Breaking Bad News in the ICU: A Systematic Review of Patients’ and Relatives’ Perceptions.

Breaking Bad News in the ICU: A Systematic Review of Patients’ and Relatives’ Perceptions. | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 26 June 2025 V1 Latest version Share on Breaking Bad News in the ICU: A Systematic Review of Patients’ and Relatives’ Perceptions. Authors : Mayra Mota Soares , Luiza Mitre Batista , Paulo Henrique Souza Oton , Thaynan Fontes Novais , and Arnaldo Santos Leite 0000-0003-4856-4166 [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.175092332.28251336/v1 709 views 227 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Communication plays an essential role in the transmission of information and feelings between individuals, significantly influencing emotional support, particularly in healthcare settings. Empathy emerges as a critical element for the effectiveness of this process, as it enables healthcare professionals to understand and adequately address the needs of patients and their relatives. It is imperative that communication remains continuous and infused with respect, considering the preferences and goals established throughout the treatment. Despite the intrinsic relevance of the communicative role of physicians, a considerable number of patients express difficulties in accessing information that is both clear and appropriate, especially in circumstances of severe illness and in the context of palliative care. Recurring complaints include the use of overly technical terminology, a lack of empathy, and ineffective methods in transmitting unfavorable news. On the other hand, relatives who report satisfaction emphasize the importance of careful and honest dialogues that preserve a sense of hope. Patients and their relatives express the desire for open communication that aligns with their emotional needs, valuing aspects such as empathy, clarity, and the recognition of the role played by caregivers. This study aims to investigate the dynamics of breaking bad news in the Intensive Care Unit (ICU), emphasizing the perceptions recorded by patients and their relatives. Breaking Bad News in the ICU: A Systematic Review of Patients’ and Relatives’ Perceptions. AUTHORS: Mayra Mota Soares. Faculdade de Medicina da Universidade Federal de Minas Gerais Luiza Mitre Batista. Faculdade de Psicologia da Pontifícia Universidade Católica de Minas Gerais Paulo Henrique Souza Oton. Faculdade de Medicina da Universidade Federal de Minas Gerais Thaynan Fontes Novais. Faculdade de Medicina da Universidade Federal de Minas Gerais Arnaldo Santos Leite. Faculdade de Medicina da Universidade Federal de Minas Gerais Mayra Mota Soares [email protected] ORCID: 0009-0006-0405-5959 Luiza Mitre Batista [email protected] ORCID: 0009-0000-1487-9835 Paulo Henrique Souza Oton [email protected] ORCID: 0009-0001-2821-0750 Thaynan Fontes Novais [email protected] ORCID: 0009-0005-1394-1699 Arnaldo Santos Leite (corresponding author) [email protected] ORCID: 0000-0003-4856-4166 Avenida Professor Alfredo Balena, 190 – Santa Efigênia – CEP 30.000 – Belo Horizonte – Minas Gerais – Brazil ACKNOWLEDGMENTS: Special thanks to the Pro-Rectorate of Research at Universidade Federal de Minas Gerais FUNDING OF SOURCES OF SUPPORT: There was no financial support for this study. CONFLICT OF INTEREST The authors declare that they have no conflict of interest. ABSTRACT Communication plays an essential role in the transmission of information and feelings between individuals, significantly influencing emotional support, particularly in healthcare settings. Empathy emerges as a critical element for the effectiveness of this process, as it enables healthcare professionals to understand and adequately address the needs of patients and their relatives. It is imperative that communication remains continuous and infused with respect, considering the preferences and goals established throughout the treatment. Despite the intrinsic relevance of the communicative role of physicians, a considerable number of patients express difficulties in accessing information that is both clear and appropriate, especially in circumstances of severe illness and in the context of palliative care. Recurring complaints include the use of overly technical terminology, a lack of empathy, and ineffective methods in transmitting unfavorable news. On the other hand, relatives who report satisfaction emphasize the importance of careful and honest dialogues that preserve a sense of hope. Patients and their relatives express the desire for open communication that aligns with their emotional needs, valuing aspects such as empathy, clarity, and the recognition of the role played by caregivers. This study aims to investigate the dynamics of breaking bad news in the Intensive Care Unit (ICU), emphasizing the perceptions recorded by patients and their relatives. KEYWORDS breaking bad news; ICU; healthcare professionals; critically ill patient; family members; terminality; SPIKES protocol HIGHLIGHTS: • ⁠Effective communication is crucial in the ICU, especially for bad news. • ⁠Information sharing is a key factor in family satisfaction. • Many patients and their relatives struggle to access information during