Communicating bad news remains a constant challenge for healthcare professionals, particularly in the context of life-threatening diseases without curative prospects. This process requires attention, presence, and active, compassionate listening to foster patients’ understanding of their condition. This article presents the case of an elderly man with breast cancer, highlighting communication challenges and compassionate strategies. Data collection was conducted retrospectively from medical records, with protocol approval by the Hospital Ethics Committee. Tools for breaking bad news that account for ethnic and cultural particularities are essential for patient-centered care. In this case, a communication protocol based on the hierarchy of patients’ needs and the ‘Go Wish’ card game proved useful in supporting communication. Preserving patient autonomy in palliative care is fundamental to ethical and comprehensive care. Structured communication strategies help to alleviate multidimensional suffering, preserve autonomy, involve family members, and promote quality of life until the end.

Keywords: cancer, elderly, communication, palliative car

Communicating bad news represents a constant challenge for healthcare professionals, especially in contexts of life-threatening diseases with no prospects of curative treatment.¹ More than simply transmitting information, this process demands attention, presence, clarity, active and compassionate listening, with the aim of fostering the patient's understanding of their own health condition, encouraging their participation in decisions, and promoting the full exercise of their autonomy.² The prevalence of oncological diseases has grown significantly in recent years, with population aging being a widely recognized risk factor for this increase. According to a review of Brazilian data published in 2020, over 60% of new cancer cases occurred in people aged 60 and over.³ The incidence and prevalence rates for all cancer types were three to four times higher among older adults compared to younger adults. In addition to an oncological diagnosis, these patients often face multiple associated comorbidities, which worsen their clinical condition and further compromise their quality of life.⁴ Given this vulnerability, it is common for them to experience a loss of autonomy in shared decisions about their own care plan - either due to the healthcare team's lack of initiative to actively involve them, or due to the actions of caregivers who assume a central role, often overriding the patient's wishes.

In this complex scenario, it is common for oncology patients to experience "total pain" - a concept developed by Cicely Saunders, which broadens the understanding of human suffering to include not only the physical aspects, but also psychological, social, and spiritual components.⁵ In this context, palliative care, with its person-centered approach aimed at promoting the quality of life for patients and families facing life-threatening illnesses, offers fundamental support through the prevention and relief of suffering in all its dimensions. Communication tools and training protocols are key pieces to solving this problem, capable of building a bond of trust between the patient and healthcare team, returning protagonism to the individual who is at the center of the care, and involving the family in a healthy and conciliatory manner in the illness process.^1,2 Although traditional and widely established protocols exist, such as SPIKES (Setting, Perception, Invitation, Knowledge, Emotions, Strategy and Summary), the cultural particularities of Latin American populations can benefit from models that more sensitively consider the social, psychological, and especially emotional aspects involved in the process.⁶ The compassionate communication strategy based on the hierarchy of needs, created by Forte et al., proves to be an effective and accessible alternative for healthcare professionals, capable of improving outcomes and positively impact the patient's healthcare experience.

Through a case report, this study aims to analyze the challenges of communicating with the family of a male patient with breast cancer and to demonstrate the effectiveness of compassionate, emotion-based communication.

A descriptive retrospective case report based on secondary data from hospital medical records of a patient treated at a high-complexity health service within the Brazilian Navy. Data collection was performed retrospectively, ensuring patient confidentiality and anonymity. This study was approved by the Research Ethics Committee for Human Beings of Hospital Naval Marcílio Dias, under opinion nº 7.303.288, in accordance with the guidelines of Resolution nº 466/12 of the National Health Council of Brazil.

