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Beyond breaking bad news: How to help patients who suffer
... Developed by Dr. Rabow and Dr. McPhee (Division of Internal Medicine, University of California, USA) and published in 1999, this protocol is summarized by the simple and mnemonic acronym "ABCDE" [24]. Subsequently, this model has been modified with additional material from other sources [18]. ...
... "E" means "ENCOURAGE AND VALIDATE EMOTIONS". Even when resolutive therapy is not available, offer hope and encouragement about the available options to alleviate the symptoms; consider an interdisciplinary approach to improve patient care (for example, hospice, psychology service support); inquire about the patient's resources, asking, for example, "When bad things happened to you before-how have you coped?" [18,24]. ...
... An adequate private setting and time for the medical consultation are always recommended. Interestingly, all the protocols advise switching off the telephone and the beeper when setting up the consultation to avoid interruptions [16][17][18][19]24]. In all the stepby-step models, before communicating the bad news, the physician should investigate what the patient already knows about the disease to identify misinformation that needs correction or to have a starting point for delivering the bad news. ...
Background/Objectives: One of the problematic situations dermatologists face with their patients is communicating dismal diagnoses. Examples are the diagnosis and prognosis of skin cancers like melanoma and Merkel cell carcinoma and the disclosure of the chronic nature of a disease that requires long-term therapies or can lead to scarring or disfiguring conditions. Likewise, receiving a diagnosis of a sexually transmitted infection can be a shocking event that can also put into question the patient’s relationship with his/her partner/partners. Some oncology and internal medicine protocols have been developed to support delivering distressing information. Regrettably, no consensus guidelines exist in dermatology, sexually transmitted infections, or other medical specialties. Methods: The protocols available in the literature to guide the disclosure of a dismal diagnosis have been reviewed in the present work. Results: The different protocols consist of several steps, from 5 to 13, and most of them are summarized by acronyms, such as “SPIKES”, “ABCDE”, and “BREAKS”. The frameworks are listened to and explained in the manuscript. Conclusions: These communication models are suggested to be adapted to dermatology and sexually transmitted infections. Indeed, several studies demonstrated that training in communication skills and techniques to facilitate breaking bad news may improve patient satisfaction and physician comfort.
... These studies, by assessing attitudes, have finally expressed the needs of patients and clinical staffs in breaking bad news. Only in 8 studies introduced a solution or model for breaking bad news [17,[40][41][42][43][44][45][46]. The views of these eight studies on the news presenter and receiver of the bad news were different (Table 1). ...
... Rabow et al. [44] Present a model for better and easier breaking bad news All Clinical Staffs All patients Table 2 Extracted items based on the presentation stage (n = 97). Ptacek et al. [52] Pressing the recipient to act on the news presenter request Ptacek et al. [52] The news presenter must identify the recipient's feelings and the reason for it and take appropriate action Kirshblum et al. [40] Giving morale and hope and at the same time not giving fake hope are known as the features of a good news presentation process, but it should be noted that disappointing the patient is not appropriate in this situation. ...
... Cognition of the recipient included personal aspects and the cultural characteristics, family, spirituality and beliefs. Some studies have reported the coping strategies, possible reactions to bad news, and prior knowledge, as recipient characteristics [17,20,[40][41][42][43][44]49,52,69]. The content of the speech becomes very important because the receivers of the news turn all attention to the statements to obtain the information they need. ...
Objective:
This study was performed with the aims of screening the previous studies on breaking bad news in all medical wards.
Methods:
Eligible observational studies were selected. The quality of the studies was assessed using the STROBE checklist. The findings were reported using Garrard's table. All the stages of the present study were performed in terms of the PRISMA statement.
Results:
Totally, 40 articles were included in the study and 96 items were extracted. The results show that breaking bad news is a recipient-centered process. Respect, empathy, and support were reported. The news presenters are better to use guidelines based on evidence-based findings. It is suggested that the presenter should use simple and understandable content. Moreover, suitable time and space are important to present the news. The results show the importance of paying enough attention to the emotions of the recipient and the need to provide support after breaking bad news.
Conclusion:
The recipient must be the center of the programs. It is necessary to pay attention to the characteristics of the news presenter, the news content, and finally the support.Practice Implication: Understand the recipient, trained presenter, and use of the evidence-based results, improve the breaking bad news outcome.
... The PRISMA 2020 statement (Page et al. 2021) was followed, and a review protocol was prospectively registered with PROSPERO (CRD42021273697). The study team extracted items from this review and supplemented these with items from guidelines in cancer (Baile et al. 2000), dementia (Peixoto, Diniz, and de Oliveira Godeiro 2020), and breaking bad news (Rabow and Mcphee 1999;Narayanan, Bista, and Koshy 2010;Vandekieft 2001). Guidelines from these areas were used in this study as they were identified during the search but excluded due to not meeting the criteria for the systematic review. ...
... There are large methodological variations in the creation of breaking bad news recommendations, as seen in ABCDE (Rabow and Mcphee 1999), SPIKES (Baile et al. 2000), SPIKES-D (Peixoto, Diniz, and de Oliveira Godeiro 2020), and BREAKS (Narayanan, Bista, and Koshy 2010), whereby items have been collated from literature, based on clinician opinion, or can be found in good practice guidelines. Adapting a current guideline to a particular condition is another way to develop a guideline. ...
Background
Multiple sclerosis (MS) misdiagnosis is common, and when discovered, frequently leads to substantial disruption to patients’ lives and anxiety for clinicians. Our objective was to develop expert consensus‐based guidelines about how to communicate a misdiagnosis of MS to a patient, to reduce the potential for both psychological distress and litigation.
Methods
A modified Delphi method using a systematic literature review on doctor and patient experiences of the MS diagnosis communication was used to populate items for a first‐round questionnaire. Our Delphi panel represented three perspectives (clinicians, people with MS, and published experts in health communication), and we recruited 18 panelists in total (6 per perspective). Consensus was defined a priori as 75% of panelists giving an item the same rating. A feedback round was undertaken with six external reviewers, naïve to the guideline development process, and the panelists. Items were reviewed by the study team and synthesized to create the finalized guidelines.
Results
Consensus was reached for 45 items rated as “very important” and presented in the feedback round. The study team synthesized the 45 items to 27 items. Ten items related specifically to the communication of the MS misdiagnosis and 17 items to generic guidelines highlighted as important in the MS misdiagnosis appointment. Seven recommendations form the guidelines presented here.
Conclusions
Seven consensus‐based recommendations offer guidance to practising neurologists in their communication with patients in a situation that has the potential to be highly distressing, for both clinician and patient.
... A number of evidence-based recommendations and guidelines for BBN (e.g. SPIKES or ABCDE (Baile et al. 2000;Rabow and McPhee 1999)) offer training and further education formats that may assist physicians. Before the news delivery, patients' communication preferences can be assessed by applying the Marburg Breaking Bad News Scale (MABBAN), which is a SPIKES-protocol questionnaire (Blanckenburg et al. 2020). ...
... This should be avoided whenever possible because it allows no visual feedback on how the patient reacts to the news and patients may not have time to ask questions (Thistlethwaite 2009). Furthermore, 'preparing' the patient-such as by arranging a safe atmosphere and allocating sufficient timeappeared to be important, (e.g. via a stepped communication approach) to facilitate the process when the bad news is broken 'unexpectedly' (Rabow and McPhee 1999). Within the perceived needs, the SPIKES component of 'knowledge' (e.g. ...
Purpose
Receiving a cancer diagnosis significantly impacts patients’ lives, and how the bad news is delivered influences patients’ trajectory, psychosocial adjustment and openness to psycho-oncological support. We explored how patients’ experiences, reactions and preferences were when receiving the news and which optimization recommendations can be made.
Methods
We conducted an exploratory qualitative study with patients who enrolled in the new integrated cross-sectoral psycho-oncological care programme ‘isPO’, being enrolled 12 months post-diagnosis. Data on the main issue (i.e. perception of the moment when the diagnosis is received) were collected via telephone interviews that were fully audiotaped and transcribed. Two independent coders conducted inductive content analyses using MAXQDA.
Results
Out of 38 approached patients, 23 cancer patients with 13 different tumour entities participated. They had a mean age of 54.2 (SD 16.2); n = 17 (74%) were female. Three major themes with 14 corresponding subthemes emerged: (1) patients’ experiences with the bad news delivery, including setting, mode, preparation and perceived needs; (2) patients’ reactions to the bad news, such as shock, fear and helplessness, disbelief and denial, anger and feeling of injustice, thankfulness and depression; and (3) patients’ receiving preferences, including psycho-oncological support, addressing informational needs, needs-driven comprehensive support and a competent multidisciplinary support team.
