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Breaking bad news: tackling cultural dilemmas
  1. Sophie Nilusha Holmes1 and
  2. Jan Illing2
  1. 1 School of Medical Education, Newcastle University, Newcastle upon Tyne, UK
  2. 2 Royal College of Surgeons in Ireland, Dublin, Ireland
  1. Correspondence to Dr Sophie Nilusha Holmes, School of Medical Education, Newcastle University, Newcastle upon Tyne, UK; sophie.holmes{at}


Requesting that serious diagnoses be concealed from patients, a widespread phenomenon in many cultures, presents a professional dilemma. Practical and sensitive communication strategies are needed.

Methodology In this paper, we use analysis of the existing literature to develop a communication tool for practitioners facing requests for diagnostic non-disclosure. Our approach builds on existing strategies, in providing a mnemonic communication tool, permitting more than one outcome, and focusing on the need for mutual understanding and cooperation.

Results Existing work on this dilemma highlights the need to appreciate the family's standpoint, affirm their benevolent intentions and correct misperceptions. To this end, we have developed a mnemonic tool, 'ARCHES', to be used in situations where the family has requested diagnostic non-disclosure. The model has six stages: acknowledge the request for non-disclosure, build the relationship, find common ground, honour the patient's preferences and outline the harm of non-disclosure, provide emotional support and devise a supportive solution.

Conclusion Facing requests for diagnostic non-disclosure is a challenge of communication. The dilemma is particularly marked when practising across cultures. Our model gives a structure for building rapport with the family and realigning their misperceptions while upholding the patient's right to knowledge.

  • cancer
  • communication
  • cultural issues
  • education and training
  • prognosis
  • family management

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  • Contributors SNH originated the project, performed the literature search and analysis, and drafted the text. JI revised the text and provided ongoing supervision.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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