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How should doctors communicate the diagnosis of cancer to patients?
Annals of Medicine
Abstract
The majority of doctors in North America, Australia and much of Europe now inform patients about a cancer diagnosis. However, many doctors report that they have difficulty disclosing a cancer diagnosis. Poor doctor-patient communication skills may lead to psychological distress including increased anxiety and depression and poorer psychological adjustment to cancer. Presenting 'bad' news in an unhurried, honest, balanced and empathic fashion has been shown to produce greater satisfaction with communication of the news. Consensus guidelines have been developed to assist doctors to disclose a cancer diagnosis. Important aspects include exploring the patient's expectations, warning him/her that the news is bad, giving the news at the patient's own pace, allowing time for the patient to react and eliciting the patient's concerns. Doctor-patient communication can be improved by including training courses in communication skills for medical students and clinicians and providing audiotapes of bad news consultations to enhance patient recall of information and increase patient satisfaction with communication. Additional research is needed to investigate effects of strategies to implement guidelines for delivering a cancer diagnosis.
... A consensus panel of health professionals and cancer patients from Australia developed the first consensus guidelines for delivering a cancer diagnosis, which were published in 1995. These guidelines suggest 13 steps: (1) have a private and comfortable place; (2) ensure adequate time during the first consultation; (3) assess the patient's understanding; (4) provide straightforward information and repeat it; (5) encourage the patient to express feelings; (6) respond to the patient's feelings with empathy (touch the hand, for example); (7) give a broad time frame for prognosis; (8) give realistic treatment aims; (9) schedule a next consultation to review the situation; (10) discuss treatment options; (11) offer assistance in breaking bad news to others; (12) provide information about supportive organizations (for example, cancer patient association); (13) write the information in a document that can be sent to other specialists [16]. ...
... The importance of empathy in physician-doctor communication has been widely demonstrated. Patients who receive bad news in an unhurried and empathetic manner report greater satisfaction, less emotional distress and better overall adjustment to cancer [12]. To express empathy, physicians can use sentences that give the patient the feeling of being understood, for example: "I understand you're suffering", "I can imagine what you are going through", "I can see things from your perspective", and "This must be difficult for you." ...
... Physicians' acquisition of effective communication skills benefits patients as well, allowing them to better adjust to the disease [12,22]. Conversely, patients who were unhappy about how their diagnosis was communicated (mainly due to a lack of empathy from the doctor) were more likely to demonstrate long-term maladjustment [12,52]. ...
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.
... The way bad news is broken can have a profound effect on improving patients' compliance with treatment, may lead to a clearer understanding of instructions or symptoms, may help reduce stress and anxiety, and improve overall patient satisfaction. [4][5] On the other hand, delivered inappropriately or insensitively, bad news may exert a lasting impact on the ability to adapt and adjust, whilst also inviting the risk of litigation. 6 Inappropriate delivery of unfavourable news includes usage of unfamiliar medical jargon or giving scanty information. ...
... 3 In recent decades there has been a dramatic shift towards disclosure of cancer diagnosis in Western Countries, especially in North America, Australia and most of Europe. 5 The previous paternalistic attitude favouring concealment in order to protect the patient has become overshadowed by the growing importance of safeguarding patient autonomy. 7 Patients are considered to have a moral and legal right to receive accurate and reliable information, and it remains the doctor's responsibility to deliver the diagnosis accurately and explain treatment options clearly. ...
... The questionnaire delivered to patients was bipartite, consisting of the Measure of Patient Preferences (MPP) Questionnaire and the Control Preferences Scale (CPS). The thirty-two-item MPP, scored on a fivepoint scale (1)(2)(3)(4)(5) and initially developed in the United States by Parker et al., was used to assess preferences for characteristics of the bad news encounter. Preferences relate to three aspects: 'facilitation' -the setting in which the news is delivered; the 'content' of the message; and the 'support' offered. ...
It is unclear among Maltese physicians whether cancer patients wish to know their diagnosis. The aim was to assess Maltese patients' preferences for receiving a cancer diagnosis and being involved in their treatment, and then compare with results from similar international studies. 199 Maltese adult patients with a diagnosis of malignancy of >1 month completed 2 standardised tools: the Measure of Patients' Perspective (MPP), a 32-item tool assessing patient's preferences for being given news about their cancer, and the 2-item Control Preferences Scale (CPS) assessing patients' involvement in the decision-making process. Patients rated characteristics of the information, context and support given, on a scale from 1-5 for the MPP, and their involvement in treatment decisions, from A-E, for the CPS. Demographic and medical data were collected. T-tests, one-way ANOVA and post-hoc analysis were used. Patients rated the 'content' subscale (mean 4.17, CI 4.08-4.25, SD 0.59) as significantly more important (p=0.047) than 'support' (mean 3.73, CI 3.63-3.83, SD 0.68) and 'facilitation' (mean 3.86, CI 3.76-3.96, SD 0.68). On the CPS, although there is a trend away from a passive role, patients still exhibit a paternalistic attitude towards their physician. Patients with higher levels of education had significantly higher scores for 'content' (p=0.018) and 'facilitation' (p<0.001) on the MPP, as well as for choice of role on the CPS (p=0.036). In conclusion, Maltese cancer patients want to be informed of their cancer diagnosis, its treatment and its prognosis, with results similar to those from international studies, though a good proportion (60%) prefer to leave treatment decisions to the physician.
... Relapse has been identified as the most stressful message, because it could signal the terminal phase [84]. The fear of being blamed for the message, the fear of facing personal illness and death [85] and a sense of powerlessness at losing words to express one's feelings may be present [86]. To regain control, the strategy of developing expertise is known to be one way of improving the oncologist's self-esteem and tackling the tasks as challenges is another way of reformulating the disease and its consequences into soluble problems [87]. ...
... Patientdoctor communication, building a relationship, is regarded by the parents of terminally ill children as a principal determinant of high-quality physician care and, when appropriate, it also allows for communication directly with the child [88]. This method has mostly been practiced by physicians in western countries [85,89]. A direct approach, talking about the cancer diagnosis and death with the child or the adolescent, presupposes cultural sensitivity [83,90], although studies of parents whose child is undergoing treatment for cancer [88] and parents who have experience of losing a child to cancer [91] emphasize openness and talking. ...
... The physicians' sense of powerlessness could be described as a medical and psychological problem and, the physician is lost for words to express his/her feelings [86]. The fear of being blamed for the message and the fear of facing personal illness and death may even be present [85]. To regain control, the strategy of developing expertise is known to be one way of improving the oncologist's self-esteem [87]. ...
... complex medical information and a significant emotional burden, all of which necessitate clear, empathetic, and individualized communication from healthcare providers [2,3]. When communication is successful, it can empower patients to actively participate in their care, cope with their illness, and maintain hope [4]. ...
... In recent years, there has been a growing recognition of the importance of patientcentered communication in cancer care [1][2][3][4][5][6][7]. This approach emphasizes active listening, empathy, and shared decision-making, where patients are viewed as partners in their care rather than passive recipients of treatment [8]. ...
Background and Objectives: Effective communication in oncology is crucial, but challenging due to the complex information and emotional burden associated with a cancer diagnosis. This cross-sectional study investigated the communication preferences of 155 Romanian adults diagnosed with ENT cancers and explored the relationship between these preferences, their levels of psychological distress, and sociodemographic factors. Materials and Methods: Participants completed the KOPRA questionnaire, assessing communication preferences, and the Hospital Anxiety and Depression Scale (HADS) to measure psychological distress. Results: The results revealed that patients strongly prioritized active involvement in their care (Patient Participation and Patient Orientation—PPO) and open communication with healthcare providers (Effective and Open Communication—EOC). While emotional support was valued, it was considered less critical than PPO and EOC. Notably, communication about personal matters was deemed the least important aspect of communication. A high prevalence of psychological distress was observed, particularly among widowed individuals and females. No direct correlation was found between communication preferences and distress. Conclusions: These findings underscore the importance of shared decision-making, clear information exchange, and a patient-centered approach in the context of ENT cancer care, while also highlighting the need for routine screening and appropriate support for psychological well-being in this patient population.
... An article by Elis and colleagues outlines general principles for communicating cancer diagnoses to patients. 21 One of the principles includes making sure every attempt to communicate the bad news in person. In our respondents who selected "yes -rarely" or "no," we did not inquire when and how the results were conveyed. ...
... However, the ability of the patient to independently access results and discover they have cancer underscores inconsistencies with current principles of breaking bad news to patients. 21 In our study, scheduling conflicts and availability of cytology were frequently reported as barriers to ROSE utilization. A pathway for noncytology-trained ROSE reading may mitigate these barriers and increase utilization. ...
Background
Rapid on‐site evaluation (ROSE) is frequently used during diagnostic procedures in patients with or suspected to have lung cancer. There is variation in ROSE use among bronchoscopists, and discussion of ROSE results can have significant consequences for patients. This study was performed to define ROSE practice and result disclosure patterns among bronchoscopists.
Methods
This cross‐sectional study was performed using an electronic survey disseminated to the members of the American Association for Bronchology and Interventional Pulmonology and the Society for Advanced Bronchoscopy. The questions centered around ROSE availability, utilization, barriers, and discussion of results with patients.