Conclusions
The quality of bad news delivery and addressing patients’ needs should be strongly considered by physicians. We recommend integrating patients’ perspective on the quality management processes of breaking bad news. For providing needs-centred high-quality care, applying existing guidelines and acquiring patient-centred communication skills are central.
... Protocols like SPIKES (Setting up, Perception, Invitation, Knowledge, Emotions with Empathy, and Strategy or Summary) (22) and the ABCDE model (Advanced preparation, Building therapeutic relationship, Communicating effectively, Dealing with reactions, and Encouraging emotions) (23,24) are increasingly employed to provide a structure to breaking bad news with synthesized evidence of their effectiveness (25). Respect, support, and empathy are central to these approaches which aim to mitigate the negative impact of breaking bad news (26). ...
Introduction
Breaking bad news is a critical yet challenging aspect of healthcare that requires effective communication skills, empathy, and cultural sensitivity. Health professionals in the World Health Organization’s (WHO) Eastern Mediterranean Region face unique cultural and social factors distinct from other parts of the world. This scoping review aims to comprehensively explore the peer-reviewed literature on the health professionals’ experiences in delivering bad news within the WHO’s Eastern Mediterranean Region.
Methods
This scoping review was conducted according to the Joanna Brigg Institute’s scoping review methodology and reported utilizing the Preferred Reporting Items for Systematic Reviews extension for scoping review (PRISMA-ScR) guidelines. A search using a combination of keywords and MeSH terms related to “breaking bad news” and “health professionals” was performed in PubMed, Scopus, CINAHL, EBSCO, ERIC via Embase, and Dar Almandumah (Arabic) databases. Common themes were synthesized from studies conducted in the WHO’s Eastern Mediterranean Region.
Results
Out of 4,883 studies initially identified in the databases, 24 studies met the inclusion criteria, involving a total of 4,710 participants, including physicians, nurses, and residents. The studies were published between 2006 and 2022, predominantly from Iran (n = 12). The majority employed a cross-sectional design (n = 21) or mixed methods (n = 3), with a notable absence of qualitative studies. No studies used theoretical frameworks. More than half of the studies (n = 14) reported that participants had positive attitudes toward breaking bad news. This positivity was evident in their willingness to share bad news, perceived possession of adequate knowledge, positive attitudes, having received training, awareness of accepted approaches, and adherence to protocols. The lack of training and limited awareness of established protocols like SPIKES, ABCDE, and BREAKS for breaking bad news were major concerns among participants.
Conclusion
The scoping review reveals both positive and negative experiences of breaking bad news by health professionals in the WHO’s Eastern Mediterranean Region. Most studies highlight the need for culturally sensitive targeted education and training programs on breaking bad news. Further research, particularly using qualitative methodologies and theoretical frameworks is warranted.
... In order to ease this situation, we recommend that healthcare professionals invest further in refining their communication skills and developing therapeutic relationships. Following protocols that are abbreviated as SPIKES, BREAKS or ABCDE may help increase communication quality when delivering a diagnosis perceived as 'bad news' [36][37][38]. ...
Background
Parkinson’s disease (PD) significantly impacts the health-related quality of life of affected individuals and their relatives. In order to support the affected individuals and their families in coping with PD, it is essential to offer comprehensive information about their experiences. A comprehensive understanding of their lived experiences with the disease, the healthcare system, applied self-management strategies and their needs is considered crucial for developing a PD support program. Therefore, we aimed to explore the lived experiences and support needs of individuals with PD and their relatives in Germany.
Methods
This non-interventional, qualitative study conducted an explorative status quo and needs assessment. It generated knowledge through semi-structured focus groups and interviews with individuals with PD at various disease stages and their relatives. The interviews were digitally recorded, transcribed verbatim, and analysed using content analysis.
Results
Fifty-two individuals with PD and 29 relatives participated in eight focus groups and 13 paired and 13 individual interviews. Four themes with corresponding subthemes emerged: (1) experiences, revealing individuals’ experiences around their diagnosis and with disease-specific care provision; (2) management support offers, clarifying who provides support and the type of support offered; (3) self-management, including comprehensibility, meaningfulness and manageability; and (4) future needs, differentiating between deficits and needs. Most participants expressed a sense of abandonment when obtaining self-management strategies and mastering their lives with PD, often referred to as ‘life 2.0’. They identified the lack of structured and adequate provision of information, system orientation and social awareness.
Conclusions
In Germany, there is an urgent need for a comprehensive PD care program that addresses the needs of individuals with PD and their relatives from the start of their care trajectory. It could assist individuals in gaining a comprehensive understanding of the disease, obtaining self-management strategies, building a support network, and becoming experts in self-managing their disease. Moreover, it may positively influence their care trajectory and reduce burdens, such as overburdening, fear of progression, and health anxiety.
Trial Registration
German Clinical Studies Register (https://www.drks.de/DRKS00030090, No. DRKS00030090, Date of registration: 15.12.2022).
... Shomoossi et al. (2013) carried out their study applying the ABCDE model suggested by some oncologists on how to communicate death news. This strategy according to Rabow and McPhee (1999) stands for "Advanced preparation", "Build a therapeutic environment", "Communicate well", "Deal with patient and family reaction", and "Encourage and validate emotion". As the current study is an educational and sociolinguistic one and its sample consists of English Language majors, the researcher will only consider Item 15 of the B section that says "I introduce myself when giving bad news", and Item 19 of the C section that says "I am clear and outspoken, but my words are sympathetic". ...
This study investigated how Saudi and Jordanian university undergraduates reported the death news of a friend to their bereaved parents. The sample of the study consisted of 64 volunteer students; 35 Jordanian students majoring in English Language, and 29 Saudi students majoring in Tourism Guidance. The researcher used a DCT to collect the data necessary for the study. Mean scores and t-test were used to analyze the data and answer the questions of the study. The findings of the study revealed that both Saudi and Jordanian undergraduates employed nine strategies to report the death news of a friend. The researcher ascribed the employment of such strategies to various factors which might help report the death news successfully. Keywords: Death, religious, Jordan, Saudi, greetings, news, arabic, university.
... In addition, bad communication can be medically significant and a source of distress for patients, relatives, and health care professionals (HCPs) [12,13]. Although communicating bad news is an integral part of an oncologists daily routine, there are only few comprehensive guidelines [14][15][16], and these have been predominantly developed by "expert opinion" and without patient involvement [17]. Most of the research focuses on patients experience, effects of breaking bad news (BBN), or communication skill trainings [18][19][20]. ...
Purpose
Studies that focus on improving the difficult process of breaking bad news in oncology should include the patient perspective and be guided by appropriate outcome measures. Endpoints such as “patient satisfaction” fall short to capture the complex nature of breaking bad news (BBN) conversations. However, this is true of many studies. The present study attempts to develop a framework model from a new, patient-centered perspective, which can be applied equally in clinical practice and in education.
Methods
Semi-structured in-depth interviews with twelve cancer patients were conducted. Transcripts were analyzed by “qualitative content analysis” following Mayring. Outcomes were further extrapolated in interpretational steps, and a model of “success” from patients view in BBN was developed.
Results
Two central needs of the patients could be identified: understanding and feelings. Their fulfillment depends on two groups of variables: first, structural characteristics, such as the inevitable shock, individuality, and processability; second, strongly influenceable variables, such as relationship, transfer of knowledge, and atmosphere. From these results, a framework model for successful breaking of bad news from the patient’s perspective was developed: The successful delivery process model (SDP model).
Conclusion
As a basic model for the framework for breaking bad news from the patient’s perspective, the SDP model can be applied to many different situations in oncology and help to frame the difficult conversations by tailoring the BBN conversations on determinants that favorably influence the process in a patient centered manner. In this sense, the model can be useful in clinical practice as well as in education.
... Para auxiliar na transmissão de uma notícia difícil, foram elaborados diversos protocolos técnicos, todos assinalados por mnemônicos, dentre os quais destacamos o breaks, o abcde, o spikes, o cone e o paciente, que orientam a sua sistematização, podendo ajudar a torná-la menos traumática tanto para o profissional quanto para o familiar e o paciente (5)(6)(7)(8)(9). ...
Objetivo:
Analisar o conhecimento que os profissionais de uma equipe que trabalha em Unidade de Terapia Intensiva possuem sobre comunicação de notícias difíceis.
Método:
estudo de caráter qualitativo e exploratório realizado em um hospital regional do estado do Maranhão no período de maio a novembro de 2019. Participaram do estudo 29 profissionais de nível superior. As informações obtidas foram coletadas por entrevista semiestruturada e tratadas pela análise de conteúdo.