illness. • Family-centered care and meetings are essential for dignity and support. INTRODUCTION: Communication is a central element in the exchange of information and feelings between individuals, playing an essential role in healthcare contexts, particularly concerning the interaction between professionals, patients, and their relatives. In the Intensive Care Unit (ICU), where critical situations are common, verbal or non-verbal communication becomes relevant, requiring empathy and sensitivity from the team 1 . In this scenario, delivering bad news – defined as information that drastically alters a patient’s future perspective, including discussions about serious illnesses 2 – is a fundamental skill for providing proper patient-centered care, impacting comprehension and decision-making 1 . Breaking bad news (BBN) in the ICU context generates anxiety for those involved, highlighting the importance of effective interaction between the team and family members 1 . This type of interaction requires consideration of patients’ and relatives’ preferences and should occur frequently and continuously, considering the dynamics of the critically evolving picture 3 . The healthcare team must adapt its communicative approach to the cultural needs and preferences of family members, allowing for effective communication that strengthens the connection with families and reduces stress 4 . Many family members of patients admitted to ICUs report dissatisfaction with BBN, criticizing the use of technical language and the lack of empathy from professionals. Many physicians face difficulties in discussing prognoses and palliative care 5 . Inadequate logistics and a lack of training in communication can obstruct clinical practice 6 . The impersonal nature of ICUs, rigid protocol dynamics, and high technology compromise the quality of care and interpersonal relationships 7 . The bidirectional exchange of information is essential for effective communication, based on the balance between honesty and optimism 4 and on the demonstration of equality and respect 7 . Family members desire honest information but expect professionals to respect their assimilation process, given that transparent interaction can be potentially stressful 3 . Meetings between the healthcare team and family members should be planned and are crucial for addressing caregivers’ needs, promoting comfort in decision-making 5 . Family-centered care promotes dignity and collaboration 8 and helps families cope with the hospitalization period 4 . This systematic review aims to analyze the perceptions of patients and relatives regarding the BBN in the ICU. METHODOLOGY: The objective of the study was defined using the SPIDER strategy. The following research question was formulated: ”What are the perceptions of patients and relatives regarding BBN in the ICU?” A systematic review was conducted according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 9 . This study was registered in the International prospective register of systematic reviews (PROSPERO) under the identification CRD42024612860. The search for articles for selection and inclusion in the systematic review was conducted on October 12, 2024, across the scientific indexing databases PubMed, Scopus, Web of Science, Lilacs, Scielo, and PsycINFO. A combination of subject descriptors and keywords related to “breaking bad news” and “intensive therapy” was employed. The keywords were derived from the Health Sciences Descriptors (DeCS) for texts in Portuguese and Spanish, and from the Medical Subject Headings (MeSH) for texts in English. Time filters were applied, restricting publications from 2004 onwards, and language filters were used, selecting articles in English, Portuguese, and Spanish. Only original articles were included, excluding review articles, book chapters, editorials, and conference proceedings. The exact search keys for each indexing database are presented in Table 1. The titles and abstracts of the studies identified in the searches were analyzed using the Rayyan application 10 , eliminating duplicate entries. A pair of reviewers (ASL/LB) independently reviewed the titles and abstracts, resolving any conflicts through consensus between the two reviewers. Articles that analyze, discuss, or describe the perceptions of patients and their relatives regarding BBN in the ICU were selected for full-text reading. Articles that involved only healthcare professionals’ perceptions were excluded. Additionally, studies focusing on patients and/or professionals outside the ICU, articles that did not address communication of news in the ICU, studies that did not effectively address the aspect of BBN but rather explored other approaches such as perceptions related to the suffering of patients and relatives due to stress caused by critical illnesses, and studies that only addressed perceptions related to illness (e.g., brain death) without discussing communication-related issues were also excluded. The authors ASL, MMS, and LB, in pairs, screened the articles after full-text reading. Using the same inclusion criteria, the articles for final analysis were selected. The articles included in the analysis were then independently reviewed by the same pairs, with