Results
There were 137 respondents. Most identified themselves as interventional pulmonologists (109, 80%); most respondents worked in an academic setting (71, 52%). Availability of ROSE was reported by 121 (88%) respondents. Time constraints (28%), availability of cytology (22%), and scheduling conflicts (20%) were the most reported barriers to ROSE use. Endobronchial ultrasound transbronchial needle aspiration (85%) and nonrobotic peripheral bronchoscopy (65%) were the most reported procedures that used ROSE. There was heterogeneity regarding discussion of ROSE results with the patient or their caregiver in the immediate postprocedure setting: yes ‐ always (40, 33%), yes ‐ sometimes (32, 26%), yes ‐ rarely (18, 15%), or no (31, 26%). Thirty‐eight respondents reported they believed ROSE was ≥90% concordant with final cytology results.
Conclusions
The results confirmed the heterogeneity of practice patterns. Estimates of ROSE‐final cytology concordance were lower than previously published concordance results. Notably, the discussion of ROSE results varied significantly.
... Previous studies have indicated that physician and patient communication regarding news about a life-threatening cancer diagnosis and subsequent treatment options should be done face-to-face and in person, since this form of communication is considered more compassionate in terms of psychosocial context [37][38][39][40]. Loss of non-verbal communication, such as body language and facial expressions, makes it difficult for physicians to show empathy and support, which is important to patients when receiving bad news [41,42]. ...
... Previous studies suggested that the presence of a family member who is able to be present to provide emotional support when the patient received bad news is very important and affects health outcomes, including cancer outcomes [37,39,[46][47][48][49]. In our study, half of the patients reported that a family member, friend, or relative was able to join them during the telemedicine visit. ...
Background and Aims
A rapid increase in the use of telemedicine for delivering healthcare has occurred since the onset of the Covid-19 pandemic. There is evidence for using telemedicine to facilitate cancer care delivery for patients with hepatocellular carcinoma (HCC). Examining how telemedicine can be used to communicate multidisciplinary tumor board (MTB) recommendations for HCC has not been studied. This study has two specific aims: (1) to evaluate the patient perspective of the MTB review process and identify best strategies for communicating treatment recommendations for HCC and (2) to pilot test a telemedicine intervention following MTB review to assess patient feasibility and satisfaction with using telemedicine to facilitate treatment decision-making and treatment referral.
Methods
We conducted a mixed-methods study. First, semi-structured qualitative interviews were conducted among patients diagnosed with HCC who were discussed in MTB review at one of three VA Medical Centers (VAMC). We collected information about the MTB process from the patient perspective and identified strategies for improving communication and delivery of care. Rapid qualitative analysis was used to inform intervention development. Using our qualitative data, a MTB telemedicine pilot intervention was developed and implemented to assess the feasibility of using this approach for patients with HCC.
Results
Almost all patients (94%) in the pilot study would recommend telemedicine to other patients with HCC, and half of the patients (50%) preferred telemedicine over in-person visits. Many patients (81%) found communication through telemedicine an acceptable platform to deliver difficult cancer information. Overall, patients felt they understood their treatment recommendations and found them clear and useful. Further, patients reported that they enjoyed being included in the decision-making process and appreciated being able to have family members easily join them for the telemedicine visit.
Conclusions
Using telemedicine to communicate treatment recommendations following MTB review was found to be feasible and an acceptable alternative to an in-person visit for patient with HCC. Future studies could include expanding this approach for communicating MTB recommendations to patients with other types of cancers.
... Unfortunately, the field of oncology is riddled with bad news, ranging from disclosure of a diagnosis, through treatment failure, to the recurrence of disease and end-of-life issues. The way bad news is broken can have a profound effect on improving patients' compliance with treatment, may lead to a clearer understanding of instructions or symptoms, help reduce stress and anxiety, and improve overall patient satisfaction (Parker et al. 2001;Ellis and Tattersall 1999). ...
... In recent decades there has been a dramatic shift towards disclosure of a diagnosis of cancer in Western Countries, especially in North America, Australia and most of Europe (Ellis and Tattersall 1999). The previous paternalistic attitude favouring concealment in order to protect the patient has become overshadowed by the growing importance of safeguarding patient autonomy (Salander 2002). ...
This chapter discusses blurred boundaries in home care at the end of life. Firstly, an overview of support structures for informal caregivers, i.e. family and friends, in Germany, Switzerland and the United Kingdom is provided. From the perspective of Care Ethics, three blurred boundaries are identified: 1. between being an informal caregiver and a non-caregiving close person, 2. between formal/professional and informal caregivers, and 3. between caring for others and self-care. The first blurred boundary relating to the role of the informal caregiver is especially crucial in dementia. With a slow progression, the line between being primarily a relative and being an informal caregiver becomes blurred. Formal and informal care in the Swiss case is blurred due to the employment of informal caregivers. The last blurred boundary lies within the informal caregivers themselves: being continuous caregivers, they are sometimes in need of care themselves. Based on that, a discussion of possible modes of support is provided: awareness promotion, supportive structures and an attitude of Care Ethics, which includes trust and responsiveness in relationships. The change from dyadic care relationships to care networks is encouraged.
... 18 Furthermore, discordance between clinician and patient understanding 19 and the quality of communication between them may lead to adverse psychological outcomes, as seen in cancer diagnoses. 20 Given the lack of guidelines or consensus for a UIA consultation, it may be preferable to use strategies typically reserved for breaking bad news and delivering diagnoses such as cancer, 21 which carry a preconceived level of danger. This may require greater consultation time and attention on the surgeon's part 20 but also may necessitate greater use of patient educational material and earlier involvement of clinical nurse specialists and mental health professionals in the referral pathway. ...
... 20 Given the lack of guidelines or consensus for a UIA consultation, it may be preferable to use strategies typically reserved for breaking bad news and delivering diagnoses such as cancer, 21 which carry a preconceived level of danger. This may require greater consultation time and attention on the surgeon's part 20 but also may necessitate greater use of patient educational material and earlier involvement of clinical nurse specialists and mental health professionals in the referral pathway. ...
... Effective communication and information provision throughout the cancer journey is associated with a myriad of benefits, including lower rates of depression and anxiety [10,18], increased patient involvement in decision making [10], greater satisfaction with treatment choices [10], greater overall satisfaction with care [18] and better quality of life [2,18]. In contrast, poor communication and the provision of inadequate information has been shown to lead to uncertainty [9,12], anxiety and depression [5,9], non-compliance [40] and difficulties in coping and adjusting to a diagnosis of cancer [11] [24]. The impacts of poor communication can be profound, with a recent study showing that more than half of patients with advanced cancer incorrectly believed that their treatment was curative and that their condition would improve within a year [38]. ...
... Effective communication and information provision throughout the cancer journey is associated with a myriad of benefits, including lower rates of depression and anxiety [10,18], increased patient involvement in decision making [10], greater satisfaction with treatment choices [10], greater overall satisfaction with care [18] and better quality of life [2,18]. In contrast, poor communication and the provision of inadequate information has been shown to lead to uncertainty [9,12], anxiety and depression [5,9], non-compliance [40] and difficulties in coping and adjusting to a diagnosis of cancer [11] [24]. The impacts of poor communication can be profound, with a recent study showing that more than half of patients with advanced cancer incorrectly believed that their treatment was curative and that their condition would improve within a year [38]. ...
Purpose:
To describe the perceptions of haematological cancer patients about the components of care deemed essential to supporting them to obtain and understand information about their cancer, its treatment and its impact on their life.
Methods:
A cross-sectional survey was conducted with individuals diagnosed with haematological cancer. Eligible patients presenting for a scheduled outpatient appointment were invited to complete a pen-and-paper survey in the clinic waiting room while waiting for their appointment. Those who completed the survey were mailed a second survey approximately 4 weeks later. Participants provided data about their demographic and disease characteristics and perceptions of optimal care for haematological cancer patients.
Results:
A total of 170 patients completed both surveys and were included in the analysis. The items endorsed as essential components of care by the highest number of participants were being able to share accurate information about their disease, treatment and ongoing care with their GP/family doctor (49%); being able to obtain up-to-date information specific to their circumstances (43%); being able to obtain information in the amount of detail that they want (34%); being able to call a health care professional at the treatment centre where they are receiving care (34%) and being able to call an experienced health care professional who has knowledge of their disease and its treatment (34%).
Conclusions:
Further research is needed to determine ways of meeting the preferences of haematological cancer patients and determining the associated impact on patient outcomes.
... Only a small portion of patients will be brought to the hospital, so for many families the EMS teams will be responsible for updating the family, delivering any bad news, providing emotional support, and explaining the next steps for their loved one. There is a paucity of research around how families are impacted by first responders breaking bad news, but we do know that poor communication from in hospital-based teams when delivering bad news has been associated with increased psychological distress, anxiety, and depression (Ellis & Tattersall, 2009). It is reasonable to assume that poor communication techniques would have a similar impact when utilized by EMS clinicians. ...