Resultados:
os dados foram distribuídos em três categorias: percebendo a si durante a comunicação da notícia difícil; percebendo o contexto do processo de comunicação; e percebendo o outro como receptor da notícia difícil.
Conclusão:
os entrevistados realizavam a comunicação de notícias difíceis de maneira instintiva e sem a adoção de protocolos. Todavia ressaltaram alguns passos do protocolo ao destacarem os cuidados com essa comunicação, e reconheceram a necessidade de preparo adicional da comunicação de notícias difíceis para melhoria do serviço.
... 28 This kind of sensitive and compassionate communication is especially important in end-of-life care contexts. There are many tools that can help guide communication such as the SPIKES 6-step protocol, 29 the ABCDE plan, 30 and the PREPARED model from Australian clinical practice guidelines. 31 In some cases, when medications are discontinued, a patient may feel abandoned, that their diagnosis is terminal or that death is near, even if that is not the case. ...
The demographic of individuals aged 65 and above represents one of the fastest-growing populations globally. As of 2020, there were 727 million individuals (9.3%) aged 65 years or older worldwide. Projections indicate that the number of older adults will double to reach 1.5 billion (16%) by 2050.1 At that point, 1 in 6 people globally will be over 65, and in Europe and North America, 1 in 4 individuals may fall into this age bracket. [...]
... 11 Several protocols outline how physicians should prepare for delivering bad news, the manner in which they should provide the information and the appropriate physical environment for discussions. [12][13][14] For the disclosure of negative information to cancer patients about their condition, the SPIKES protocol was outlined by Baile et al. 13 This acronym denotes (i) Setting up the interview, (ii) assessing the patient's Perception, (iii) obtaining the patient's Invitation, (iv) providing Knowledge and information to the patient, (v) addressing the patient's Emotions, and (vi) Strategy and Summary. 13 Limited evidence exists regarding adherence to these tools and the impact of their use on patients' satisfaction. ...
Background: The first medical oncology appointment serves as a platform for patients to comprehend their diagnosis and prognostic implications of cancer. This study aimed to determine patients' communication preferences during their first medical oncology appointment and to assess the disparities between patients' preferences and perceptions.
Methods: A total of 169 cancer patients participated by completing the Communication in First Medical Oncology Appointment Questionnaire (C‐FAQ), a two-section questionnaire designed to assess patients’ preferences and perceptions regarding Content (information provided and its extent), Facilitation (timing and location of information delivery), and Support (emotional support) during their first medical oncology appointment. A comparative analysis was conducted to assess the variations between preferences and perceptions.
Results: Content emerged as the most significant dimension compared to Facilitation and Support. The physician's knowledge, honesty, and ability to provide clear information were considered the most important attributes. Patients evaluated most of their preferences as “very important”. Patients’ perception of the communication dimensions present during their appointment was below preferences for 11 items, indicating significant discrepancies in clinical practice.
Conclusions: Patients highly valued their preferences concerning Content, Facilitation, and Support dimensions of communication. However, patient preferences were more prominently oriented towards the Content dimension. The discrepancies between preferences and perceptions should be viewed as an opportunity for enhancing communication skills through training.
... Receiving bad news regarding a serious chronic disease or diagnosis is life-altering for patients and their family members (Miller et al. 2022a). Research abounds with guidelines and protocols aiming to aid health practitioners in effectively communicating bad news in ways that support the recipient and provide a supportive experience (Baile et al. 2000;Berkey et al. 2018;Narayanan et al. 2010;Rabow and McPhee 1999), but there is still room for improvement. Often bad news is delivered by the patient's general practitioner (GP) within a familiar environment and where therapeutic relationships have already been established, enabling a smoother bad news delivery process (Berkey et al. 2018). ...
Fourteen semi-structured interviews were conducted with patients and family members in regional Victoria, Australia to understand their experiences with bad news delivery and the hospital environment. It was found that bad news needs to be delivered in a quiet, calm and emotionally safe environment within a supportive therapeutic relationship.
... That participants in this study appreciated or wanted to enhance their knowledge of the clinical course highlights the importance of prognosticating in the context of lifelimiting disorders as a major pillar supporting patient-centred care [96,[98][99][100]. Despite this, we found that conversations on this topic were of poor quality or omitted altogether which is congruent with several lines of evidence on this topic [101][102][103]. This information should, therefore, be made available to PwCM as its provision has important implications for a chronic illness patient's onward health decision making, mental and emotional health and openness to treatment [104,105]. ...
Background
Individuals with lifelong illnesses need access to adequate information about their condition to make optimal health decisions. Degenerative Cervical Myelopathy (DCM) is the most common form of spinal cord dysfunction in adults worldwide. Its chronic and debilitating nature, varied impact, clinical trajectory, and management options necessitate appropriate informational support to sustain effective clinical and self-directed care strategies. However, before clinicians can meet patients’ information needs, they must first have an understanding of their baseline requirements. This study explores the information needs of people with DCM (PwCM). In doing so, it provides a starting point for the development of patient education and knowledge management strategies in clinical practice.
Methods
Semi-structured interviews with PwCM were conducted using an interview guide. Interviews were audio-recorded and transcribed verbatim. Thematic analysis according to Braun and Clarke’s six-phase approach was used to analyse the data. Findings were reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.
Results
Twenty PwCM (65% female, 35% male), with ages ranging from 39 to 74 years old participated in the interviews. The findings indicated that the provision of information to PwCM during clinical interactions varies. Accordingly, PwCM’s information needs were broad-ranging, as was the nature of the information they found useful. Three main themes were identified (1) Variation in the provision of information to PwCM during clinical interactions, (2) Variations in the information needs of PwCM, and (3) Information that PwCM find useful.
Conclusion
Efforts must turn to adequately educating patients at the time of the clinical encounter. A comprehensive and consistent patient-centered information exchange in DCM is necessary to achieve this.
... Receiving bad news regarding a serious chronic disease or diagnosis is life-altering for patients and their family members (Miller et al. 2022a). Research abounds with guidelines and protocols aiming to aid health practitioners in effectively communicating bad news in ways that support the recipient and provide a supportive experience (Baile et al. 2000;Berkey et al. 2018;Narayanan et al. 2010;Rabow and McPhee 1999), but there is still room for improvement. Often bad news is delivered by the patient's general practitioner (GP) within a familiar environment and where therapeutic relationships have already been established, enabling a smoother bad news delivery process (Berkey et al. 2018). ...
Objectives:
Receiving bad news about one's health can be devastating, yet little is known about how the therapeutic nature of the environment where bad news is delivered affects the experience. The current study aimed to explore how patients and their families were affected by the language and the built, natural, social, and symbolic environments when receiving bad news, through the Therapeutic Landscapes theoretical framework.
Methods:
Patients diagnosed with a life-limiting illness living in regional Victoria who had a hospital admission within 24 months and a diagnostic/prognostic conversation were invited to participate, as well as a family member who witnessed the conversation. Participants were recruited through social media and snowballing, resulting in 14 online semi-structured interviews being conducted between November 2021 and March 2022, audio-recorded, and transcribed verbatim. Reflexive thematic analysis was used to develop the themes.
Results:
Fourteen semi-structured interviews were conducted with women aged between 30 and 77 years. Interviews lasted between 45 and 120 minutes, with an average of 69 minutes, and were conducted online or via mobile phone. Four central themes were developed: "Hearing bad news for the first time," "Preferences for having hard conversations," "Creating a sense of safety for ongoing care," and "The therapeutic nature of the ward."
Significance of results:
This body of work will help inform practice and future policy regarding bad news delivery and the design and aesthetics of environments where bad news is delivered. It is essential that bad news is delivered within a quiet, calm, and emotionally safe environment within a supportive therapeutic relationship.
... La crisis generada por la covid-19 ha obligado a tener que comunicar informaciones difíciles de asimilar a través del teléfono. Para ello, se han adaptado diferentes pautas y protocolos ya existentes a la comunicación a distancia (Baile et al., 2000;Buckman, 1992;Fine, 1991;Rabow & McPhee, 1999), sin tener en cuenta en muchas ocasiones las especificidades, limitaciones y obstáculos de la comunicación telefónica en situación de emergencia. A esto hay que unirle la ausencia de experiencia de algunos profesionales en este tipo de práctica, la falta de formación específica en comunicación telefónica y general en notificación de malas noticias y las situaciones de alta exigencia e impacto emocional vividas. ...