data extraction being collected and managed using the electronic data storage tool REDCap (Yale University) 11 , hosted at the Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais. Any discrepancies were resolved by consensus among the pairs. From each study, the following information was extracted, when applicable: author, publication journal, location of the study, type of study, year of publication, language of the article, study objectives, methodology, type of hospital unit, multicentric or single-center study, professional involved in communication, number of participants, perceptions of family members, and authors’ conclusions. The selected studies underwent a quality assessment conducted independently by a pair of reviewers (ASL/LB) using Qualsyst (Quality Assessment Standard Criteria for Primary Research Articles in Various Fields) 12 . Each study was scored based on its compliance with established criteria, with response options categorized as ”yes” (2 points), ”partial” (1 point), and ”no” (0 points). This assessment included a total of 10 criteria for qualitative studies, 14 criteria for quantitative studies, and 24 criteria for mixed-methods studies. For each study, a total score was calculated by summing the scores assigned to each criterion, which was divided by the total potential points. The results were reported in tables, described and discussed in the body of the article. The perceptions of patients and their relatives, including both quantitative and qualitative outcomes, were analyzed and categorized into six thematic groups according to the steps of the SPIKES protocol 13 . As this systematic review represents secondary research, meaning that there are no participants directly involved in the study, it was not submitted for approval by an ethics review board. RESULTS: Among 201 different titles and abstracts that were potentially relevant identified in the indexing databases, 46 articles were selected for full-text reading, and 16 of these were included in the systematic review (Figure 1). Table 2 presents a description of the included articles. The quality rating of the studies according to the Qualsyst tool ranged from 0.65 to 0.9, with an average of 0.75 (Table 2). The lowest ratings were attributed to deficiencies in the description of the applied methodology, a small number of participants, a lack of evidence related to verification and reflexivity procedures, as well as a lack of assessment of confounding variables. From the 16 articles, 137 distinct items related to the perceptions of patients and relatives regarding BBN were extracted. A list of the items, as extracted, is published as supplementary material. Most family members’ perceptions regarding the BBN were negative. Table 3 categorizes the items related to the perceptions of patients’ relatives according to the steps of the SPIKES protocol, illustrating some examples of positive and negative perceptions. DISCUSSION: The SPIKES is a validated and recommended protocol to guide BBN. The six structured steps of the protocol emphasize the need to involve the family, create an appropriate environment, practice empathy, and articulate care plans clearly 13 . Adequate preparation and structuring of both the professional and the environment are essential for communicating the clinical situation empathetically 13 . The following discussion contextualizes the steps of the protocol with the findings of this review, particularly regarding the perceptions of patients and their relatives. S (Setting up the Interview) Delivering bad news is a challenging task for healthcare professionals and a difficult experience for relatives, as it directly affects their perception of the future and how family members will cope with the situation 24 . Inadequate communication and the lack of preparation among healthcare professionals in delivering difficult news undermine the bond between the team and the families, adversely affecting the understanding of the diagnosis and prognosis of the patient 24 . It is essential for the professional to adopt a calm attitude and avoid hurrying, being fully aware of all necessary information 25 . Mental exercise is a useful method for preparing for stressful tasks. This can be accomplished by reviewing the plan for how to communicate with the patient and how to respond to the patient’s emotional reactions or difficult questions. Sometimes, the physical environment makes discussions about sensitive topics even more challenging. Unless there is a minimum level of privacy and the environment is favorable to focused, distraction-free discussion, the goals of the interview may not be met 13 . In practical experience in the ICU, family members highlighted the lack of guidance and support from healthcare professionals during the BBN process 14 . The constant waiting for new – good or bad – renders the hospital environment emotionally exhausting for relatives 17 . The absence of an appropriate location and the lack of flexibility in the organization and work routine of professionals were perceived as barriers to adequate support 14 . Some family members reported that conversations with the physician did not take place in an environment they considered