Out-of-hospital cardiac arrest (OHCA) can have significant adverse sequelae for both the patient’s families, as well as the responding EMS clinicians. Despite advances in medicine, 90% of OHCA result in death. The sudden and unexpected nature of these events, adds to the complexity of grief for the surviving family members. OHCA specifically has been shown to have deleterious mental health impacts on EMS clinicians who have self-reported experiencing negative emotions after delivering bad news to families such as a death notification. Given the grim prognosis associated with OHCA outcomes and associated emotional fallout, we must find ways to better support our patients, families, and EMS clinicians. The goal of this paper is to offer recommendations and tools that can be used by EMS clinicians to better address the emotional burden experienced by families during an OHCA resuscitation. Many Pre-hospital clinicians receive limited training around the psychologic and emotional consequences that accompany OHCA scenarios. Currently no national curriculum or writings that the authors are aware of have covered the concept of how to run an emotionally supportive OHCA. The following is an expert consensus of recommendations from a group of experienced EMS clinicians, a child life specialist, a licensed clinical social worker and physicians with backgrounds in emergency medicine, palliative care and EMS. The strategies outlined would ideally be utilized by first responders helping to anticipate and subsequently support the emotional needs of families. The strategies range from ways to enhance communication, help combat common misperceptions from families around cardiac arrest and prepare EMS clinicians for what to do if a resuscitation is unsuccessful. Ultimately the goal of this paper is to provide the tools to help EMS clinicians better align themselves with families to minimize the emotional impact on all involved.
... 9,10 Inadequate doctor-patient communication skills can lead to psychological distress, including heightened anxiety and depression, and hinder effective psychological adaptation to cancer. 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. ...
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.
... Referral waiting times, [21][22][23] quality of communication at the time of diagnosis, patient personality traits, 9,10 and patient understanding are all factors suspected of mediating psychological impairment among neurosurgical patients. 14,[23][24][25] In addition, long-term imaging surveillance has been found to reinforce negative psychological states in other medical conditions. 26,27 With respect to UIAs, however, it is unclear which service-or patient-related factors most negatively influence mental health. ...
BACKGROUND
Following a diagnosis of a small unruptured intracranial aneurysm (sUIA), patients often experience psychological ailments which may be attributable to the neurovascular consultation, referral pathway, or long‐term imaging surveillance. Here, we aim to characterize the early sUIA patient journey and evaluate their psychosocial status.
METHODS
A mixed‐methods analysis of sUIA patients attending a large tertiary neurosciences center was performed. For patients presenting to the neurovascular service in 2020, this included: (i) a thematic analysis of patient perspectives extracted from semistructured telephone interviews, (ii) a quantitative assessment of psychological status using the Hospital Anxiety and Depression Scale and (iii) an evaluation of functional independence using a customized activity of daily living questionnaire. The relationship between service or clinical factors, and Hospital Anxiety and Depression Scale subscale scores was statistically tested.
RESULTS
The sUIA patient cohort (n=105) had a mean age of 56.8 years (SD=15.8, female=69). Thematic analysis of interview responses (n=33) identified 5 recurrent themes underpinning the sUIA patient experience: referral, diagnosis and information sharing, imaging surveillance, psychological impairment and coping strategies, and activities of daily living, all of which contributed to patient concerns. A total of 53.6% of patients achieved a Hospital Anxiety and Depression Scale score signifying at least mild anxiety and/or depression. Lifestyle changes most frequently affected after diagnosis included avoidance of straining‐intensive exercise, change in patterns of substance use, and work‐related performance. Multivariate analysis revealed no significant service or clinical predictors for anxiety or depression.
CONCLUSION
For some patients, an sUIA diagnosis appears to be associated, at least qualitatively, with a psychological burden. This is likely mediated through stressors related to the referral, diagnosis, neurosurgical consultation, and image surveillance. In the absence of evidence‐based guidelines regarding these aspects of the early patient journey, we offer suggestions aimed at improving both the neurovascular service and sUIA patient experience.
... The poor doctor-patient communication skills may lead to psychological distress including increased anxiety and depression and poor psychological adjustment to cancer. Presenting 'bad' news in an unhurried, honest, balanced and empathic fashion has been shown to produce greater satisfaction with communication of the news [4]. Additionally, when delivering bad news; physicians should assess the patient's emotional state, readiness to engage in the discussion, and level of understanding of the condition. ...
The traditionally assumed medical dictum is that a physician who expresses his or her emotions in font of patients or their families is almost deemed unprofessional. This feeling may be common place, particularly among traditional physicians who still hold the belief that professionalism is endangered if physicians deliver bad news laced with their true emotions. Discussion of this important topic surfaces now and then and are then hidden away without definite answers possibly due to lack of attention by physician's fraternity to dispense with this out-of-date dictum. Though we understand the protection of professionalism is the basis for this practice, the topic is rarely revisited because the community of physicians remains distant from this sensitive issue, in spite of its importance in achieving high care satisfaction from patients and their families. In view of the increased emphasis on enhancing patients’ hospital experiences and satisfaction, the demonstration of sensitivity on the part of physicians in some form as a component of their compassionate care may require renewed attention.
... Among the most common potential areas of improvement of the perception of the bad news are the knowledge of the patient expectations, the speed and timing of presenting the news to the patient, the incremental presentation of the information, sharing of troublesome information warning, allowing the patients to express their emotions and worries (Ellis & Tattersall, 1999), following the patient's pace, avoidance of medical jargon and euphemism and answering of the patient's questions (VandeKieft, 2001). The medical professionals should give enough time for the conversation, they must insure high quality of the information and facilitate the patient's understanding, provide emotional support and allowing expression of emotions (Fujimori et al., 2005). ...
In the medical profession, communicating bad news about a malignant formation is often associated with experience, obstacles, and problems faced by the medical professionals and related to the communication with the patient. Our survey included 232 medical specialists - doctors and nurses with diverse internship in the profession and working in Bulgarian healthcare facilities. It aimed to find: (i) the most common difficulty in communicating the bad news to cancer patients, (ii) the most difficult aspects of that information, and (iii) the specific words the medical professionals prefer to avoid when communicating the bad news. Also, the medical specialists were asked about the factors with the largest interference with the disclosure of the bad news to the patients. The survey results show that only 66 percent of the medical professionals are ready to respond directly and definitively to the question from the patient if he/she has cancer. Almost all of the surveyed medical specialists believed that the most difficult part of communicating the bad news was related to the prognosis of the disease and the survival expectancy; many of the medical professionals preferred to avoid the word "cancer", and the fatality of the disease was the most common barrier in communicating bad news, followed by the relatives’ negative position towards bringing up the bad news to the patient, and the low level of patient’s education and the short life expectancy. The study shows the need for support and training of the medical professionals in addressing bad news situations and the importance of the protocols with guidelines and steps to be performed during that communication.
... All participants requested more sensitivity and empathy in their communication with healthcare providers, starting with the diagnosis. Cancer diagnosis is associated with significant psychosocial morbidity (Burgess et al., 2005;Ellis & Tattersall, 1999). Women who are unsatisfied with their cancer diagnosis communication are more likely to show long-term maladjustment (Mager & Andrykowski, 2002). ...
Purpose: The purpose of this qualitative research study was to explore patient perceptions of patient-centered communication from oncology care providers among Black and White women taking an adjuvant endocrine therapy (AET) medication to treat breast cancer.
Methods: Four 90-minute focus groups were conducted from December 2017 to January 2018 in Memphis, TN, a Mid-South region of the United States with significant Black-White breast cancer mortality disparities. Focus groups were stratified by race (Black and White) and patient length on AET (i.e., < 6 month AET use or > 6 month AET use) (N=28). They were moderated by a race-concordant moderator, using a semistructured interview guide, and audio recorded, transcribed verbatim, coded according to conventions of value-based coding, and analyzed by emergent themes. Participants were compensated with a notebook and $40 merchant gift card. Results In our study, race-based differences in participants' perceptions of information provision and patient-centered patient-provider communication emerged. Black women were more likely than White women to report being proactive and assertive in requesting information related to AETs. Yet, Black women were less likely than White women to report having their informational needs met by providers, namely treatment length, AET symptom management, and effects of AET on pre-existing chronic conditions. One Black participant said, “Nobody will tell you about it [her lab reports]. You've got to ask! If you don't, you won't get any answers.” White women in our study were more likely to report receiving social support from health care providers and praise longstanding relationships. Conversely, Black women in our study shared personal stories of disempowered, paternalistic interactions with providers and frequently mentioned the importance of changing providers to increase their comfort. As such, they were more likely than White women to report relying on their faith in God and nonmedical social support networks to manage symptoms and adhere to prescribed AET regimens. In addition, unlike White women in our sample, Black women said they had no problem discussing sensitive topics, like sexual dysfunction and menopause, with providers but believed those discussions made their providers feel uncomfortable.
Conclusion: Race-based differences in patient-provider communication may contribute to unmet informational and social support needs among Black women with breast cancer during the AET phase. Findings from our study suggest that Black women, compared to White women, experience poorer patient-provider communication and patient-centered cancer care.
Implications: Study results have implications for cancer care in diverse clinical settings. Communication skills training programs should include cultural competency curricula and help oncologists identify and address social support challenges facing Black female patients during the adjuvant phase of breast cancer treatment.
Citation Format: Janeane N. Anderson, Ryan Blue, J. Carolyn Graff, Rebecca A. Krukowski, Ilana Graetz. “Nobody will tell you. You've got to ask!” Race-based differences in patient-provider communication efficacy and social support between Black and White women with breast cancer [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A005.
... All participants requested more sensitivity and empathy in their communication with healthcare providers, starting with the diagnosis. Cancer diagnosis is associated with significant psychosocial morbidity (Burgess et al., 2005;Ellis & Tattersall, 1999). Women who are unsatisfied with their cancer diagnosis communication are more likely to show long-term maladjustment (Mager & Andrykowski, 2002). ...