Introducción: La crisis generada por el virus SARS-CoV-2 ha supuesto un gran impacto en el plano sanitario, económico y social. En el ámbito sanitario, las circunstancias excepcionales en las que se han producido muchos fallecimientos han obligado a los profesionales a realizar la comunicación de malas noticias de manera remota a través del teléfono. Objetivo: El presente artículo pretende sintetizar de forma organizada las principales pautas que contribuyen a una comunicación eficaz, permitiendo a los profesionales reducir sus niveles de estrés y lograr una mayor eficiencia a la hora de comunicar un fallecimiento telefónicamente en una situación de emergencia como la actual pandemia. Metodología: Se realizó una revisión con base en la evidencia científica recogida en la bibliografía existente sobre el tema. Se consultaron las bases de datos PubMed, Scopus, y el buscador Google Académico. Resultados: Para comunicar malas noticias, el profesional debe contar tanto con unas buenas habilidades de comunicación, como con un manejo adecuado de unas pautas técnicas básicas de actuación. Conclusión: El uso de pautas con cierto grado de estructura, puede aumentar la eficacia de las comunicaciones de malas noticias a través del teléfono en situaciones de emergencia, maximizando los beneficios tanto para el receptor como para el emisor.
... ▪ difficult news [100][101][102][103] ; ...
Introduction: Communication is an essential competence for the physician and other professional categories, and must be developed their professional training. The creation of a communication project including a Brazilian consensus aimed to subsidize medical schools in preparing medical students to communicate effectively with Brazilian citizens, with plural intra and inter-regional characteristics, based on the professionalism and the Brazilian Unified System (SUS) principles. Objective: The objective of this manuscript is to present the consensus for the teaching of communication in Brazilian medical schools. Method: The consensus was built collaboratively with 276 participants, experts in communication, faculty, health professionals and students from 126 medical schools and five health institutions in face-to-face conference meetings and biweekly or monthly virtual meetings. In the meetings, the participants’ experiences and bibliographic material were shared, including international consensuses, and the consensus under construction was presented, with group discussion to list new components for the Brazilian consensus, followed by debate with everyone, to agree on them. The final version was approved in a virtual meeting with invitation to all participants in July 2021. After the submission, several changes were required, which demanded new meetings to review the consensus final version. Result: The consensus is based on assumptions that communication should be relationship-centered, embedded on professionalism, grounded on the SUS principles and social participation, and based on the National Guidelines for the undergraduate medical course, theoretical references and scientific evidence. Specific objectives to develop communication competence in the students are described, covering: theoretical foundations; literature search and its critical evaluation; documents drafting and editing; intrapersonal and interpersonal communication in the academicscientific environment, in health care and in health management; and, communication in diverse clinical contexts. The inclusion of communication in the curriculum is recommended from the beginning to the end of the course, integrated with other contents and areas of knowledge. Conclusion: It is expected that this consensus contributes the review or implementation of communication in Brazilian medical schools’ curricula.
... 22,23 A number of evidencebased recommendations and guidelines for BBN (e.g. SPIKES or ABCDE 24,25 ) offer training and further education formats that may assist physicians. Before the news delivery, patients' communication preferences can be assessed by applying the Marburg Breaking Bad News Scale (MABBAN), which is a SPIKES-protocol questionnaire. ...
Purpose: Receiving a cancer diagnosis significantly impacts patients’ lives, and how the bad news is delivered influences patients’ trajectory, psychosocial adjustment and openness to psycho-oncological support. We explored how patients’ experiences, reactions and preferences were, when receiving the news and which optimization recommendations can be made.
Methods: We conducted an exploratory qualitative study with patients who enrolled in the new integrated cross-sectoral psycho-oncological care programme ‘isPO’, being enrolled 12 months post-diagnosis. Data on the main issue (i.e. perception of the moment when the diagnosis is received) were collected via telephone interviews that were fully audiotaped and transcribed. Two independent coders conducted inductive content analyses using MAXQDA.
Results: Out of 38 approached patients, 23 cancer patients with 13 different tumour entities participated. They had a mean age of 54.2 (SD 16.2); n = 17 (74%) were female. Three major themes with 14 corresponding subthemes emerged: (1) patients’ experiences with the bad news delivery, including setting, mode, preparation and perceived needs; (2) patients’ reactions to the bad news, such as shock, fear and helplessness, disbelief and denial, anger and feeling of injustice, thankfulness and depression; and (3) patients’ receiving preferences, including psycho-oncological support, addressing informational needs, needs-driven comprehensive support and a competent multidisciplinary support team.
Conclusions: The quality of bad news delivery and addressing patients’ needs should be strongly considered by physicians. We recommend integrating patients’ perspective on the quality management processes of breaking bad news. For providing needs-centred high-quality care, applying existing guidelines and acquiring patient-centred communication skills are central.
Aims
To systematically review and integrate qualitative‐research results pertaining to psychological distress in patients with breast cancer and to clarify its causes and drivers.
Background
Patients with breast cancer experience psychological distress in the stages of diagnosis, treatment, and rehabilitation, which seriously affects their quality of life. Through comprehensive qualitative research, the study comprehensively describes the experiences of patients with breast cancer to guide medical personnel in taking better care of them.
Design
A systematic review and synthesis of qualitative studies.
Methods
Qualitative studies were included if they were related to the psychological‐distress experiences of patients with breast cancer. The Joanna Briggs Institute Qualitative Assessment and Review Instrument was used to appraise study quality. Data were synthesised using the Thomas and Harden method of thematic and content analysis.
Data Sources
Nine electronic databases (PubMed, Embase, Cochrane Library, CINAL [via EBSCO], and PsycINFO, China Knowledge Resource Integrated Database, Wanfang, Chinese Biomedical, and Weipu) were searched from inception until February 2024.
Results
Thirteen studies were included in the meta‐synthesis. Four analytical themes were identified: diagnostic and therapeutic, individual, environmental, and interpersonal factors.
Conclusions
Psychological distress is a subjective feeling influenced by interactions among individual, therapeutic, environmental, and interpersonal factors, and it is commonly encountered among patients with breast cancer. Therefore, to optimise the management of psychological distress, the characteristics and external environment of patients with breast cancer should be carefully considered when delivering routine nursing care.
Impact
Patients experience psychological distress at different stages of breast cancer; however, the causes of psychological distress at different stages differ. Medical staff should implement targeted psychological‐distress intervention measures based on factors relevant to different stages.
Reporting Method
The Enhancing Transparency in Reporting the Synthesis of Qualitative Research statement.
Registration
The protocol of this study has been registered in the database PROSPERO (registration ID: CRD42023417364).
In amyotrophic lateral sclerosis/motor neuron disease (ALS/MND), it is necessary to communicate difficult news during the initial diagnosis and throughout the disease trajectory as the condition progresses. However, delivering difficult news to people with ALS/MND is an emotionally demanding task for healthcare and allied health professionals-one for which many feel ill-prepared because of limited training in this area. Ineffective communication of difficult news damages the patient-provider relationship and negatively impacts patient quality of life (QoL). To address this issue, we developed the A-L S-PIKES protocol based on available literature and our extensive clinical experience. It provides easy-to-follow, stepwise guidelines to effectively deliver difficult news to people with ALS/MND (PALS) that includes: Advance Preparation (preparing for the discussion logistically and emotionally); Location & Setting (creating a comfortable setting that fosters rapport); Patient's Perceptions (assessing PALS' understanding and perception of their condition); Invitation (seeking PALS' permission to share information); Knowledge (sharing information in a clear, understandable manner); Emotion/Empathy (addressing emotions with empathy and providing emotional support); and Strategy & Summary (summarizing the discussion and collaboratively developing a plan of action). A-L S-PIKES provides practical guidelines on how to prepare for and conduct these challenging conversations. It emphasizes effective communication tailored to the individual needs of PALS and their families, empathy, sensitivity, and support for PALS' emotional well-being and autonomy. The aim of A-L S-PIKES is to both enhance skills and confidence in delivering difficult news and to improve the QoL of PALS and their families. Future studies should systematically evaluate the feasibility and effectiveness of A-L S-PIKES to establish its utility in clinical practice.
Background & Aim: Patients’ preferences in breaking bad news to the patients may vary from one culture and society to another. This study aimed to determine patients' preferences for breaking bad news. Methods & Materials: This scoping review study was conducted on the articles published in databases, including Scopus, Web of Science, Proquest, Embase, and Medline (PubMed) up to the end of December 2023. After removing the duplicate results. The titles and abstracts of the articles were reviewed to observe the probable connections with the review question, and the unrelated items were omitted. The original articles, which were published in English entered into the study. The articles that have reported patients’ preferences in emergency settings or parents’ preferences for breaking bad news, were excluded from the study. The textual data were extracted from the remaining articles and then analyzed using conventional content analysis. Results: Fifty-nine studies included in this review about the patients’ preferences were classified into four categories: “the right to know what is happening to them”, “receiving emotional support”, “participating in decision-making”, and “observing the requirements of giving the bad news to the patients”. Nonetheless, there were variations in patients' preferences among different backgrounds. Conclusion: Given the influence of the patient’s background in breaking bad news, the existing solutions in Western communities may not be practical or completely useful for Eastern. The results of this study can be used to observe patients’ preferences in breaking bad news from different backgrounds.