pleasant, which impacted the quality of communication 18 . They also emphasized the importance of having sufficient time to dialogue and clarify doubts without hurry 18 . The continuity of the discussion without interruptions was an important factor in making the parents feel heard and respected during the BBN process 18 . Some family members expressed discomfort with the rules of the ICU, highlighting an impression of a prison-like environment, accompanied by noise and limited privacy 22 . When the team demonstrates little emotional support, it generates feelings of isolation, lack of welcome, and consequent dissatisfaction 22 . P (Perception) In this step of the SPIKES protocol, the professional must understand what the family member already knows about the situation, gaining insight into their perspective and adjusting the approach if necessary. Family members often do not immediately comprehend the information provided and frequently resort to other sources to understand 23 . Thus, clarifying the relative’s level of understanding regarding the patient’s condition becomes critical. The comprehension and acceptance of information depend on the clarity and intellectual capacity of the family members, demanding a personalized approach 15 , which requires the responsible professional to establish a solid connection with the family members. When the healthcare team establishes an open and therapeutic dialogue with the family, it facilitates understanding of the situation and helps alleviate distress, especially when explaining the necessary procedures 23 . Nonverbal communication, such as smiling, physical proximity, and facial expressions, enhances understanding and contributes to the care process, creating an atmosphere of support and trust. It allows the identification of feelings of fear, anxiety, and other emotions, assisting professionals in adapting their approach and improving interaction 24 . When information is unclear, family members explore other sources for clarification, such as known physicians, web search tools, and scientific articles 23 . Besides seeking technical details, the family wishes to capture the essence of what is happening with their relative, striving for a genuine and human understanding of the situation 23 . It can be inferred that information regarding the patient’s health status should preferably be delivered by the professionals directly caring for the patient. Having a ”reference person” is crucial for enhancing communication and decision-making, establishing a bidirectional inclusive communication between both parties, and promoting more effective interaction in the ICU 1 . I (Invitation) The third step of the SPIKES protocol involves inviting the individual to engage in the conversation, verifying and respecting the amount of information the recipient wishes to receive 13,25 . This step requires the clinician to listen to the patient to determine if they are prepared to hear the information that needs to be shared and to give the family control over the situation. A conflict may arise between the desire for prognostic information and the need to maintain hope in the face of difficult circumstances. These two aspects can conflict and may create moments of emotional difficulty for patients and relatives during the conversation 29 . Some family members do not wish to hear details about the clinical condition 29 , expressing frustration and resistance to acceptance, particularly due to a lack of complete understanding of the situation 23 . In this review, most family members reported not being appropriately invited to participate in discussions, indicating a low sensitivity to being called upon, which hindered their involvement in the process 16 . Professionals frequently addressed family members in a rude manner, without asking if they were ready for the conversation 16 . Consequently, mothers, for instance, felt unmotivated to seek information out of fear, as there was no adequate invitation to discuss their children’s conditions 22 . Caregivers suggested that physicians inquire about the families’ preferred communication style, emphasizing that different individuals have varying needs and reactions 29 . K (Knowledge) The “Knowledge” stage refers to the gradual and comprehensible transmission of information regarding the patient’s condition, utilizing pauses and repetitions to facilitate the assimilation of content 1,2,13,25 . Language undoubtedly constitutes one of the most crucial aspects of the entire protocol. Family members, lacking expertise, struggle to comprehend the technical language used by professionals, and do not always manage to assimilate information clearly 23 . In this review, many family members expressed that the language employed by healthcare professionals was ambiguous and difficult, preventing their understanding of the patient’s actual condition 15,16,22,23,25 . Thus, the necessity for language that is comprehensible, accessible, devoid of technical jargon, and free from complex terminology was among the primary concerns of patients and relatives to facilitate their understanding of the situation 18 . Interviewees also highlighted that the disposition and lack of preparedness of professional – who appeared rushed, nervous, or anxious during the transmission of information – affected how news was received and understood 23,25 . Communication regarding critical matters should be conducted gently and gradually, respecting the family members’ pace of understanding and consistently checking if the information has been comprehended 1,15,23 . Family members do not accept vague information and incessantly seek to understand every detail of what taking place, questioning until they achieve complete comprehension 23 . Abrupt and brief communication, lacking detailed explanations or emotional support, generates suffering and despair among family members, as evidenced by a mother’s narrative of distress stemming from uncertainty about her child’s situation 24 . When the healthcare team engages in an open and therapeutic dialogue with family members 27 , it facilitates understanding of the situation and helps alleviate distress, particularly when explaining procedures and needs 23 . Appropriate communication, which includes non-verbal behaviors, can reduce fear and insecurity 24 . Family members recognize that clear communication and proper guidance provide a greater sense of care and attention 14 , and they appreciate when professionals respect and incorporate their knowledge about the patient into the diagnosis and treatment planning, remaining open to hearing their opinions and concerns 28 . The absence of this quality, where physicians do not listen to or value family members, or are sometimes offended by questioning, is perceived as disturbing, with relatives feeling that they are not taken seriously or could learn from professionals 28 . Some professionals utilize time as a strategy to soften the gravity of the clinical situation, providing explanations about the evolution of the patient’s condition without fully disclosing the reality. This is an attempt to calm those involved; however, for some relatives, vague responses regarding the timeframe and prognosis can generate additional stress, denoting ambiguity in conveying a serious situation 27 . Understanding and acceptance of information also depend on the clarity and intellectual capability of family members, necessitating a more personalized approach 15 . Therefore, in addition to the language used, many family members, including parents and caregivers, emphasized the significance of clear and detailed communication about the patient’s health status 18,25,27 . Some studies highlight the importance of receiving clear, honest, careful, and realistic explanations about the patient’s condition, even when the news is unfavorable, enabling them to process the information and cope with the situation more serenely, thus allowing for a true comprehension of the severity of the case 22,24,27 . The use of simple and clear language in critical communication enhances understanding and instills confidence, especially when physicians and nurses choose their words carefully 26 . When the transmitted message is vague, unclear, or difficult to comprehend, families perceive that professionals are not being entirely transparent, resulting in feelings of insecurity and a desire for more information, creating the impression that something is being hidden 27 . The opportunity to ask questions and ensure that family members understand the information is crucial for satisfaction with the communication process 18 . A significant percentage of family members considered the information regarding diagnosis, prognosis, and treatment to be insufficient 19 . Family members do not accept vague data and continuously strive to understand the details of the situation, either asking until they achieve complete clarity or looking for other sources of information 23 . E (emotion): The experience of hospitalization and the way each family member experiences it is unique, with its own reactions and needs. Therefore, BBN should be conducted considering this uniqueness, acknowledging the emotional impact on each individual 6,13,23 . Communication should not be understood merely as an exchange of information; rather, when difficult news is delivered with empathy and care, it is received more positively by family members, offering safety and understanding regarding the situation 24,27 . Thus, communication should be carried out sensitively, creating a trusting relationship between the person delivering the news and the one receiving it, while respecting the pace at which family members comprehend the information and continually checking for their understanding. The way information is communicated directly impacts relatives’ ability to cope with loss, emotional distress, and any subsequent grief 15,26 . The hope, strength, security, or insecurity of relatives depend on the way health professionals deliver bad news, generating different emotional reactions. These reactions can be alleviated when professionals allow for the expression of family experiences through attentive listening and appropriate communication 27,28 . Hope should not be underestimated, as it represents a form of resistance and a daily struggle to overcome challenges, even surrounded by critical situations 17 . In the ICU setting, the emotional dimension remains