Patient-provider communication is a critical component of healthcare and is associated with treatment quality and outcomes for women with breast cancer. This qualitative study examines similarities and differences in patient perspectives of communication needs between Black and White breast cancer survivors. We conducted four focus groups (N = 28) involving women with early-stage breast cancer on adjuvant endocrine therapy (AET), stratified by race and length of time on AET (< 6 months and >6 months). Each group was moderated by a race-concordant moderator and analyzed by emergent themes. Participants expressed common patient-provider communication needs, namely increased sensitivity from oncologists during the initial cancer diagnosis, personalized information to facilitate treatment decisions, emotional support during the transition from active treatment to maintenance, and rapid provider responses to mobile app-based queries. Communication differences by race also emerged. Black women were less likely than White women to describe having their informational needs met. White women praised longstanding relationships with providers, while Black women shared personal stories of disempowered interactions and noted the importance of patient advocates. White women more often reported privacy concerns about technology use. Unlike White women, Black women reported willingness to discuss sensitive topics, both online and offline, but believed those discussions made their providers feel uncomfortable. Early-stage breast cancer patients on AET, regardless of race, have similar needs for patient-centered communication with their oncologists. However, Black women were more likely to report experiencing poorer communication with providers than White women, which may be improved by technology and advocates.
... Important aspects include "exploring the patient's expectations, warning him/her of bad news, delivering the news at the patient's own pace, allowing time for the patient to react, and eliciting the patient's concerns". There is little evidence about the best methods for giving bad news and most recommendations/ guidelines are not recent and are based on opinion [41,42]. Several professional groups have published consensus guidelines on how to discuss bad news; however, few of those guidelines are evidencebased and they generally recommend individualized disclosure by tailoring the interview to the individual patient [43]. ...
To understand communication as a complex human activity
also requires knowledge of older patients’ experience of cancer and
their need for honest and compassionate care. Research findings
on physician–older cancer patient communication needs to be
translated into medical education, training, and practice to improve
an important dimension of healthcare service to older cancer
patient [53]. The design of ethically sensitive research to assess
the impact of various methods of communicating cancer diagnosis
needs to be explored to advance future practice. In addition,
since the strategy of how bad news should be communicated to
patients constitute a major area of interest in medicine, more
studies need to be conducted focusing on patients’ perspectives
to better serve the customer and really provide Patient-Centred
care. Doctor-patient communication can be improved by including
training courses in communication skills for medical students and
clinicians. Professional training programs on improving doctors’
communicating a bad cancer diagnosis are needed, and emphasis
might be placed on providing emotional support to cancer patients.
Doctors could involve family to find out ways of personalized
disclosure. What a patient wants to know, not what a patient’s
family wants to know, and determines the disclosure strategy [54].
The task of delivering bad news is an important task that, if done
well, improves patients’ ability to cope with their disease [55].
Finally, it is believed that good communication offers the most
rewarding aspect of total patient care and that communication
specialists and clinical psychologists are the main role players
in defining the optimum cognitive communication strategy that
improves Patient-Centred healthcare service and disease outcome.
... Among the most common potential areas of improvement of the perception of the bad news are the knowledge of the patient expectations, the speed and timing of presenting the news to the patient, the incremental presentation of the information, sharing of troublesome information warning, allowing the patients to express their emotions and worries (Ellis & Tattersall, 1999), following the patient's pace, avoidance of medical jargon and euphemism and answering of the patient's questions (VandeKieft, 2001). The medical professionals should give enough time for the conversation, they must insure high quality of the information and facilitate the patient's understanding, provide emotional support and allowing expression of emotions (Fujimori et al., 2005). ...
Communicating bad news about a malignant entity in the medical profession is often associated with experiences, obstacles, and problems faced by medical professionals that they must overcome in communicating with the patient. The survey includes 232 medical specialists - doctors and nurses with different internships in the profession working in healthcare facilities in Bulgaria. It aims to find what is the most common difficulty in communicating the bad news to cancer patients, which part of the information is the most difficult to share, and which words they prefer to avoid using when communicating bad news. Also, they were asked which factors interfere most in communication about bad news and which and how many of the necessary conditions of communication are respected by medical professionals during the conversations. The results show that only 66% of medical professionals are ready to respond directly to the question of the presence of a malignant entity with a positive definitive response. Almost all of the surveyed medical specialists believe that the most difficult part of communicating the bad news is related to the prognosis of the disease and the time, which remains to the patient; 73% of medical professionals prefer to avoid the word "cancer", and the fatality of the disease is the most common barrier in communicating bad news. More than half of the surveyed health care professionals assess whether a patient wants information, use understandable language, and take into account patient feedback, but considerably fewer of the living environment conditions are respected in this type of communication. The study shows that more action is needed to support medical professionals in addressing bad news situations and introducing protocols with guidelines and steps to follow.
... Traditionally, theoretical and empirical research on physician-patient communication has focused on how to improve the flow of information from the former to the latter [7,[53][54][55][56][57]. Patients' understanding of medical terms and concepts, including the pros and cons of available treatments, as well as relevant statistical information, is no doubt needed to help them be fully informed and actively involved in their own care. ...
Background
The management of localized prostate cancer is challenging because of the many therapeutic options available, none of which is generally acknowledged as superior to the others in every respect. The selection of the most appropriate treatment should therefore reflect patients’ preferences.
Objective
The purpose of the following study was to pilot a new approach for investigating whether urologists who had previously provided patients with therapeutic advice actually knew their patients’ importance weights concerning the relevant aspects of the treatments at issue.
Method
Participants were patients recently diagnosed with localized prostate cancer (n = 20), urologists (n = 10), and non-medical professionals (architects, n = 10). These last served as a control group for the urologists and were matched to them for age and gender. Patients’ importance weights were elicited by two standard methods (Direct Rating and Value Hierarchy). Each urologist was asked to estimate (with Direct Rating) his/her patient’s importance weights. The same task was performed by a corresponding architect, who never met the patient and knew only the patient’s age. Univariate and bivariate statistical analyses were performed to investigate the association between importance weights as elicited from patients and as estimated by urologists and architects, as well as to assess whether such agreement was attribute-dependent.
Results
Participants found both elicitation methods easy to use. The correlation between patients’ actual importance weights and urologists’ estimates was poor and comparable to that obtained between patients and architects. This result did not depend on the attribute considered, with the sole exception of the attribute “Effectiveness in curing the cancer”, which was evaluated as the most important attribute by the majority of participants.
Conclusion
These findings demonstrate the feasibility of the employed methodology and highlight the need to support preference-sensitive decisions in clinical practice by facilitating the elicitation of patients’ importance weights, as well as their communication to physicians.
... Asking questions can be considered a first index of active participation in the discussion and an expression, at the same time, of a patient's most immediate information needs. [3][4][5][6][7] Asking questions can lead to positive benefits for cancer patients, including greater satisfaction and better treatment adherence. 8 9 Two main techniques have been tested in the oncology setting to promote question asking. ...
Objectives
To investigate, prior to an oncology consultation, the use of a pre-prepared list of evidence based questions, Question Prompt Sheet (QPS), compared with a Question List (QL), a patient self-generated list of questions.
Design
Multi-centred, randomised controlled trial.
Setting
Secondary-care patients attending three outpatient oncology clinics in Northern Italy.
Participants
308 women completed the study. Inclusion criteria were an age between 18 and 75 years, a recent diagnosis of early stage, non-metastatic breast cancer, adequate Italian language skills, no previous oncology visits and no evidence of cognitive impairment.
Intervention
Patients received the QPS or the QL prior to the consultation, completed it without suggestion or coaching session and delivered back before the visit.The consultations were audio-recorded and analysed for the number and content of questions. Multilevel linear models were used to compare the two groups.
Outcome measures
The primary outcome was the comparison of questions asked between QPS and QL group. Secondary outcomes included satisfaction about questions asked, satisfaction with decision, and level of anxiety.
Results
Patients in the QPS and QL group asked 13 and 16 questions respectively. The difference was not significant (b=1.7, CI –0.3 to 3.6, p=0.10). A mean of 22 questions was selected in the QPS, while a mean of 2 questions was written in the QL. Patients in the QPS group were significantly less satisfied (t=3.60, p<0.01) with questions asked but wanted less additional information (t=2.20, p<0.05). Levels of patient decisional satisfaction were equivalent between groups. Similarly, anxiety levels were equal between groups prior to the consultation and decreased in similar way after the consultation.
Conclusions
Both interventions have similar impact on patients’ participation in terms of question asking during the consultation. Future research is needed in order to explore which components of the interventions are really useful and efficacious.
Trial registration
ClinicalTrials.gov NCT01510964
... Consensus guidelines on breaking bad news in the field of cancer suggest that disclosure should take place across several meetings including enough time to assess the patient's understanding and emotional status, encourage expression of feelings and respond empathetically, arrange a time to review the situation, offer assistance telling others, and provide information about support services as well as discussing treatment (63,64). Yet, some caregivers in the studies reviewed here believed disclosure should be a discreet event (31). ...
