news over bad news—or vice versa—depends on what you want the recepient to do.

Photograph by Dennis Sabo, Alamy

Cathy Newman

National Geographic

Published November 17, 2013

Do you want the good news or the bad news first?

It's the setup line to a well-worn genre of joke, but it's no laughing matter, according to Angela Legg, a Ph.D. student in psychology at the University of California, Riverside.

Legg's research—done with Kate Sweeney, also of UC Riverside, and published online in the Personality and Social Psychology Bulletin—put a scientific lens to the question.

The answer, Legg found, depends on whether you are the giver or receiver of the bad news, and if the information will be used to modify behavior.

If you are on the receiving end, Legg says, experiments showed that an overwhelming majority—more than 75 percent—wanted the bad news first. "If people know they are going to get bad news, they would rather get it over with," she says. Then, if there is good news to follow, "you end on a high note."

Conversely, news givers—between 65 and 70 percent—chose to give good news first, then the bad news. "When news givers go into a conversation, they are anxious. No one enjoys giving bad news. They don't understand that having to wait for bad news makes the recipient more anxious."

But good news first, then bad could be a useful strategy if the goal is to get someone to change a behavior—when, for example, Legg says, "you are giving feedback to a patient needing to lose weight, who has to take action. The recipient doesn't feel good about the news, but may do something about it."

The Sandwich Approach

Then there is what she calls the good news, bad news, good news sandwich—when the bad news comes between piece of good news on either side. Example: "Your cholesterol is down. By the way, your blood pressure is morbidly high. Your blood sugar levels are good."

That's fine if you want someone to feel good, she says. "But hiding the bad news in the sandwich is generally not a good strategy. It downplays the bad news, and the recipient gets confused."

The person who delivers a bad news sandwich is engaging in what Legg calls conversational acrobatics. "They believe they are making the conversation easier, but the message gets garbled."

There's even an acronym in psychological jargon for people who delay giving out bad news or avoid it altogether—MUM (mum about undesirable messages).

"The best news-giving strategies take into account that sometimes we want to make people feel good and sometimes we need them to act," she says.

Legg's advice to doctors is that when relaying a diagnosis or prognosis, it's better to give the bad news first, and then the positive information to help the patient accept it.

What If There's No Good News?

But how do physicians deliver bad news when there is no good news to soften it?

"Many physicians prefer not to have to give bad news until it's obvious," says Thomas J. Smith, director of palliative medicine at the Johns Hopkins Institutions in Baltimore. Palliative care is a relatively new field that emphasizes open and honest communication with seriously ill patients.

According to one study, "If we look at the charts of people with lung cancer, only 22 percent of the charts have any notation that the doctor and patient talked about the fact that the patient is going to die," he says. "Most of the time the conversation goes along the lines of 'it's incurable, but treatable.' Many times it doesn't get mentioned again." In reality, 90 percent of people say they want truthful and honest information.

The "bad news" conversation, Smith stresses, needs to be more than one conversation. "When you give a bad diagnosis, they don't hear anything [anyone says] for the next three weeks anyway. They are stunned. "

The situation is improving. "Forty years ago when I started, palliative care wasn't the norm," he says. Now, at Johns Hopkins, medical students practice breaking bad news to a trained actor "patient."

"Many [other] countries are changing, as well. Japan has shifted from no one being told to everyone being told" the truth, even if it's bad news.

And sometimes, even when the news is bad, good news can follow unexpectedly. Recently, Smith met with a survivor group at the National Institutes of Health, where a woman shared her story: "My doctor told me I had eight months to live. He did say, 'Some do better, some worse.' So I took that to heart and told the kids and prepared them, and my husband and I went and picked out our burial plots. I thought at the time it would all be grim, but it turned out to be really important planning.

"That was three years ago," she added.

Have you, a friend, or family member been on the receiving end of bad news? Tell us about your experience, positive or negative.

13 comments
Christie Bradley
Christie Bradley

I believe that truth is usually best.  When my granny was in the hospital, we were told that she was recovering and would be allowed to go home, so we spent the day before cleaning up her house and getting it ready for her.  That night we got a call telling us to get to the hospital fast because she probably wouldn't make it through the night.  Sure enough, at about 1 or 2 in the morning she died.  That was rough, but it was worse when we found out that her organs had been failing one by one for about a week and no one had told us.  We could have been preparing to say goodbye instead of preparing to welcome her home.  Why on earth we were told she was recovering when she was in fact dying is just beyond me.

Shubha SA
Shubha SA

I was 14 year old. It was early morning 4.30-5 am and I was sleeping in my room and my aunt was sleeping at the other room.
Our door bell rang, which disturbed my sleep abruptly. I woke up my aunt and went to the door with her.
It was my neighbor. She had bought a message : "You have got to visit the hospital as soon as possible".

My dad was admitted in the hospital and he had gangrene developed in his leg. My mother was in hospital taking care of him.

When my neighbor bought that message, I was scared and thinking my father might be serious.
I was too young but old enough to understand that something really terrible has happened.
Somewhere from the corner of my heart was screaming and crying for losing something really valuable.
It took over an hour to reach the hospital. And all the way each and every second I was praying to God for my father.