Objectives: This study aimed to investigate knowledge, attitudes, and experiences in sharing unpleasant health information and adherence to the SPIKES protocol among physicians at a tertiary hospital in Muscat, Oman. Methods: This cross-sectional study was conducted at the Sultan Qaboos University Hospital (SQUH) from August to October 2022. An electronic, self-administered questionnaire was used to gather data from 400 physicians across various SQUH departments. Results: A total of 89 physicians completed the questionnaire (response rate: 22.3%). Most (96.6%) recognised the need for additional training in the delivery of unpleasant health updates, with 78.7% expressing their willingness to undertake such training. However, 32.6% reported negative experiences due to improper delivery of bad news, with an equal proportion admitting to disclosing unpleasant updates to the patient’s family without their consent. The majority (86.5%) demonstrated a high level of overall adherence to the SPIKES protocol, with 59.6–85.4%, 12.4–34.8%, and 1.1–11.2% of physicians reported usually, sometimes, and never following specific steps of the protocol, respectively. Marital status (P = 0.015) and qualifications (P = 0.032) were the only variables to correlate with adherence level, with married physicians and those with board or fellowship certificates reporting significantly better adherence compared to their counterparts. Conclusion: Physicians in Oman encountered challenges in delivering unpleasant health updates, underscoring the interplay of cultural influences, training, and adherence to protocols. To address these challenges, targeted and frequent training programs are recommended, starting from undergraduate medical education and extending to continuous opportunities for physicians at various career levels. Keywords: Physician-Patient Relations; Truth Disclosure; Clinical Protocols; Communication; Empathy; Oman.
Objective
The objective of this scoping review was to examine teaching approaches used to teach interprofessional health professional learners how to break bad news collaboratively.
Introduction
When breaking bad news, health professionals must be equipped to deliver it skillfully and collaboratively; however, the literature shows that this skill receives little attention in program curricula. Consequently, health professionals can feel inadequately prepared to deliver bad news, which may lead to increased burnout, distress, and compassion fatigue.
Inclusion criteria
Studies that describe teaching approaches used to teach learners how to break bad news collaboratively were considered for inclusion. Studies must have included 2 or more undergraduate and/or postgraduate learners working toward a professional health or social care qualification/degree at a university or college. Studies including lay, complementary and alternative, or non-health/social care learners were excluded. Due to the primary language of the research team, only English articles were included.
Methods
The JBI 3-step process was followed for developing the search. Databases searched included MEDLINE (Ovid), CINAHL (EBSCOhost), Embase, Education Resource Complete (EBSCOhost), and Social Work Abstracts (EBSCOhost). The initial search was conducted on February 11, 2021, and was updated on May 17, 2022. Title and abstract screening and data extraction were completed by 2 independent reviewers. Disagreements were resolved through discussion or with a third reviewer. Results are presented in tabular or diagrammatic format, together with a narrative summary.
Results
Thirteen studies were included in the scoping review, with a range of methodologies and designs (pre/post surveys, qualitative, feasibility, mixed methods, cross-sectional, quality improvement, and methodological triangulation). The majority of papers were from the United States (n=8; 61.5%). All but 1 study used simulation-enhanced interprofessional education as the preferred method to teach interprofessional cohorts of learners how to break bad news. The bulk of simulations were face-to-face (n=11; 84.6%). Three studies (23.1%) were reported as high fidelity, while the remainder did not disclose fidelity. All studies that used simulation to teach students how to break bad news utilized simulated participants/patients to portray patients and/or family in the simulations. The academic level of participants varied, with the majority noted as undergraduate (n=7; 53.8%); 3 studies (23.1%) indicated a mix of undergraduate and graduate participants, 2 (15.4%) were graduate only, and 1 (7.7%) was not disclosed. There was a range of health professional programs represented by participants, with medicine and nursing equally in the majority (n=10; 76.9%).
Conclusions
Simulation-enhanced interprofessional education was the most reported teaching approach to teach interprofessional cohorts of students how to break bad news collaboratively. Inconsistencies were noted in the language used to describe bad news, use of breaking bad news and interprofessional competency frameworks, and integration of interprofessional education and simulation best practices. Further research should focus on other interprofessional approaches to teaching how to break bad news, how best to incorporate interprofessional competencies into interprofessional breaking bad news education, whether interprofessional education is enhancing collaborative breaking bad news, and whether what is learned about breaking bad news is being retained over the long-term and incorporated into practice. Future simulation-specific research should explore whether and how the Healthcare Simulation Standards of Best Practice are being implemented and whether simulation is resulting in student satisfaction and enhanced learning.
This study aimed to assess whether Spanish hospitals have enhanced their protocols and training for breaking bad news in response to the pandemic. Employing a qualitative approach, the research integrated three tools: in-depth interviews with healthcare professionals, content analysis of medicine curricula from universities in Catalonia and Andalusia, and a literature review of protocols for communicating bad news. The findings revealed a significant increase in the contents and subjects in the communication of bad news within the analyzed curricula due to the pandemic. Additional topics such as technology, emotional management, and humanism were incorporated. While the hospital protocols showed a relatively less pronounced increment, there was evidence of the development of protocols specifically focused on communicating bad news via phone or video calls. In conclusion, the COVID-19 pandemic has brought about changes in the training of doctors, leading to an enriched curriculum despite a more modest increase in hospital protocols.
Whereas most research in AI system explanation for healthcare applications looks at developing algorithmic explanations targeted at AI experts or medical professionals, the question we raise is: How do we build meaningful explanations for laypeople? And how does a meaningful explanation affect user’s trust perceptions? Our research investigates how the key factors affecting human-AI trust change in the light of human expertise, and how to design explanations specifically targeted at non-experts. By means of a stage-based design method, we map the ways laypeople understand AI explanations in a User Explanation Model. We also map both medical professionals and AI experts’ practice in an Expert Explanation Model. A Target Explanation Model is then proposed, which represents how experts’ practice and layperson’s understanding can be combined to design meaningful explanations. Design guidelines for meaningful AI explanations are proposed, and a prototype of AI system explanation for non-expert users in a breast cancer scenario is presented and assessed on how it affect users’ trust perceptions.
One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.
Prehabilitation is a comprehensive preparation of a patient for primarily surgical treatments. Its aim is to improve the patient'sgeneral condition so as to reduce the risk of complications and ensure the fastest possible recovery to full health. Thebasic components of prehabilitation include: improvement of nutritional status, appropriate exercises to improve functioning,psychological support, and help in eliminating addictions. Other important aspects of prehabilitation are: increasinghemoglobin levels in patients with anemia, achieving good glycemic control in patients with diabetes, treatment or stabilizationof any concurrent disorders, or specialist treatment associated with a specific procedure (endoprostheses, ostomyprocedure). This article organizes and outlines the indications for prehabilitation, its scope, duration, and the method to conductit. Experts of various specialties related to prehabilitation agree that it should be an element of surgery preparationwhenever possible, especially in patients with co-existing medical conditions who have been qualified for major procedures.Prehabilitation should be carried out by interdisciplinary teams, including family physicians and various specialists in thetreatment of comorbidities. Prehabilitation requires urgent systemic and reimbursement solutions.