While the psychological and health benefits of knowing one’s HIV diagnosis have been documented for adults and adolescents, practice is still in development for younger children. Moderating conditions for whether or not to tell a child he/she has HIV vary by region and local context. They include accessibility of treatment, consideration of HIV as a stigmatizing condition, prevalence of HIV, and an accompanying presumption that any illness is HIV-related, parent or caregiver concerns about child reactions, child’s worsening health, assumptions about childhood and child readiness to know a diagnosis, and lack of policies such as those that would prevent bullying of affected children in schools. In this systematic review of the global literature, we summarize the reasons caregivers give for telling or not telling children 12 and under their HIV diagnosis. We also include articles in which children reflect on their desires for being told. While a broad number of reasons are given for telling a child – e.g., to aid in prevention, adaptation to illness (e.g., primarily to promote treatment adherence), understanding social reactions, and maintaining the child–adult relationship – a narrower range of reasons, often related to immediate child or caregiver well-being or discomfort, are given for not telling. Recommendations are made to improve the context for disclosure by providing supports before, during, and after disclosure and to advance the research agenda by broadening samples and refining approaches.
... consensus in a nonemergency setting [15][16][17][18][19]. Guidelines on how to BBN in the ED are very limited and often related to death notification situations, therefore, not including other types of bad news [20]. ...
Objective:
Our main objective was to assess patient and family members' perception of bad news communication in the emergency department (ED) and compare these with physicians' perceptions.
Methods:
This is a cross-sectional study carried out at the ED of a tertiary teaching hospital. To compare physicians' and receivers' (patient and/or family member) perceptions, we created a survey based on the six attributes derived from the SPIKES protocol. The surveys were applied immediately after communication of bad news occurred in the ED. We analyzed agreement among participants using κ-statistics and the χ-test to compare proportions.
Results:
A total of 73 bad news communication encounters were analyzed. The survey respondents were 73 physicians, 69 family members, and four patients. In general, there is a low level of agreement between physicians' and receivers' perceptions of how breaking bad news transpired. The satisfaction level of receivers, in terms of breaking bad news by doctors, presented a mean of 3.7±0.6 points. In contrast, the physicians' perception of the communication was worse (2.9±0.6 points), with P value less than 0.001.
Conclusion:
Doctors and receivers disagree in relation to what transpired throughout bad news communications. Discrepancies were more evident in issues involving emotion, invitation, and privacy. An important agreement between perceptions was found in technical and knowledge-related aspects of the communication.
... n Apply effective communication, e.g. patient satisfaction leaving consultation, high use of open-ended questions, great empathy, use of psychosocial probing [17,136,137,138,139]. ...
Evidence-based clinical practice guidelines are widely used to promote effective and efficient health care. Clinical oncology practice guidelines are developed for a variety of purposes: to improve quality of care, outcomes of patients, reliability of medical decisions and costeffectiveness; to increase patients' information and autonomy of choice; to disseminate best practice by use of standardized criteria; to facilitate training, research and education; to inform third parties; and to decrease practice variation, harm to patients, and professional misconduct. The ethical implications for guideline use are complex and far-reaching. However, practice guidelines can never substitute the clinical judgment of qualified health care professionals, and it is crucial not to be allowed to hinder the development of more effective treatment strategies in the management of cancer patients. This work reviews the pros and cons of using guidelines in Oncology for patients, healthcare professionals, policy-makers, payers and managers. Moreover, it presents potential barriers to physician adherence to guidelines and their dependence on physician knowledge, attitudes and behavior. Finally it examines the minimum requirements for a local group or national body to develop / adopt / review / appraise and evaluate guidelines for a specific clinical area and the ways to disseminate and implement them.
... A time-deficient emergency physician usually cannot develop a satisfying communication with patients, which is necessary for a trustful physician-patient relationship and effective breaking bad news according to current guidelines. [11][12][13] The nature of bad news in the ED is also different from nonemergency departments. Bad news in oncology departments is usually associated with a terminal disease, but severe nonterminal diseases, mild diseases interfering with patients job (e.g., Welder's keratitis), and any condition at an inappropriate time (e.g. ...
Objective
To find whether Western guidelines on breaking bad news in a nonemergency department are appropriate for an emergency department of a non-Western country; according to patients’ preferences.
Method
We designed a 19 items questionnaire of Likert-type scale and interviewed 156 patients in the emergency department of a referral hospital in Iran.
Results
The patients’ preferences in 9 out of 19 statements were similar to the guidelines. “Using the maternal language” received the strongest agreement. The strongest disagreement was on “encouraging the patients to talk after receiving bad news.” The summative scores of subsection indicated strong agreement for cultural issues, followed by communication skills, breaking bad news session, and privacy.
Conclusion
The patients’ preferences were not completely consistent with the guidelines. We could not determine if it was a situational or cultural issue. However, it is reasonable to design a new guideline for breaking bad news, considering these factors.
... Übersichtsarbeiten zufolge können auch Kommunikationstrainingsprogramme die Zufriedenheit onkologischer Patienten positiv beeinflussen (Bredart, Bouleuc und Dolbeault, 2005;Kennedy Sheldon, 2005;Merckaert, Libert, Delvaux, Marchal et al., 2005). Krebserkrankung insgesamt empfunden wird (Burke, Lowrance und Perczek, 2003;Ellis & Tattersall, 1999;Fallowfield, 1993;Fallowfield & Jenkins, 2004;Gordon, 2003;Jakel, 2002;Spiegel, 1997). Dabei kann auch die Art der Informationsvermittlung den Patienten bei seiner Krankheitsverarbeitung unterstützen (Molen, 1999 (Lorenzo et al., 2004;Stanton et al., 2005). ...
... La información es una necesidad, los pacientes la demandan y constituye una vía para entender su proceso, adherirse mejor al tratamiento y actuar de la mejor manera frente a los cambios que se puedan presentar, la barrera surge cuando los profesionales no ofrecen la información suficiente al paciente, cuando solamente responden a la pregunta del paciente y restringen la información si no es solicitada, esto coincide con lo reportado en otros estudios donde se argumenta que en el encuentro médico-paciente existe información pero no existe comunicación, entendida esta última como la capacidad de responder a las expectativas de información de pacientes y familiares; la información se suele proveer de forma parcial, centrándose en la enfermedad y su tratamiento, ignorando a veces aspectos tan importantes como los efectos secundarios de la terapia (18,31,32, ,78). Ante esto, debieran generarse estrategias para entrenar habilidades de comunicación en profesionales y pacientes, de hecho desde hace varios años existen guías y manuales dirigidas a los médicos y demás profesionales de la salud, sería interesante desarrollar guías para el contexto colombiano (91,92) Al hablar del acceso a la atención integral en salud, es importante destacar que una buena atención depende de las decisiones y acciones de los pacientes y del equipo de atención durante los diferentes niveles asistenciales, a las que se debería llegar por consenso; lo importante de encontrar las fallas en el sistema asistencial no es sólo mejorar la calidad de la atención, sino garantizar la seguridad del paciente (86). Siendo el mejor estar del paciente lo que debe interesar deben tenerse en cuenta las necesidades y barreras identificadas desde su perspectiva, en ese sentido, todos los pacientes necesitan contar con acceso oportuno a profesionales y especialistas idóneos, así como a exámenes diagnósticos y tratamientos requeridos, esto durante los distintos momentos de la enfermedad, particularmente durante el proceso de detección y diagnóstico, es clara la importancia de la detección precoz y la posibilidad de iniciar un tratamiento cuyo desenlace sea la curación; según los reportes de los participantes es durante estos momentos de su proceso cuando mayor incertidumbre, temor, preocupación y sufrimiento se conjugan generando un alto grado de malestar en la persona; desafortunadamente también es el período en el que se evidencia con más fuerza la poca agilidad e incluso ineficacia del sistema de salud como barreras para la atención del paciente. ...
... For physicians, our findings provide two possible ways to encourage positive emotional responses in their patients: encouraging comprehension and promoting a sense of control over treatment decisions. Fortunately, researchers have identified a number of ways to improve patients' understanding of complex health information, [30][31][32] and physicians are increasingly adopting a shared-decisionmaking approach to patient care. 33,34 We also examined how emotional reactions to a health-care experience relate to patients' intentions to adhere to treatment recommendations. ...
ContextGood patient–provider interactions promote satisfaction with health care, adherence to treatment recommendations and improved health. However, little research has examined patients' emotions and how they relate to patients' experiences with health care and their adherence intentions in acute care settings.Objective
This study examined the predictors and consequences of two emotions pertinent to the uncertainty of acute health-care experiences: anxiety and hopefulness.DesignPatients who arrived at a general surgery clinic for an initial consultation were interviewed before and after the consultation. Prior to the consultation with a physician, patients completed baseline measures of their emotional state. Following the consultation, patients completed measures of understanding of the information provided by the surgeon, perceived control over treatment decisions, adherence intentions and emotional state.ResultsUnderstanding and control predicted less anxiety and greater hopefulness, compared to baseline. Only hopefulness predicted adherence intentions. These relationships remained even after controlling for characteristics of the patients and interactions.DiscussionThese findings identify aspects of psychosocial care that are critical for promoting positive (and mitigating negative) emotional states in patients. Even in a brief consultation in a clinic setting, physicians may be able to improve patients' emotional state by promoting a sense of control and clarifying information they convey, and patients' positive emotional states may be critical for raising adherence intentions.
