ltidisciplinary care team. Medication with riluzole should be initiated as early as possible. Control of symptoms such as sialorrhoea, thick mucus, emotional lability, cramps, spasticity and pain should be attempted. Percutaneous endoscopic gastrostomy feeding improves nutrition and quality of life, and gastrostomy tubes should be placed before respiratory insufficiency develops. Non-invasive positive-pressure ventilation also improves survival and quality of life. Maintaining the patient's ability to communicate is essential. During the entire course of the disease, every effort should be made to maintain patient autonomy. Advance directives for palliative end-of-life care should be discussed early with the patient and carers, respecting the patient's social and cultural background.20:T54e,Six key questions will help readers to assess qualitative research #### Summary points Over the past decade, readers of medical journals have gained skills in critically appraising studies to determine whether the results can be trusted and applied to their own practice settings. Criteria have been designed to assess studies that use quantitative methods, and these are now in common use. In this article we offer guidance for readers on how to assess a study that uses qualitative research methods by providing six key questions to ask when reading qualitative research (box 1). However, the thorough assessment of qualitative research is an interpretive act and requires informed reflective thought rather than the simple application of a scoring system. #### Box 1 Key questions to ask when reading qualitative research studies One of the critical decisions in a qualitative study is whom or what to include in the sample—whom to interview, whom to observe, what texts to analyse. An understanding that qualitative research is based in experience and in the construction of meaning, combined with the specific research question, should guide the sampling process. For example, a study of the experience of survivors of domestic violence that examined their reasons for not seeking help from healthcare providers might focus on interviewing a …21:T542,

Objective.

—To review the literature on breaking bad news while highlighting its limitations and describing a theoretical model from which the bad news process can be understood and studied.

Data Sources.

—Sources were obtained through the MEDLINE database, using "bad news" as the primary descriptor and limiting the sources to English-language articles published since 1985.

Study Selection and Extraction.

—All articles dealing specifically with bad news were examined. These works included letters, opinions, reviews, and empirical studies. Recommendations from these articles were examined, sorted into discrete categories, and summarized.

Data Synthesis.

—The 13 most consistently mentioned recommendations (eg, delivering the news at the patient's pace, conveying some hope, and giving the news with empathy) were examined.

Conclusion.

—Although much has been written on the topic of breaking bad news, the literature is in need of empirical work. Research should begin with the simple question of whether how the news is conveyed accounts for variance in adjustment before moving to more specific questions about which aspects of conveying bad news are most beneficial. It is suggested that the bad news process can be understood from the transactional approach to stress and coping.

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Abstract

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