For a long time it was considered bad news when a diagnosis with an unfavorable prognosis had to be communicated to the patient or the relatives, in this case the parents. Delivering bad news about a child’s illness to parents and families and involving the child in the communication process, is a complex and difficult task. The person receiving the news could broadly define bad news as any information that is unexpected and perceived as negative. The question of whether this “bad news” should be delivered by doctors at all arose time and again, as it was assumed that the recipients of the message would lose hope and the will to live, and that children as patients, should not be told anything about the low chances of recovery or even death. This is in many ways a paternalistic intervention, withholding important information from the patient’s family and assuming that children and young people do not have an age-appropriate understanding of health, health-related knowledge and skills, and illness. In this case, one of the main questions seems to be what are “bad news” and what does “breaking bad news” mean, especially for parents, sick children and adolescents? Bad news is first of all pure information for identifying and naming a disease and the associated treatment options; however, the meaning of this information only comes from the people involved, parents, children, doctors and regularly differs in many ways. A strict diet that offers hope from a medical point of view can be disastrous for the family. A prognosis that includes the child’s death can give parents a sense of direction in a situation of child suffering that they can no longer control. How such a message should be delivered, the framework for delivery, and the way in which clinicians should deal with parents are discussed and the implementation is illustrated with case vignettes. Shared decision-making or more generally participatory decision-making, should serve as a model for how doctors can involve children and parents in diagnostic and therapeutic decisions, so that almost all forms of treatment can be designed together. Decision-making for sick children is complex and challenging for parents as well as healthcare professionals. The model of shared decision-making should be more actively implemented in routine care. It takes a long time for patients, parents and professionals, perhaps it takes the total diagnostic and therapeutic process, to learn to communicate, develop trust and make decisions together. In The Lancet, Fallowfield described a reason for further development in this area: when bad news is insensitively broken, the impact can be distressing for both the bringer and the recipient.
Giving bad news is one of the most important yet stressful moments clinicians can experience. Although practical recommendations on how to give bad news are abundant, systematic and evidence‐based research is still lacking on what an effective episode of giving bad news entails and what the outcomes of specific strategies of giving bad news are. This entry first summarizes major communication guidelines on giving bad news and their limitations. Next, this entry presents recent works focusing on conceptualizing giving bad news as a communication process. Last, this entry discusses potential directions of future research on giving bad news.
not available J Shaheed Suhrawardy Med Coll 2021; 13(2): 89-90
Bad news communication is a frequent and difficult task for health care professionals. There are valuable protocols that systematize this task through a series of steps. However, these protocols have important limitations. The objective of this work is to analyze the main shortcomings of the protocols for CMN, according to the available ethical and clinical evidence. An orientation by objectives is recommended, considering that communication of bad news is a contextual process that involves different actors, and that requires reflection and flexibility to determine the best course of action according to the circumstances of each particular case. The importance of affectionate attention for patients and their relatives is highlighted.
In this narrative medicine essay, a resident physician practicing how to deliver bad diagnostic news to patients struck a balance upon learning that authenticity and presence were more important than the exact words he chose.
Stroke is a prevalent neurologic condition that portends a high risk of morbidity and mortality such that patients impacted by stroke and their caregivers can benefit from palliative care at the time of diagnosis and throughout the disease trajectory. Clinicians who care for stroke patients should be adept at establishing rapport with patients and caregivers, delivering serious news, responding to emotions, discussing prognosis, and establishing goals of care efficiently in an acute stroke setting. Aggressive stroke care can be integrated with a palliative approach to care that involves aligning the available treatment options with a patient's values and goals of care. Reassessing the goals throughout the hospitalization provides an opportunity for continued shared decision-making about the intensity of poststroke interventions. The palliative needs for stroke patients may increase over time depending on the severity of disease, poststroke complications, stroke-related symptoms, and treatment intensity preferences. If the decision is made to transition the focus of care to comfort, the support of an interdisciplinary palliative care or hospice team can be beneficial to the patient, family members, and surrogate decision makers.
Objective:
Truth-telling in oncology is a major challenge, particularly in the absence of disclosure protocols in Egypt and the lack of Egyptian studies examining patients' preferences regarding cancer disclosure. This study aimed to reveal the preferences of patients seeking care at the National Cancer Institute - Cairo University regarding disclosing cancer diagnosis and the type and amount of information to be told.
Methods:
This cross-sectional study was conducted on 200 patients selected consecutively from those attending the outpatient clinics of the National Cancer Institute - Cairo University. Face-to-face interviews were performed with the patients according to a structured questionnaire. The questionnaire consisted of five parts: socio-demographic characteristics, knowledge about cancer disease, attitudes towards cancer disease, experience during the disclosure of the diagnosis, and preferences regarding disclosure of cancer diagnosis.
Results:
Most patients (89.5%) preferred to know the diagnosis. Of them, 94.4% wished to know from the physician. No agreement was found between most patients' preferences and physicians' practice. On multivariate logistic regression analysis, patients' education was the only significant predictor of the preference to know the diagnosis (OR = 5.298, 95% CI = 1.258 - 22.301, P = 0.023).
Conclusion:
Patients have a great desire to know the diagnosis and other information related to treatment and prognosis.
Background:
This study aimed to characterize the barriers faced by Brazilian dentists to deliver bad news (DBN) about oral and oropharyngeal cancer diagnoses to patients by using a questionnaire based on the guidelines of the SPIKES protocol.
Material and methods:
This was an observational cross-sectional study. The questionnaire contained 27 questions based on the SPIKES protocol, which were answered in the SurveyMonkey platform.
Results:
A total of 186/249 dentists answered the questionnaire. The main specialties reported were 36.02% oral medicine, 21.5% oral pathology, and 9.13% oral and maxillofacial surgery. A total of 44.6% expressed concern about the patient's emotional reactions, and 46.24% of respondents had never participated in any specific training to communicate bad news.
Conclusions:
The lack of training and low confidence in dealing with patients' emotional reactions dentists were considered the greatest barriers to DBNs. Moreover, most dentists who participated in the survey believe that a protocol to guide the communication of bad news would be useful for clinical practice. For those protocols to be used by dentists, training is critical for these protocols to be incorporated by professionals.
The diagnosis of type 2 diabetes initiates a new health-illness transition. However, little is known about the immediate support that people need to successfully cope with this diagnosis. This qualitative study explored the experiences and immediate support needed at the point of diagnosis among individuals with type 2 diabetes. The findings suggest the need for health care professionals to render immediate emotional support in the form of reassurance and partnership to manage the condition together. Pre- and post-counseling sessions can minimize the emotional and psychological strain associated with the new diagnosis. Individuals should be given information on available resources, as well as an immediate connection with a health care partner who can provide guidance and help with the transition.
Resumo: Introdução: A comunicação é uma competência essencial para o(a) médico(a) e outras categorias profissionais, e deve ser desenvolvida durante sua formação profissional. A elaboração de um projeto de comunicação, incluindo um consenso brasileiro, visou subsidiar as escolas médicas a preparar os estudantes de Medicina para se comunicarem efetivamente com os(as) cidadãos/cidadãs brasileiros(as), de características plurais intra e inter-regionais, pautando-se no profissionalismo e nos princípios do Sistema Único de Saúde (SUS). Objetivo: Este manuscrito apresenta o consenso para o ensino de comunicação nas escolas médicas brasileiras. Método: O consenso foi construído colaborativamente com 276 participantes, experts em comunicação, docentes, profissionais de saúde e discentes, de 126 escolas médicas e cinco instituições de saúde, ao longo de nove encontros presenciais em congressos e de encontros virtuais quinzenais ou mensais. Nos encontros, compartilharam-se as experiências dos participantes e o material bibliográfico, incluindo os consensos internacionais, e apresentou-se o consenso em construção, com discussão em grupos para elencar novos componentes para o consenso brasileiro, seguida por debate com todos para pactuá-los. A versão final foi aprovada em reunião virtual, com convite a todos(as) os(as) participantes em julho de 2021. Após submissão, diversas alterações foram requeridas, o que demandou novos encontros para revisão da versão final do consenso. Resultado: O consenso tem como pressupostos que a comunicação deve ser centrada nas relações, pautada nos princípios do SUS, na participação social e no profissionalismo, e embasada nas Diretrizes Curriculares Nacionais do curso de graduação em Medicina, em referenciais teóricos e nas evidências científicas. São descritos objetivos específicos para desenvolver a competência em comunicação nos estudantes, abrangendo: fundamentos teóricos; busca e avaliação crítica da literatura; elaboração e redação de documentos; comunicação intrapessoal e interpessoal no ambiente acadêmico-científico, na atenção à saúde em diversos contextos clínicos e na gestão em saúde. Recomenda-se a inserção curricular da comunicação do início ao final do curso, integrada a outros conteúdos e áreas de saber. Conclusão: Espera-se que esse consenso contribua para a revisão ou implementação da comunicação nos currículos das escolas médicas brasileiras.
Prognosticating is central to primary palliative care in neurology. Many neurologic diseases carry a high burden of troubling symptoms, and many individuals consider health states due to neurologic disease worse than death. Many patients and families report high levels of need for information at all disease stages, including information about prognosis. There are many barriers to communicating prognosis including prognostic uncertainty, lack of training and experience, fear of destroying hope, and not enough time. Developing the right mindset, tools, and skills can improve one's ability to formulate and communicate prognosis. Prognosticating is subject to many biases which can dramatically affect the quality of patient care; it is important for providers to recognize and reduce them. Patients and surrogates often do not hear what they are told, and even when they hear correctly, they form their own opinions. With practice and self-reflection, one can improve their prognostic skills, help patients and families create honest roadmaps of the future, and deliver high-quality person-centered care.
