## 4 Discussion
### Key Points for Improvement in the Communication and Management of Bad News  
The dimensions related to the process of communicating bad news in nursing with the person in a palliative care situation and their caregivers/family members identified were continuous and advanced training in end-of-life care; training in communication and breaking bad news; religiously and culturally sensitive nursing interventions; nursing interventions to promote hope and maintain faith; emotional management; therapeutic relationships; the use of a bad news communication protocol; and the respect for autonomy, needs, and preferences. Communicating bad news effectively requires that nurses acquire, through pre- and postgraduate training, as well as reflective practice, a set of communication tools and structures that allow them to reveal the truth, answer difficult questions, and gather complex information with security, sensitivity, and empathy [30; 33; 36; 37]. Although nurses feel prepared to provide care to people at the end of their life, they often do not feel comfortable communicating bad news with the person in the palliative care situation and their caregivers/family members. This situation derives from the lack of communication skills that give them the confidence necessary to address complex topics as well as to manage the emotions that arise from these conversations [15; 19; 28]. Studies indicate that caregivers and family members supported by professionals trained in the area of communicating bad news recognize the good work and the positive repercussions that adequate communication and information have on themselves and on the person in a palliative situation, thus reinforcing the relevance of training and communication skills training [29; 30]. Providing training in communicating bad news based on the application of a model (COMPORT, SPIKES, ABCDE, or others) is effective in improving the quality of communication perceived not only by the person in a palliative care situation and their caregivers/family members but also by the professionals themselves, increasing their confidence to approach difficult topics, and to manage bad news and family crises and topics related to the end of life in general [29]. The use of a protocol when communicating bad news is associated with greater skills and experience in this area; however, studies indicate that the majority of nurses do not anchor the communication of bad news in any specific model [15]. It is also important that nurses' training includes the acquisition of communication skills that are culturally sensitive, as communication needs and ways of approaching bad news and the end of a patient's life are different between cultures and/or religions. For this reason, it is particularly important to acquire communication skills that allow them to effectively address the psychological and spiritual aspects of death so that they can reveal bad news while maintaining the hope of the patient and their caregivers/family members and avoiding cultural and religious conflicts [15; 28]. Also, the felt need to reveal the truth, as well as the way professionals' approach bad news and the end of a patient's life are different between cultures and/or religions. Despite the widespread trend towards greater and more detailed revelations of the truth at the end of life, cultural and religious differences continue to exist, particularly those related to the diagnoses and prognoses of illness. In various cultures/religions, family pressure is common so that the truth is not revealed to the person in the palliative care situation (conspiracy of silence) since knowledge could cause hopelessness or a lack of faith. In some cultures, such as Asian cultures, there is a tendency for people in palliative care situations not to be informed, nor to participate in the decision-making process regarding the end of their life.