neglected. In this review, family members expressed the desire for greater comfort and emotional support, such as simple gestures of empathy and guidance during times of great vulnerability 15 . Although technical care provided to the patient is perceived as excellent, it often comes at the expense of a high workload for professionals, resulting in insufficient attention to the emotional and practical needs of families. It is noteworthy that when family members receive attention and support, these gestures are greatly valued and remembered positively 15 . Both verbal and non-verbal communication are fundamental to the care provided to patients and their relatives, being perceived as a means of conveying dedication and support 24 . Relatives who received news appropriately highlighted the clarity, delicacy, and empathy of professionals, who explained the situation calmly, instilling hope and, in some cases, utilizing resources such as videos or detailing procedures to facilitate understanding 25 . On the other hand, comments from interviewees who experienced inadequate communication included descriptions of nervous professionals, difficult-to-understand language, and a lack of attention and empathy, which left family members feeling worried and unsupported 25 . Relatives reported that a combination of body language, tone of voice, facial expressions, and sincerity conveyed a sense of welcome and accessibility, which is essential for fostering a good relationship with the healthcare team, thereby transmitting empathy and comfort 27,28 . Empathetic and gradual communication is essential in delivering bad news, as it fosters the establishment of a trusting relationship between professionals and families, helping them cope better with the emotional impact and understand the situation without generating additional anguish 25,26,29 . Some professionals adopt a stance of detachment, indifference, and devaluation of the family’s suffering, which can negatively affect communication 23 . Conversely, a welcoming posture, over time, allows family members to overcome their initial resistance, recognize the dedication of the medical team, and understand that the actions taken always aim for the best possible care, facilitating the acceptance of the situation and comprehension of the evolution of their loved one’s condition 23 . Another relevant aspect to consider is the spiritual support that offers comfort, strengthens trust in caregivers, and fosters hope, making it an important strategy for coping with bad news 26 . In this review, faith in God was mentioned as essential for believing that it is possible to overcome difficult moments and achieve better outcomes 17 . However, it was noted that the support from chaplains, social workers, and psychologists remains weak in the ICU environment, indicating the need for greater integration of these professionals in supporting families 15 . Relatives feel supported when professionals demonstrate empathy by offering words of comfort, affection, and care 24 , acknowledging the emotional pain experienced by relatives upon receiving bad news. The absence of empathy was viewed as distressing by some family members, resulting in a negative experience 22,27 . It is suggested that nursing, although this can be extended to the entire multidisciplinary team, should routinely include inquiries about the well-being of family members and consider their needs as an integral part of general care 15 . Attitudes valued by family members also included those that demonstrated a personal connection between the professional and the patients, such as greeting them by name and interacting in a manner that conveys genuine interest, thereby contributing to a more welcoming and comfortable environment 28 . S (strategy and summary): The final step of the SPIKES protocol is to summarize the entire conversation for the family and establish strategies moving forward, including treatment options and planning the next steps in conjunction with the family. While summarizing the information, the professional should check if there are any further questions or if more clarifications are needed 2,13 . In the planning process, communicators should be aware of the available support organizations, ensuring appropriate sequential assistance 6 . It is essential that healthcare professionals provide a clear treatment plan to patients to reduce anxiety and uncertainty. The approach should include asking if the patient is ready to discuss treatment, presenting available options, sharing decisions, and verifying the patient’s understanding 2,13 . Structured family meetings in the context of critical illness offer psychological benefits to caregivers, promoting an understanding of prognosis and strengthening the therapeutic alliance 15 . These meetings facilitate clear communication regarding diagnosis, objectives, and the treatment plan, providing direct emotional support 5 . Although this practice is recognized as essential for increasing satisfaction with the care provided, family involvement in making important decisions remains scarce 15 . The effects of BBN extend beyond the moment the information is conveyed. A study included in this review, which analyzed BBN in