But, it was too late for my prayer. My dad had passed away on the previous night itself!
The incomplete message gave me an ray of hope that my dad will be OK soon and come back home.
When the hard bitter truth hit me, I was shattered.

Am not sure whether the sudden burst of shocking news would have been better or the prolonged toggling sting was better.
End of the day I had only one truth left with, which is an loss of my father.....

Amir Hossain
Amir Hossain

We live for hopes. And truth struggles with bad news to fulfill hopes. Truth comes first. 

Jody Johnsen
Jody Johnsen

My doctor moved our closing conversation to his office and closed the door. I knew it was serious. He said, " I want you to know we can walk across the street to the hospital right now and remove this ovary. I found a growth .... on the ovary. I need to order more tests but we can walk across the street right now...." 

There was more. I had ovarian cancer. He told me the truth and I have always respected that. He was concerned I would panic. I didn't. I tried treatment first though surgery was always an option. I beat it with no real complications. That was 12 years ago. I kept the ovary, it was the only one I had. (The first was lost to an earlier problem) I'm going through mentalpause normally now because of this amazing physician. 

I watched my life flash before my eyes. I said good bye to my family. I was convinced this would kill me but there was never a moment when I wished he had lied to spare my feelings. That man saved my life in the examining room but he saved my sanity when he gave me the honest truth. 

I vote for truth - warts and all. 

Hany T.
Hany T.

i want to know the truth, so that i could prepare my self for unforgettable ending

Charlaine Boa
Charlaine Boa

I would want/need to know the truth.  It give you the ability to do what you need to do, to prepare yourself and loved ones and to (hopefully) live out your remaining days with peace and tranquility.

karen kalpin
karen kalpin

I just had lung cancer surgery about 18 months ago. My oncologist was excellent at 'breaking the news' especially since I was not hospitalized for anything to do with cancer! Complicated story (as most are) but I was hospitalized for an auto immune disorder after battling with it for 12 years. Working, working - no choice - and worked myself to the point of collapse. I was hospitalized for severe costal chondritis (couldn't breathe) acute pain, very high blood pressure etc. My local hospital refused to admit me and my Uncle (a doctor) had  an old friend of his (lung cancer specialist - what are the chances!) hospitalize me at his hospital. He did an unbelievable amount of tests - which would never have happened if I was not a family member of friend) and......... he found stage one lung cancer. He just 'told me' straight up and said he doubted if I was too surprised since I had smoked for over 30 years. Very true.  He stated the 'facts' only about early detection and surgery and also the facts that there was no way of knowing at that point if it had metastasized I just had to wait and see. I found the 'just honest fact' approach very very helpful. Including the 'possible bad news' that he didn't have to give - he could have just focused on 'stage one great chances!' and left it at that but he didn't  - and I am very grateful for that. To the gentleman whose mother passed so brutally - this is why honesty is necessary! Hope is one thing but false hope/denial helps nobody. This is another reason why euthanasia for people must become a conversation in this country.

Andrew Booth
Andrew Booth

Doctors and other medical staff should just be honest. 

My mother died of breast cancer in 1999 which spread to her bones and organs. She underwent radiotherapy and drugs but got weaker and weaker until she faded away and died. However, the doctors kept saying "Don't give up hope", "Her hair will start to grow back in 7 or 8 months", "There are another couple of treatments we'll use after this if this doesn't work" etc. Then, once my mother had become so weak and wasted she couldn't even walk .....she died! 

That was a complete shock! The doctors and nurses had always given the impression my mother would still be around in the months to come and kept telling us not to give up hope. But then they said "What did you expect? She had terminal cancer!" We've also met other people with similar experiences. We've all agreed how upset and angry we are with the doctors and how we'll never trust them.   

If someone is dying of a terminal disease then everyone involved should be told the truth so they can prepare. No one can argue with the truth. To argue that some people can't cope with hearing the truth is ridiculous. It puts doctors in the position of deciding who they think can cope and who can't and must therefore be given the wrong impression. No one can be blamed for telling the truth. To do otherwise is not only unnecessary - it is particularly cruel and leaves many people angry and distressed!

Ali Bukhari
Ali Bukhari

@Andrew Booth So Sorry over the loss Andrew! I does agree that truth should be revealed. I from the above details resulted that doctors have faith in fighting for disease, that patient should not lose hope, emotionally and mentally to let the medicine work effectively. But even if they thinks it right, they should at least reveals the news to the family member and let them decide whether they should reveal or conceal further. Even some times telling the truth makes patient more brave that 'No this I won't let happen" 

Anyway I favour the Truth!

Kheun Tan
Kheun Tan

@Andrew Booth IMHO, without telling the truth to the patient and the family, it is like robbing away their chance of fulfilling the last wishes of the patient. Since everyone is thinking that there is always a tomorrow, they will not cherish the last minute and doing things for the patient so that the patient can pass on peacefully. 

Richard D.
Richard D.

@Andrew Booth If the doctors know for sure that it's terminal then I agree. However, hope has a way of increasing one's chances of surviving. I think it's worth implying that the chance of survival is a bit better than it is if the implication itself increases the chance.

Cathy Newman
Cathy Newman

@Andrew Booth  

Andrew, thank you for sharing your story.  It is not an uncommon experience, I suspect.  It would be good to hear from others about their experiences

both positive and negative. 

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