A.B.A., a 72-year-old male lawyer, a member of the administrative staff of the Brazilian Navy, diagnosed with metastatic breast cancer, sought help from the palliative care team in March 2024 to assist him in communicating to his family his wish to discontinue chemotherapy treatment. A.B.A. reported having undergone a biopsy in 2018, which confirmed invasive breast carcinoma of no special type. At the time, with a KPS of 80%, the Oncology team proposed radical mastectomy with left lymphadenectomy, a procedure performed without complications. After surgery, complementary treatment with adjuvant chemotherapy was initiated. Over the course of one year, the patient experienced events such as acute thrombophlebitis, ascites, pleural effusion, renal function changes, and massive micro albuminuria, with a significant loss of his well-being. In February 2023, despite ongoing treatment, bone metastases were identified in the thoracic spine and sacroiliac region, with a therapeutic suggestion of radiotherapy and a new chemotherapy cycle for a more aggressive line. In November 2023, he was admitted to the emergency department with anemia and active gastrointestinal bleeding, requiring a blood transfusion and an urgent upper endoscopy. After clinical stabilization, chemotherapy was resumed with a new adjuvant medication.

In March 2024, A.B.A. returned to the emergency service with shortness of breath and oscillating oxygen saturation, and an evident drop in KPS to 60%. In this context, he requested help from the palliative care team to assist him in communicating his wish to discontinue medical treatments to his family. In the individual approach, the team invited him to express his feelings and fears regarding communication. A.B.A. reported concern about hurting his wife feelings, who had accompanied him throughout the disease progression process, and mentioned that his only son, from a previous marriage, who resides abroad, had been following him remotely, without full knowledge of the adverse effects of the ongoing treatments. In this meeting, a relationship of trust was established between A.B.A. and the palliative care team, with a family conference scheduled with him and his wife within a few days to establish his advance directives (AD). The family conference included A.B.A. and his wife, his son, and his daughter-in-law. The conversation began with A.B.A., who was encouraged to narrate his illness journey, recounting the intercurrences and challenges experienced until that moment. The son expressed surprise, realizing he was unaware of all the suffering his father had endured due to the treatment. A.B.A. stated that, although his tests were relatively better, he felt physically debilitated and wished to live fully, not just survive. He mentioned wanting to travel, spend time with family, and especially meet his grandson, recognizing that such goals would be unfeasible if he continued chemotherapy treatment. He then expressed his desire to suspend chemotherapy, which was met with surprise and apprehension by family members, as this possibility had never been considered in previous discussions with medical teams. There was a moment of intense crying as A.B.A.'s decision could signify imminent death. During the meeting, the team actively listened to everyone present, validated feelings, addressed physical, emotional, and spiritual aspects, and provided guidance on a multidisciplinary approach focused on quality of life and dignity. A.B.A. had the opportunity to clarify doubts about the decision to interrupt therapy, and the legitimacy of his choice was reaffirmed, highlighting the ethical principles of palliative care. Finally, his AD was established, focusing exclusively on comfort care, with his reaffirmation of not wishing to undergo any intervention that would cause suffering or prolong his life.

Over the months, he remained under follow-up with the palliative care team, including three hospitalizations for symptoms arising from the progression of the disease. In October 2024, he was readmitted due to significant worsening of the disease, including a decreased level of consciousness. During the first night, he showed worsening respiratory symptoms, and injectable morphine administration was indicated. At this moment, his wife expressed apprehension about the use of the opioid. Considering that A.B.A. had already developed his AD, the "Go Wish" card game was used in a dynamic with his wife to reaffirm these decisions.⁷ She confided that, although she was aware of her husband's choices, it was difficult to accept them without suffering. The approach allowed for addressing the wife's feelings and clarifying misconceptions about the use of morphine, demonstrating the safe and appropriate role of the medication for pain relief and respiratory discomfort. Over the following days, with his improvement, A.B.A. was discharged, proceeding as established through his advance directives and living will. In December 2024, under palliative sedation, in a general ward accompanied by his family members, A.B.A. died.