The loss of teeth affects the aesthetics, function (mastication and speech), confidence, mental state, and the overall quality of life of an individual. Aggressive periodontitis is a destructive condition leading to loss of teeth at early stages of the disease. Individuals facing this inevitable condition of losing the teeth and replacement at a younger age experience formidable psychological distress. The prosthodontic procedure when supported with psychotherapeutic interventions can support the patient in accepting the prognosis and treatment. We report the scenario where psychological intervention was provided in a systematic manner adopting the SPIKES protocol for a 42-year-old man presenting with aggressive periodontitis.
To determine parent's views on how death of their children should have been handled.
Retrospective questionnaire survey of parents who had experienced death of their child.
Charitable organisation of bereaved parents.
150 bereaved parents, all members of the organisation, of whom 120 (80%) participated voluntarily in the study.
Child's age; date and cause of death; details of person breaking the news and handling of the interview; time parents spent with dead child, their attitude to requests for organ donation, and follow up support received.
122 children's deaths were described; the largest single group was due to road traffic accidents, 16 were suicides, and eight were murders. Twice as many interviews were rated as sympathetically or reasonably handled as badly or offensively handled (68 v 34). The interview ratings depended on the sensitivity and personal skills of the interviewers rather than on their previous contact or professional position; police were rated as more sympathetic than doctors and nurses. Of 109 respondents, 81 had seen their child's body, 44 of whom thought that sufficient time had been denied. Of the 28 parents who did not see the body, 17 subsequently stated their regret. In 82 parents organ donation had not been discussed. Only 16 parents recorded any follow up support from hospital staff and very few support at the time.
The consistency of the responses suggests a serious need to revise the in service training and education of the police and health professionals in their approach to informing of death; organ donation should be discussed sensitively and parents allowed time with their dead child with fewer restrictions.
Recognition of psychological distress in patients with cancer, some of which can be ameliorated with appropriate intervention, is a crucial aspect of patient care. Previous studies, with the exception of one, indicate that oncologists often fail to detect general distress and do not identify those patients with significant psychological disorder. As approximately 25-30% of patients experience anxiety and/or depression severe enough to merit psychological intervention, this is a serious problem. This study assessed the ability of five oncologists to recognise distress in newly referred out-patients who were receiving bad news. Self-report measures of the oncologists' satisfaction with their performance during the bad news interviews were also collected. Each patient had two clinical interviews in which information concerning diagnosis and treatment were given. Prior to each interview patients reported their own levels of distress by completing two self-report questionnaires. These were correlated with the ratings of distress and satisfaction made by each clinician on a visual analogue scale after each interview. Only one oncologist's ratings consistently correlated with patients' self-reported scores. The clinicians tended to under-rate the distress in their patients and were mostly satisfied with their performances during each interview. The ability to detect distress varied between each clinician and confirmed the conclusions of past studies that oncologists would benefit from up-grading their psychological assessment skills.
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.
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.
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.
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.
To assess the level of residents' competence in delivering bad news to patients.
In June 1995, 25 residents (of 116) in the Wayne State University general internal medicine residency program volunteered to participate in the study, which consisted of videotaped interviews of a simulated patient whose profile had been developed to highlight the delivery of a diagnosis of lung cancer. The residents were evaluated using an instrument based on a review of the current literature regarding the skills considered necessary for giving bad news in a caring and informative manner. The instrument contained 16 items, seven in the informative category and nine in the affective category. Each item was rated on a five-point Likert scale (from 1 = "doesn't do this" to 5 = "does this very well"). A rating of > or = 4 on any item indicated competence in the skill area measured by that item. All interviews included in the study were rated by all six of the authors. Interrater reliability was calculated to be .91.
In all, 22 interviews (three by women, 19 by men) were included in the study. The residents' ages ranged from 26 to 35 years; the numbers of years since graduation from medical school ranged from two to six. Twenty were third- or fourth-year residents ready to graduate; the other two were completing their first year. Mean ratings in the informative category ranged from 1.51 to 4.51; for three items, mean ratings were > or = 4. The total mean rating for all the items in this category was 3.42. Mean ratings in the affective category ranged from 1.15 to 4.75; for three items, mean ratings were > or = 4. The total mean rating for all the items in this category was 3.45.
The residents showed a general lack of competence in delivering bad news. The skill items with the lowest ratings were primarily related to eliciting the patient's perspective, which may represent a weakness on the part of the residency program in teaching the residents to use a "patient-centered" interviewing style. The results of this study will form the basis of a curriculum to improve residents' comfort with and skills for delivering bad news to patients.
Nonpharmacological treatments with little patient cost or risk are useful supplements to pharmacotherapy in the treatment of patients with chronic illness. Research has demonstrated that writing about emotionally traumatic experiences has a surprisingly beneficial effect on symptom reports, well-being, and health care use in healthy individuals.
To determine if writing about stressful life experiences affects disease status in patients with asthma or rheumatoid arthritis using standardized quantitative outcome measures.
Randomized controlled trial conducted between October 1996 and December 1997.
Outpatient community residents drawn from private and institutional practice.
Volunteer sample of 112 patients with asthma (n = 61) or rheumatoid arthritis (n = 51) received the intervention; 107 completed the study, 58 in the asthma group and 49 in the rheumatoid arthritis group.
Patients were assigned to write either about the most stressful event of their lives (n = 71; 39 asthma, 32 rheumatoid arthritis) or about emotionally neutral topics (n = 41; 22 asthma, 19 rheumatoid arthritis) (the control intervention).
Asthma patients were evaluated with spirometry and rheumatoid arthritis patients were clinically examined by a rheumatologist. Assessments were conducted at baseline and at 2 weeks and 2 months and 4 months after writing and were done blind to experimental condition.
Of evaluable patients 4 months after treatment, asthma patients in the experimental group showed improvements in lung function (the mean percentage of predicted forced expiratory volume in 1 second [FEV1] improved from 63.9% at baseline to 76.3% at the 4-month follow-up; P<.001), whereas control group patients showed no change. Rheumatoid arthritis patients in the experimental group showed improvements in overall disease activity (a mean reduction in disease severity from 1.65 to 1.19 [28%] on a scale of 0 [asymptomatic] to 4 [very severe] at the 4-month follow-up; P=.001), whereas control group patients did not change. Combining all completing patients, 33 (47.1%) of 70 experimental patients had clinically relevant improvement, whereas 9 (24.3%) of 37 control patients had improvement (P=.001).
Patients with mild to moderately severe asthma or rheumatoid arthritis who wrote about stressful life experiences had clinically relevant changes in health status at 4 months compared with those in the control group. These gains were beyond those attributable to the standard medical care that all participants were receiving. It remains unknown whether these health improvements will persist beyond 4 months or whether this exercise will prove effective with other diseases.
We have been closet Cartesians in modern medicine, treating the mind as though it were reactive to but otherwise disconnected from disease in the body. Although medical science has productively focused on the pathophysiology of disease, such as tumor biology, coronary artery disease, and immunology, it has done so at the expense of studying the body's psychophysiological reactions to these disease processes. These reactions are mediated by brain and body mechanisms, including the endocrine, neuroimmune, and autonomic nervous systems. While a large portion of the variance in any disease outcome is accounted for by the specific local pathophysiology of that disease, some variability must also be explained by host resistance factors, which include the manner of response to the stress of the illness. For example, in a series of classic experiments in animals, Riley¹,2 showed that crowding accelerated the rate of tumor growth and mortality. In a recent authoritative review of human stress literature, McEwen³ documented the adverse health effects of cumulative stressors and the body's failure to adapt the stress response to them. Activation of the hypothalamic-pituitary-adrenal axis (HPA) is an adaptive response to acute stress, but over time, in response to cumulative stress, the system's signal-to-noise ratio can be degraded, so that it is partially "on" all the time, leading to adverse physiological consequences, including abnormalities of glucose metabolism,⁴ hippocampal damage,⁵ and depression.⁶,7
The narrative from a real patient encounter is used to illustrate the powerful effect that delivering bad news can have on both patient and physician. The meaning of bad news to the patient may be quite different than the medical or the personal meaning to the physician. Differences in perception must be explored and understood before the common ground necessary for joint decision making is established. Initial patient responses can be divided into three categories: (1) basic psychophysiologic (fight-flight or conservation-withdrawal), (2) cognitive, and (3) affective. Responses vary considerably depending on the meaning of the diagnosis to the patient, the degree of immediate threat, and the patient's previous experience with illness. Desired outcomes of the initial meeting include (1) minimizing aloneness and isolation for both patient and physician; (2) achieving a common perception of the problem; (3) giving information tailored to the immediate needs of the patient; (4) addressing immediate medical needs, including the risk of suicide; (5) responding to immediate discomforts; and (6) ensuring a basic plan for follow-up. Though all clinicians deliver bad news, few have had formal training or open exploration of the profound potential impact of the experience.