... 22,23 Extensive studies by Martin Tattersall and others have evaluated patients' communication preferences, including prompt sheets and taped consultations. 24 Having to turn questions around and battle for answers can be exhausting: Clinicians who become patients themselves may readily appreciate the need to understand the psychology of illness: ...
... [5,6] Therefore, when bad news is broken inadequately, the patient's comprehension of information may be thwarted further, [7,8] they may be dissatisfied or frustrated with medical care, [9,10] as well as develop poor psychological adjustment to the news. [11,12] In addition, physicians who find it difficult to give bad news may subject patients to harsh treatments beyond the point where treatment may be expected to be helpful. [13] The task of breaking bad news (BBN) however, can be improved by understanding the process involved and approaching it as a stepwise procedure, applying well-established principles of communication and counseling. ...
Background:
Communication skills are vital in clinical settings because the manner in which bad news is delivered could be a huge determinant of responses to such news; as well as compliance with beneficial treatment option. Information on training, institutional guidelines and protocols for breaking bad news (BBN) is scarce in Nigeria. We assessed the training, experience and perceived competence of BBN among medical personnel in southwestern Nigeria.
Materials and methods:
The study was a cross-sectional descriptive study conducted out among doctors and nurses in two healthcare institutions in southwestern Nigeria using an anonymous questionnaire (adapted from the survey by Horwitz et al.), which focused on the respondents training, awareness of protocols in BBN; and perceived competence (using a Five-Point Likert Scale) in five clinical scenarios. We equally asked the respondents about an instance of BBN they have recently witnessed.
Results:
A total of 113 of 130 selected (response rate 86.9%) respondents were studied. Eight (7.1%) of the respondents knew of the guidelines on BBN in the hospital in which they work. Twenty-three (20.3%) respondents claimed knowledge of a protocol. The median perceived competence rating was 4 out of 5 in all the clinical scenarios. Twenty-five (22.1%) respondents have had a formal training in BBN and they generally had significant higher perceived competence rating (P = 0.003-0.021). There is poor support from fellow workers during instances of BBN.
Conclusion:
It appears that the large proportion of the respondents in this study were unconsciously incompetent in BBN in view of the low level of training and little or no knowledge of well known protocols for BBN even though self-rated competence is high. Continuous medical education in communication skills among health personnel in Nigeria is advocated.
... An extensive body of prior research has established an association between ineffective communication between cancer patients and their health care providers and anxiety and depression [14,15], poor psychological adjustment [16], reduced coping [17], hopelessness [18], inadequate pain relief [19], and reductions in a range of quality of life indices [20]. ...
In this program of research, we sought to expand our understanding of how cancer patients' communication needs and preferences change across the course of their illness trajectory. To address known limitations in the empirical knowledge base, we designed a study capitalizing on representative patient reports as they occurred within time and across experience obtaining care for this disease.
We used a longitudinal cohort design informed by interpretive description methodology to follow 125 patients over a multi-year period as they reflected on their ongoing experiences with cancer care communication.
In relation to each phase of their cancer care trajectory, patients identified tension points and contextual challenges impinging on what they felt constituted helpful and unhelpful patient-provider communication.
Findings from this study create a dynamic portrait of how we can better inform communication approaches and interventions through interpretations of population knowledge and individual experience.
... This tension can erode communication and result in poor outcomes for both news-recipients and news-givers. For example, people who feel that a news-giver did a poor job of communicating bad news report less satisfaction with the communication, more anxiety about the news, and poorer adjustment (Ellis & Tattersall, 1999), and news-givers who are unsure of the best way to give bad news experience anxiety, distress, poor mental health, and distrust from newsrecipients (Ambuel & Mazzone, 2001;Holland, 1989;Ramirez et al., 1995). Our finding that news-givers can improve their communication simply by remembering to take the recipient's perspective provides a potentially powerful antidote to some of the negative consequences of poor news delivery. ...
Information often comes as a mix of good and bad news, prompting the question, "Do you want the good news or the bad news first?" In such cases, news-givers and news-recipients differ in their concerns and considerations, thus creating an obstacle to ideal communication. In three studies, we examined order preferences of news-givers and news-recipients and the consequences of these preferences. Study 1 confirmed that news-givers and news-recipients differ in their news order preferences. Study 2 tested two solutions to close the preference gap between news-givers and recipients and found that both perspective-taking and priming emotion-protection goals shift news-givers' delivery patterns to the preferred order of news-recipients. Study 3 provided evidence that news order has consequences for recipients, such that opening with bad news (as recipients prefer) reduces worry, but this emotional benefit undermines motivation to change behavior.
... • la considération des ressources d'aide pour le malade et la famille (par exemple, Girgis et Sanson-Fisher, 1998, Ellis et Tattersall, 1999, Parker et al., 2001 1 . ...
Because of social and personal implications, disclosing an Alzheimer's disease diagnosis to a person is not a simple task for a physician. Positions stated in medical literature and in the legal framework converge towards the idea of informing patients in a clear and detailed manner. The researcher conducted 23 semi-structured interviews involving hospital heathcare providers, majoritarily physicians, in France and Quebec. These interviews show that practices vary according to modes of doctor/patient relationships, representations of Alzheimer's disease, and the organization of the professional sector. Because of the length of the disease and the effects on patients, the issue of disclosing the diagnosis opens a discussion about how to accompany and care for patients and their families in the course of time.
... Il primo passo, quindi, dovrebbe consistere nell'approfondire le componenti psicologica, sociale e culturale del paziente per individuarne le reali esigenze ed aspettative, rendendosi disponibile ad ogni eventuale chiarimento sulla malattia e la sua prognosi. Tale approccio richiede una formazione del medico sulle tematiche psicologiche connesse al morire e sulle tecniche di comunicazione [227][228][229][230][231][232] . Questa, infatti, si compone di segnali verbali e non che stabiliscono lo stato di empatia necessario al rapporto terapeutico. ...
There are roughly 1000 prehospital cardiac arrests in the US daily with a mortality rate approaching 90%1. In 2011 and the national association of EMS physicians position statement supporting prehospital termination of cardiac arrest has led to an increase in the number of patients dying in the prehospital environment. EMS clinicians responding to these emergencies are often tasked with breaking bad news (BBN) to families that their loved one has died. Currently no national curriculum, standardized training or mandated education around this subject exists for EMS clinicians. Recent research suggests that EMS clinicians are breaking bad news with frequency, are not receiving training on how to break bad news, are motivated to receive additional training around this subject and are suffering negative sequalae directly related to these conversations. Current existing curriculums around breaking bad news are designed for in hospital and clinic-based settings and are not wholly applicable to the dynamic prehospital environment. The following paper is a guide created by clinicians with EMS, palliative care, pediatric palliative care, and emergency medicine backgrounds to better help EMS clinicians navigate these difficult conversations. This guide is a step wise approach including dos and don’ts to help them navigate these challenging conversations as well as to help them navigate special circumstances such as topics around anger and pediatric patients. Currently no such guide exists, and it is the authors hope that this guide will be utilized to help EMS clinicians successfully engage in these conversations as well as help to inspire future research and education around this topic.
Purpose
It is unclear whether Maltese cancer patients wish to know their diagnosis or to what extent they want to be informed. The aim was to assess patients’ preferences for receiving a cancer diagnosis and being involved in the decision-making process, and then compare this with results from similar international studies.
Methods
A total of 252 patients were invited to complete two standardised tools: a Measure of Patients’ Perspective (MPP), assessing patients’ preferences for receiving news about their cancer, and a Control Preferences Scale (CPS), examining involvement in decision-making.
Results
Patients rated ‘content’ (information given; mean 4.17, standard deviation: SD 0.59) as more important (p < 0.001) than ‘support’ (offering comfort/support; mean 3.73, SD 0.68) and ‘facilitation’ (how information is given; mean 3.86, SD 0.68). Patients with higher levels of education had higher scores for ‘content’ (p = 0.018) and ‘facilitation’ (p < 0.001) on MPP, while lower education levels preferred a passive role (p = 0.01) on CPS. Although there is a trend towards a collaborative and even active role in treatment decisions, patients still exhibit a submissive attitude towards their physician.
Conclusions
Maltese cancer patients want to be informed of their cancer diagnosis, its treatment and prognosis, similarly to other international studies. However, 60% prefer to leave medical decisions in their physician’s hands when compared to other studies.
Most healthcare providers (HCPs) work from ethical principles based on a Western model of practice that may not adhere to the cultural values intrinsic to Indigenous peoples. Breaking bad news (BBN) is an important topic of ethical concern in health research. While much has been documented on BBN globally, the ethical implications of receiving bad news, from an Indigenous patient perspective in particular, is an area that requires further inquiry. This article discusses the experiences of Māori (Indigenous peoples of New Zealand) lung cancer patients and their families, in order to investigate the ethical implications of receiving bad news. Data collection occurred through 23 semistructured interviews and nine focus groups with Māori lung cancer patients and their families in four districts in the Midland Region of New Zealand: Waikato, Bay of Plenty, Lakes and Tairāwhiti. The findings of this study were categorised into two key themes: communication and context. Avenues for best practice include understanding the centrality of the HCP–patient relationship and family ties in the healthcare journey, and providing patients with the full range of viable treatment options including hope, clear advice and guidance when the situation calls for it. Overall, the findings of this study hold implications for providing culturally safe and humanistic cancer care when BBN to Māori and Indigenous patients.