Delivering difficult news constitutes an ongoing challenge for healthcare professionals, especially in situations of severe and potentially fatal illnesses where there is no prospect of cure. The structured communication tool based on the hierarchy of needs was developed in Brazil during the COVID-19 pandemic and initially applied to patients admitted to intensive care units.⁸ Based on neurobiological concepts, the strategy is organized into three sequential and ascending levels. The first level seeks to establish a bond of trust between healthcare professionals, patients, and families, since, in an environment marked by distrust, the patient tends not to share values, fears, and expectations. The second level consists of emotional alignment, a stage where intense emotions-such as fear, anguish, anger, or shame-emerge in the face of difficult news. The third level involves the discussion of the therapeutic plan, including sharing information about prognosis and joint deliberation on conduct. At this stage, the patient's values and objectives are reaffirmed, respecting their autonomy.⁷ In the presented case, the utility of this model applied to the context of palliative care is evident, as clear socio-emotional issues were identified in the relationship between family members. Healthcare professionals working in palliative care often encounter patients and families on journeys of revolt, insecurity, fear of loss, and high levels of distrust. With A.B.A., only after building a trustworthy relationship was it possible to hold a family conference, which allowed for the validation of the emotions and feelings of those involved and, moreover, opened up transparent dialogue about issues where suffering is present, such as death. This process also enabled the clarification of clinical and ethical doubts, consolidating the development of a new therapeutic plan centered on the patient's autonomy and values.

Historically, most traditional communication methods described in literature have been developed from the perspective of European and North American populations, often disregarding the ethnic and cultural characteristics of other groups. The SPIKES protocol, one of the most widely utilized models globally, is a structured tool for communicating bad news, composed of six steps that guide professionals to inform patients with empathy and clarity.⁶ However, its application to the Latin American population may be limited, as the model was developed in an Anglo-Saxon cultural context, which is more individualistic and rational. In Latin American cultures, where there is greater emotional expressiveness, centrality of family in decisions, and a profound influence of spirituality, SPIKES may not adequately address these particularities. Thus, the importance of developing and adopting tools created for the specific populations they are intended for, which considers and highlights their specific realities and contexts.⁹ From the patients’ perspective, conventional protocols also proved to be limited and received criticism regarding their application. More than half of the oncology patients who received bad news using the SPIKES method expressed dissatisfaction with the approach, highlighting issues such as difficult-to-understand language, lack of opportunity to ask questions, and insufficient attention to time and privacy during the conversations.¹⁰ The teaching of communication techniques in medical schools, which are still incipient, is the first step to train professionals capable of relating clearly and sensitively with patients and families, especially in delicate contexts such as bad news and palliative care. For this to happen effectively, it is necessary to include communication as a basis in curriculums, with theoretical and practical classes, realistic simulations, qualified supervision, and spaces for reflection on listening, welcoming, and relational ethics. Integrating these strategies from the early years of training contributes to a more humanistic and patient-centered medical practice.¹¹ As illustrated in A.B.A.'s case, other complementary tools can support the development of advance directives and the reaffirmation of patient autonomy, notably the "Go Wish" card game.⁸ This is a communication resource inspired by the Go Wish deck that allows patients and families to express preferences and values related to healthcare, promoting dialogue about end-of-life decisions.¹² Through its use, it was possible to address the feelings of A.B.A.'s wife and remind her of his wishes when he was no longer able to express himself.¹¹

The preservation of patient autonomy is a central principle in palliative care, ensuring that decisions about treatment and symptom management respect their individual values, beliefs, and wishes. This care is founded on the bioethical principles of autonomy, beneficence, non-maleficence, and justice, which guide person-centered conduct. In addition to strengthening the therapeutic relationship, autonomy promotes dignity, welcoming, and quality of life, even in contexts of severe or terminal illness. Effective communication strategies and family involvement are essential to ensure that the patient's choices are understood and respected.^7,13 A.B.A.'s death, in the presence of his family, demonstrates that effective communication, based on empathy and compassionate listening, allows for the reaffirmation and execution of the wishes of the suffering person and, in parallel, provides necessary supportive care for the family. This balance will be achieved through the healthcare professional who, equipped with social skills and humbleness, will provide impeccable care for the dying person, as well as help them remain alongside family members.^7,13

Communicating bad news in serious illnesses requires sensitivity, active listening, and a compassionate approach. Structured protocols that consider emotions and strategies adapted to the cultural reality of patients are essential to preserve autonomy, strengthen individuality, and involve family members in a supportive manner. When integrated into palliative care, these tools contribute to reducing multidimensional suffering and promoting shared decisions that favor the patient's quality of life until the last moment

None.

The authors declares that there are no conflicts of interest.

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