Physicians do not receive from the medical model the same explicit guidance in relating to their patients as in making diagnoses and prescribing pharmacologic and other treatments. To meet this need, we offer a framework for expanding the model. Therapeutic contact takes place within a connexional, or transpersonal, dimension of human experience, within which basic human needs for connection and meaning are met. Although seldom explicitly recognized, connexional experience is basic to medical care. Awareness of this dimension of experience leads clinicians to appreciate that establishing a therapeutic relationship is one of the principal goals of medical practice. It also reframes the doctor's task to make clinical uncertainty more tolerable and situations in which there is no appropriate biomedical response (such as care of the terminally ill) less frustrating and more fulfilling.
A British senior registrar in medical oncology discusses the major difficulties encountered by physicians in disclosing unfavorable diagnoses and prognoses to patients. These difficulties are attributed to an unwarranted assumption by the physician of responsibility for the disease itself; to fears arising from personal reactions to illness, death, and expression of emotions; and to a lack of training in coping with the nonmedical aspects of serious illness. The author suggests that, with only minor changes in the curriculum, instruction in communication can be integrated into orthodox medical education.
The question of suffering and its relation to organic illness has rarely been addressed in the medical literature. This article offers a description of the nature and causes of suffering in patients undergoing medical treatment. A distinction based on clinical observations is made between suffering and physical distress. Suffering is experienced by persons, not merely by bodies, and has its source in challenges that threaten the intactness of the person as a complex social and psychological entity. Suffering can include physical pain but is by no means limited to it. The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick. Physicians' failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself.
PURPOSE AND DESIGN: One of the more difficult tasks that clinicians must perform as part of their care of patients is that of conveying bad news, such as a severe diagnosis or death. However, there is a paucity of empirically founded information that relates to the specific steps for breaking bad news. We report on a set of guidelines for breaking bad news that was developed using a consensus process and incorporates the views of medical oncologists, general practitioners, surgeons, nurse consultants, social workers, clergy, human rights representatives, cancer patients, hospital interns, and clinical directors of medical schools in Australia. RESULTS AND CONCLUSION: It is recommended that further research be undertaken in a number of areas. First, there is a need to assess patients' versus providers' perceptions of the importance of each of the steps in breaking bad news, in order to define criteria for minimal levels of competence in this area. Second, controlled trials are needed to assess the effectiveness of the guidelines in changing clinical practice, and to identify the most effective strategies for breaking bad news to patients.
Nonabandonment is one of a physician's central ethical obligations; it reflects a longitudinal commitment both to care about patients and to jointly seek solutions to problems with patients throughout their illnesses. The depth of this commitment may vary depending on the physician's and the patient's values and personalities, their shared experiences, and the patient's clinical circumstances. Traditional principled ethical analyses must balance the personal histories, values, motivations, and intentions of the participants with more general considerations. Such analyses often focus on a particular act, isolated in time, and yet the consequences of one decision immediately lead to a new set of choices. Nonabandonment places the physician's open-ended, long-term, caring commitment to joint problem solving at the core of medical ethics and clinical medicine. There is a world of difference between facing an uncertain future alone and facing it with a committed, caring, knowledgeable partner who will not shy away from difficult decisions when the path is unclear.
In Reply.
—Drs Honig and Weiner succinctly summarize the concept that aging itself does not cause physical and intellectual decline. Presumably, these declines are the result of undiagnosed or undiagnosable disease. This belief, which was explored with insight and wit by Goodwin,1 is no longer tenable unless one is willing to reject more than a decade of careful clinical and basic science research, much of which is referenced in my article. Despite the belief that a centenarian who remains entirely healthy should be as physically and intellectually functional as he or she was 50 or 80 years earlier, millennia of careful observations of the process of aging (and, at the risk of being too imprecise, common sense) indicate otherwise. Unfortunately, there are no persuasive data to contradict the observations that decline precedes a natural death and that death eventually comes to all, whether healthy or ill. If there were
Although there has been a dramatic increase in education about death and dying in medical school curricula, the physician's interaction with terminally ill patients and their families still causes concern. The purpose of our study was to determine the impact of the third-year clerkship on education of medical students about death and dying.
From August 1, 1988, to August 1, 1990, a questionnaire concerning the care of terminally ill patients was distributed to all students completing the third-year clinical clerkship at our medical school.
One hundred and eighty questionnaires were distributed, of which 106 were returned, yielding a response rate of 59%. All students had cared for a terminally ill patient during their third year. Forty-four (41%) students responding had never been present when an attending physician talked with a dying patient, and 37 (35%) had never discussed with an attending physician how to deal with a terminally ill patient. During the surgical clerkship 77 (73%) students had never been present when a surgeon had to tell the family of a patient bad news after surgery, and 90 (85%) had never been present when an attending surgeon had informed a family that their relative had died. Despite the fact that the curriculum addresses the stages of death and dying, almost half of the students could not remember these. When they were discharging a terminally ill patient home, one third of students could not identify problems that would be encountered by the family in caring for the patient.
Fifty-seven (54%) felt that they were poorly equipped to deal with terminally ill patients on graduation from medical school, and 91% welcomed the opportunity to be educated in this area during the clinical years.
Healers must try to understand what the illness means to the patient and create a therapeutic sense of connection in the patient-clinician relationship. A favorable climate for "connexional" experiences can be created through the use of various interviewing techniques. Attending to rapport, silencing internal talk, accessing unconscious processes, and communicating understanding can help clinicians enhance their sensitivity to the subtle clues on which issues of meaning and connection often depend. Several risks are associated with the establishment of closer patient-clinician relationships, including dependence and power issues, sexual attraction, and deeper exposure of the clinician to the patient's pain. Prepared with an awareness of these risks and techniques to address them, clinicians are encouraged to deepen their level of dialogue with patients, to compare their experiences with those of other clinicians, and to thereby develop a more systematic understanding of therapeutic relationships.
Encountering a patient who is suffering in the midst of terminal illness is an all-too-common occurrence for clinicians who care for the elderly. This article explores the personal experience of suffering in the context of life-limiting illness. The concept of personhood is used to illuminate the nature of suffering. Clinical observation documents that some persons experience a subjectively heightened sense of well-being as they die. The concept of personhood and the model of life-long human development is applied to the explication of this apparent paradox, enabling an understanding of the nature of opportunity at the end of life.
We have been closet Cartesians in modern medicine, treating the mind as though it
were reactive to but otherwise disconnected from disease in the body.
Although medical science has productively focused on the
pathophysiology of disease, such as tumor biology, coronary artery
disease, and immunology, it has done so at the expense of studying the
body's psychophysiological reactions to these disease processes. These
reactions are mediated by brain and body mechanisms, including the
endocrine, neuroimmune, and autonomic nervous systems. While a large
portion of the variance in any disease outcome is accounted for by the
specific local pathophysiology of that disease, some variability must
also be explained by host resistance factors, which include the manner
of response to the stress of the illness. For example, in a series of
classic experiments in animals, Riley1- 2 showed that
crowding accelerated the rate of tumor growth and mortality. In a
recent authoritative review of human stress literature,
McEwen3 documented the adverse health effects of cumulative
stressors and the body's failure to adapt the stress response to them.
Activation of the hypothalamic-pituitary-adrenal axis (HPA) is an
adaptive response to acute stress, but over time, in response to
cumulative stress, the system's signal-to-noise ratio can be degraded,
so that it is partially "on" all the time, leading to adverse
physiological consequences, including abnormalities of glucose
metabolism,4 hippocampal damage,5 and
depression.6- 7
Here and now: living in the spirit
- Hjm Nouwen
Nouwen HJM. Here and now: living in the spirit.
New York: Crossroads; 1994.
The naturalness ofdying
- Jd Mccue
McCue JD. The naturalness ofdying. JAMA
1995;273:1039-1043.
Man's search for meaning
- Ve Frankl
Frankl VE. Man's search for meaning. Boston (MA):
Beacon Press; 1959.
14 Byock IR The nature ofsuffering and the nature of opportunity at the end of life
14 Byock IR The nature ofsuffering and the nature of
opportunity at the end of life. Clin Geriatr Med
1996; 12:237-252.