Africa has the highest infant mortality rate in the world. However, the quality of hospital care for children there has rarely been studied. This qualitative research, conducted in a pediatric unit in Dakar (Senegal), analyzes the silence of medical professionals and conflicts among children with cancer, their families and such professionals concerning the communication of information about their disease and the end of life. Despite protocol and parents’ requests, doctors often do not inform parents of their child’s diagnosis and prognosis, citing their inability to comprehend medical explanations and the need to protect them from psychological trauma. In conclusion, doctors remain silent in order to avoid facing the reactions of the parents who would learn the gravity of their child’s condition. Two types of reasoning are at work in this situation: a highly hierarchical doctor–patient/family relationship and the non-recognition of death in the medicine of Dakar. (Key words: children, cancer, pain, end-of-life care, West Africa)
School counselors often have to give difficult news to parents, a process that can be stressful and troubling for everyone involved. While the reaction of each parent is unique, research indicates that many parents who have been given difficult news about their children feel that the information was delivered poorly. This article provides guidelines for the delivery of difficult news to parents, including strategies for appropriate preparation and follow-through.
Breaking bad news is a complex task that requires multiple communication skills from health professionals. Clinical practice demands to communicate all type of bad news, from a diagnosis of cancer to adverse effects of a treatment. On the other hand, since the beginning of the health reform in 2003, the need to improve the quality of services was proposed, among which the concern about the rights and duties of patients stands out. Therefore, the health care provider-patient relationship becomes again the subject of discussion and study, and a topic of great importance for clinical work. We revise the consequences of breaking bad news for the patient and for the health care provider, as well as the current protocols available for this purpose. The importance of developing communication skills both for future health professionals as for those who currently work in the area is emphasized.
Considerable debate has occurred about educational processes within undergraduate courses for health-care professionals. Less attention appears to have been directed to issues of curriculum content. This paper examines the potential influence of curriculum content on a number of outcomes, and examines the methods that can be used determine curriculum content. The balance between different content areas in a curriculum has the potential to affect allocation of human resources, research capacity and output, and hence the power base of discipline groups. Changes to the balance of content will therefore be sensitive, and threatening to some groups. While the optimal way to determine curriculum content would be on the basis of evidence from experimental studies, such studies have not been conducted. Opinion-based approaches have been commonly used. While such processes demonstrate increasing commitment to determining content that is most relevant to producing good clinicians, the results depend on the stake-holders involved. Despite the considerable difficulties in conducting rigorous research concerning curriculum content, there is a need to develop a research agenda in this area.
During the first French Convention of cancer patients, the way of disclosing the disease has been questioned by the patients and their close relations. The question of what we can and have to say or not say during diagnostic disclosure has been discussed. In solid cancers, studies have shown that a clear, transparent announcement, without insinuation or use of complicated terms, can facilitate the patients' approach of their illness and promote the physician/patient relationship, which is so important for the two protagonists. In the context of hematologic malignancies where terminologies are specific and do not directly signify cancer for patients, the choice of using or not the word "cancer" at the announcement appears fuzzy, uncertain. A study of a particular case with lymphoma observed in a study of the impact of diagnosis disclosure and a review of the literature will allow us to discuss the interest of the announcement of a hematologic malignancy by using the term "cancer" when adequate without detours.
The importance of the topic of 'breaking bad news' to cancer patients is underscored by a recent Medline search, which revealed close to 500 articles published on this subject in the past ten years, and by the fact that the cancer clinician is likely to give bad news many thousands of times during the course of his or her career. Paradoxically, however, despite the argument for its importance, very few training programmes in oncology thoroughly cover the topic and provide adequate learning experiences for trainees. Only a minority of oncologists have formal training in breaking bad news and other key communication skills. This chapter reviews the concept of breaking bad news, highlighting salient points and controversies in the literature and making training recommendations. It considers a definition of bad news, why the topic is so important, the challenges to clinicians in breaking bad news, protocols for giving bad news, research on bad news disclosure, and directions for the future.
Disclosing a new, life-threatening diagnosis to a patient is difficult for the physician, the patient, and the family. The disclosure provokes a wide range of reactions from to which the emergency physician must respond. This both the patient and family, interaction is further complicated by the limited time the emergency physician can spend with the patient, the strained resources of a busy emergency department (ED), and, oftentimes, the inability to make a definitive diagnosis based on the ED workup and evaluation. We present a case seen recently in the ED in which a new, life-threatening illness requires disclosure. We offer guidelines for the emergency physician that emphasize patient- and family-centered disclosure of the worrisome diagnostic findings. Additionally, we discuss the essential roles of other allied health professionals in addressing the patient's nonmedical concerns (eg, health insurance, social issues) and in creating a smooth transition for the patient from the ED to further inpatient or outpatient care.
p> Background and Objectives: One of the most important and complicated problems in medical ethics is to disclose the full truth about diagnosis of incurable diseases which leads to death, and each therapist may be encountered with it during the years of medical profession.
The aim of this study was to survey on attitude of professors and residents of clinical wards to disclose the diagnosis for incurable patients leading to death.
Methods: In this descriptive study, sampling was carried out by a survey. All faculty members and their residents of teaching hospitals of Urmia University of Medical Sciences, Urmia, Iran, were surveyed as sample in 2007. Of 145 subjects, 138 responded to the questionnaire. The collected data were analyzed using Pearson and Spearman correlation tests with a p≤0.05 being considered as significant.
Results: In this study, the tendency to disclose the diagnosis among faculty members and residents was 64.63%. Also, there was no significant relation between age, sex, university degree, educational field, years of service of the faculty members and residents of clinical wards with the tendency for telling the truth to incurable patients.
Conclusion: Final analyses revealed that the faculty members and clinical residents of different fields in terms of diagnosis disclosure do not have a definite idea. However, the majority of them agree to disclose the full truth about diagnoses.
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Disclosing a new, life-threatening diagnosis to a patient is difficult for the physician, the patient, and the family. The disclosure provokes a wide range of reactions from both the patient and family, to which the emergency physician must respond. This interaction is further complicated by the limited time the emergency physician can spend with the patient, the strained resources of a busy emergency department (ED), and, oftentimes, the inability to make a definitive diagnosis based on the ED workup and evaluation. We present a case seen recently in the ED in which a new, life-threatening illness requires disclosure. We offer guidelines for the emergency physician that emphasize patient- and family-centered disclosure of the worrisome diagnostic findings. Additionally, we discuss the essential roles of other allied health professionals in addressing the patient's nonmedical concerns (eg, health insurance, social issues) and in creating a smooth transition for the patient from the ED to further inpatient or outpatient care.
Disease announcement system witnesses a certain progress in patient care policy in oncology. However no system will solve by itself the difficulties to speak or to hear about the disease. Our article aims to analyze this announcement content by listing the questions which should be taken into consideration in the interaction between doctor and patient. It highlights the weight of a relationship which places the patient like an autonomous subject in therapeutic action.
Despite the growing attention to the how, when and where of disclosing a cancer diagnosis, not all patients are satisfied with how the news is broken to them. As in German-speaking countries there is a lack of empirical studies on this subject, this analysis was conducted to determine how the cancer diagnosis was given in a German sample, and how satisfied the patients are with the disclosure experience.
162 outpatients received a self-report questionnaire focusing on their experiences with physician-patient communication when the diagnosis was disclosed.
Guidelines had been respected in most cases. 17% of patients were dissatisfied with the diagnosis disclosure. They reported a significantly shorter duration of the interaction, lack of privacy, deficits in understanding the information, and less emotional support by the physician.
Adherence to guidelines of diagnosis disclosure in the German sample was fairly high. Respecting both informational and emotional needs is essential for patient satisfaction and can be taught in communication training.
Introduction. – Announcing to a patient that he has cancer is a key moment both in the relationship between this patient and his doctor and in the setting up of quality communications. However, the quality of this communication is often impaired by the presence of paradoxes and misunderstandings.Current knowledge and key points. – The particularities of cancer, the defense mechanisms of the different contributors and cancer representations can increase the sources of misunderstandings, which will leave an indelible mark on the patient at the beginning of the disease.Future and projects.– What’s at stake in that type of announcement in terms of compliance should not be neglected. Practitioners becoming aware of those phenomena and communication rules should improve the modes of announcement.
Active participation in the medical consultation has been demonstrated to benefit aspects of patients' subsequent psychological well-being. We investigated two interventions promoting patient question-asking behaviour. The first was a question prompt sheet provided before the consultation, which was endorsed and worked through by the clinician. The second was a face to face coaching session exploring the benefits of, and barriers to, question-asking, followed by coaching in question-asking behaviour employing rehearsal techniques. Sixty patients with heterogeneous cancers, seeing two medical oncologists for the first time, were randomly assigned to one of three groups: two intervention groups and one control group. Sociodemographic variables and anxiety were assessed prior to the intervention which preceded the consultation. The consultations were audiotaped and subsequently analysed for question-asking behaviour. Anxiety was assessed again immediately following the consultation. Questionnaires to assess patient satisfaction, anxiety and psychological adjustment were sent by mail 2 weeks following the consultation. Presentation and discussion of the prompt sheet significantly increased the total number of questions asked and the number of questions asked regarding tests and treatment. Coaching did not add significantly to the effects of the prompt sheet. Psychological outcomes were not different among the groups. We conclude that a question prompt sheet addressed by the doctor is a simple, inexpensive and effective means of promoting patient question asking in the cancer consultation.