brain death situations, found that some family members reported feeling alone and helpless after the decision to withdraw life support, due to a lack of adequate assistance from the medical team 15 . They highlighted those simple actions, such as clarifying who would accompany them home, could have provided greater comfort during this delicate moment 15 . Furthermore, they suggested that a follow-up contact, via a letter or call offering psychological support or information about support groups, would be extremely valuable for the grieving process 15 . Finally, they reported that small gestures of farewell, such as being accompanied by a nurse to the exit, were deeply appreciated, as they conveyed care and empathy 15 . Thus, it is evident that an empathetic approach, combined with continuous support, helps families during this vulnerable time. The closure of the conversation should include a clear care plan centered on the patient and their relatives 25 . Professionals must inform the relatives that the patient will not be abandoned, regardless of the level of care established, even if minimal invasive support is defined. The perception that comfort and the least possible suffering will be ensured by the team was an important aspect of family satisfaction at the end of difficult conversations regarding BBN 20,21 . Limitations of the study and strengths This systematic review presents several limitations that deserve attention. Firstly, it is impossible to determine whether the perceptions reported by family members and patients themselves – which tend to be predominantly negative regarding the experience of receiving difficult news – indicate a bias in the data collection that prioritized the adversities faced, or whether they reflect subjective preconceptions. The observation that sample sizes were relatively small in a significant portion of the studies reviewed may have limited the range of the experiences captured, thereby affecting the perceptions presented in the synthesis. Furthermore, most studies did not consider the familiarity of patients and their relatives with communication approaches related to delivering bad news, which complicates the assessment of the impact of this understanding on the reported experiences. Many articles focused solely on the interactions between patients and physicians, neglecting the role of other healthcare professionals and the importance of the family support network. An important aspect that was not evaluated is the experience of family members of patients with prior or repeated ICU admissions, which could possibly influence their responses to the situations presented. Additionally, the mental health of both the patients and their relatives considering the bad news was not analyzed. On the other hand, a positive aspect of this review lies in the adoption of a comprehensive research strategy, which involved searches in reputable indexing databases with the aim of selecting relevant articles that related to the research objectives. This included diverse approaches and perceptions from patients and family members across different countries, reflecting a wide ethnocultural diversity. CONCLUSION: The review demonstrates the profound and lasting impact of BBN in the ICU on the lives of patients and their relatives, highlighting the need for enhancement of this skill among healthcare professionals. The way information is shared stands out as the primary aspect of family satisfaction. Family discomfort arises not only from technical failures but also from inadequate communication, characterized by the use of excessively technical language, impersonal interaction, and a lack of warmth or respect in critical moments. 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Schenker Y, White DB, Crowley-Matoka M, Dohan D, Tiver GA, Arnold RM. ”It hurts to know… and it helps”: exploring how surrogates in the ICU cope with prognostic information. J Palliat Med. 2013;16(3):243-9. Supplementary Material File (figure 1.docx) Download 54.92 KB File (table 1.docx) Download 18.81 KB File (table 2.docx) Download 31.56 KB File (table 3.docx) Download 19.42 KB Information & Authors Information Version history V1 Version 1 26 June 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords breaking bad news critically ill patient healthcare professionals icu spikes protocol Authors Affiliations Mayra Mota Soares Universidade Federal de Minas Gerais Faculdade de Medicina View all articles by this author Luiza Mitre Batista Pontificia Universidade Catolica de Minas Gerais - Campus Praca da Liberdade View all articles by this author Paulo Henrique Souza Oton Universidade Federal de Minas Gerais Faculdade de Medicina View all articles by this author Thaynan Fontes Novais Universidade Federal de Minas Gerais Faculdade de Medicina View all articles by this author Arnaldo Santos Leite 0000-0003-4856-4166 [email protected] Universidade Federal de Minas Gerais Faculdade de Medicina View all articles by this author Metrics & Citations Metrics Article Usage 709 views 227 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Mayra Mota Soares, Luiza Mitre Batista, Paulo Henrique Souza Oton, et al. 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