The purpose of this study was to investigate the effectiveness, dynamics, and consequences of a health education intervention designed to increase patient question asking during the patient's medical visit.
Data were collected at a Baltimore family and community health center which provides outpatient services to a low income, predominantly black and female population. The majority of the study participants were, in addition, elderly and chronically ill. A total of 294 patients and 3 providers took part in the study. The study design included random assignment of patients to experimental and placebo groups with two non-equivalent (non-randomized) control groups.
Findings included: (1) The experimental group patients asked more direct questions and fewer indirect questions than did placebo group patients. (2) The experimental group patient-provider interaction was characterized by negative affect, anxiety, and anger, while the placebo group patient-provider interaction was characterized as mutually sympathetic. (3) The experimental group patients were less satisifed with care received in the clinic on the day of their visit than were placebo patients. (4) The experimental group patients demonstrated higher appointment-keeping ratios (an average number of appointments kept divided by an average number of appointments made) during a four-month prospective monitoring period.
The purpose of this study was to investigate the effectiveness, dynamics, and consequences of a health education intervention designed to increase patient question asking during the patient's medical visit. Data were collected at a Baltimore family and community health center which provides outpatient services to a low income, predominantly black and female population. The majority of the study participants were, in addition, elderly and chronically ill. A total of 294 patients and 3 providers took part in the study. The study design included random assignment of patients to experimental and placebo groups with two non-equivalent (non-randomized) control groups. Findings included: (1) The experimental group patients asked more direct questions and fewer indirect questions than did placebo group patients. (2) The experimental group patient-provider interaction was characterized by negative affect, anxiety, and anger, while the placebo group patient-provider interaction was characterized as mutually sympathetic. (3) The experimental group patients were less satisfied with care received in the clinic on the day of their visit than were placebo patients. (4) The experimental group patients demonstrated higher appointment-keeping ratios (an average number of appointments kept divided by an average number of appointments made) during a four-month prospective monitoring period.
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To assess outside a clinical trial the psychological outcome of different treatment policies in women with early breast cancer who underwent either mastectomy or breast conservation surgery depending on the surgeon's opinion or the patient's choice. To determine whether the extent of psychiatric morbidity reported in women who underwent breast conservation surgery was associated with their participation in a randomised clinical trial.
Prospective, multicentre study capitalising on individual and motivational differences among patients and the different management policies among surgeons for treating patients with early breast cancer.
12 District general hospitals, three London teaching hospitals, and four private hospitals.
269 Women under 75 with a probable diagnosis of stage I or II breast cancer who were referred to 22 different surgeons.
Surgery and radiotherapy or adjuvant chemotherapy, or both, depending on the individual surgeon's stated preferences for managing early breast cancer.
Anxiety and depression as assessed by standard methods two weeks, three months, and 12 months after surgery.
Of the 269 women, 31 were treated by surgeons who favoured mastectomy, 120 by surgeons who favoured breast conservation, and 118 by surgeons who offered a choice of treatment. Sixty two of the women treated by surgeons who offered a choice were eligible to choose their surgery, and 43 of these chose breast conserving surgery. The incidences of anxiety, depression, and sexual dysfunction were high in all treatment groups. There were no significant differences in the incidences of anxiety and depression between women who underwent mastectomy and those who underwent lumpectomy. A significant effect of surgeon type on the incidence of depression was observed, with patients treated by surgeons who offered a choice showing less depression than those treated by other surgeons (p = 0.06). There was no significant difference in psychiatric morbidity between women treated by surgeons who offered a choice who were eligible to choose their treatment and those in the same group who were not able to choose. Most of the women (159/244) gave fear of cancer as their primary fear rather than fear of losing a breast. The overall incidences of psychiatric morbidity in women who underwent mastectomy and those who underwent lumpectomy were similar to those found in the Cancer Research Campaign breast conservation study. At 12 months 28% of women who underwent mastectomy in the present study were anxious compared with 26% in the earlier study, and 27% of women in the present study who underwent lumpectomy were anxious compared with 31% in the earlier study. In both the present and earlier study 21% of women who underwent mastectomy were depressed, and 19% of women who underwent lumpectomy in the present study were depressed compared with 27% in the earlier study.)
There is still no evidence that women with early breast cancer who undergo breast conservation surgery have less psychiatric morbidity after treatment than those who undergo mastectomy. Women who surrender autonomy for decision making by agreeing to participate in randomised clinical trials do not experience any different psychological, sexual, or social problems from those women who are treated for breast cancer outside a clinical trial.
The uncertainty and anxiety experienced by cancer patients and their ways of coping with uncertainty and anxiety were studied on the basis of a questionnaire completed by 418 patients. The study shows that 28.2% of the patients had a low and 33.5% had a high uncertainty score, while 50% had a low and 9% had a high anxiety score. Four ways of coping with uncertainty and anxiety can be distinguished, of which the use of self-instruction means was most common. Expert help proved to be important for reduction of uncertainty. For reduction of anxiety the support of the home environment and of fellow-patients was also of importance. The implications of these findings for the doctor's performance and for the care of cancer patients are discussed.
An audit was carried out of 51 oncology patients referred to a clinical psychology service to identify the characteristics of patients selected for referral and to assess change following psychological intervention. A survey was conducted of an unselected sample of oncology patients representative of the workload of the oncology department from which the referrals came, to determine the prevalence of comparable psychosocial problems among patients who were not referred for help and to assess whether doctors were aware of the problems patients reported. Data were collected using the Hospital Anxiety and Depression (HAD) and Mental Adjustment to Cancer (MAC) scales and a problem checklist devised for this study. Referred patients were significantly more anxious and depressed (P < 0.001) and showed poorer adjustment on MAC scales than the surveyed sample, but 30% of the latter group warranted assessment for anxiety and 23% for depression. The number of psychosocial problems of their severity. Intervention was clinically significant mood disorder irrespective of the specific problems of their severity. Intervention was associated with a significant improvement in distress and problems for referred patients by the time of discharge. Psychosocial problems were often undetected by staff even in referred patients. The checklist is a feasible screening method for potentially remediable problems which are cumulatively a significant contributor to cancer patients' distress.
Open or uncontrolled studies have suggested that providing cancer patients with audiotapes of their clinical interviews can improve information recall and reduce psychological distress. We tested these hypotheses in a 'clinician-blind', prospective, randomised controlled trial. A total of 117 patients newly referred to a medical oncology clinic who were to be given 'bad news' had their consultations audiotaped. Blind to the clinician, patients were randomly allocated to receive a copy of the tape to play at home or not (control group). At 6 months follow-up, tape group patients reported positive attitudes to the audiotape and were shown to recall significantly more information about their illness than did controls. Overall improvement in psychological distress at 1 and 6 months follow-up, as measured with the 30-item General Health Questionnaire and the Hospital Anxiety and Depression Scale was no different in the two groups. However, a second-order interaction suggested that poor-prognosis patients were disadvantaged specifically by access to the audiotape, with less improvement in psychological distress at 6 months follow-up than non-tape controls. Patient access to audiotapes of clinical interviews promotes factual retention but does not reliably reduce psychological distress and may be actively unhelpful in some subgroups of patients.
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.
Active participation and asking questions are important ways in which patients can ensure they understand what the doctor has said. This study evaluated a question prompt sheet designed to encourage patients to ask questions in the cancer consultation.
Patients (n = 142) were randomised to receive (i) a question prompt sheet or (ii) a general sheet informing patients of services available through the regional Cancer Council. Recall of information was assessed in a structured interview 4-20 days after the consultation. Questionnaires to assess patient satisfaction and adjustment to cancer were sent by mail.
The question prompt sheet had a significant effect in one content area: prognosis. Thirty-five percent of patients who received the question handout asked questions about prognosis compared to 16% of those receiving the information handout. The prompt sheet did not increase the mean number of questions asked overall. Age, in/out-patient status, gender and involvement preference were predictive of both number and duration of patient questions.
A question prompt sheet has a limited but important effect on patient question asking behaviour in the cancer consultation.
Despite reports of poor patient understanding and recall after cancer consultations, few doctors provide communication aids. We conducted a randomized trial comparing an audiotape of the consultation versus individualized summary letters to patients after their first consultation with a medical oncologist.
One hundred eighty-two cancer patients were randomized to receive either (1) the audiotape followed 7 to 10 days later by the letter or (2) the letter followed by the audiotape. Outcome measures included patient recall, anxiety and depression, satisfaction with and use of the communication aids, and patient preferences for six communication options. Demographic and disease variables and information and involvement preferences were documented.
Eighty percent of patients wanted all information and 72% wanted to participate in treatment decisions. Patients listened to the tape on average 2.3 times and read the letter 2.8 times over 4 weeks, and 90% showed the tape or letter to a friend, relative, or doctor. Satisfaction with the tape and letter were uniformly high and they did not differentially affect recall, anxiety, or depression. When asked to rank six communication options, 46% of patients gave the highest rank to the tape and 21% to the letter.
Patients use audiotapes of their cancer consultation and individualized letters to review the information given and communicate information to relatives and friends. They prefer audiotapes to letters. Clinicians should consider installing audiotape-recording facilities that could be used to tape new-patient consultations.
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.
Although there is considerable controversy about what information regarding the diagnosis of cancer is most helpful to patients in meeting their psychological and medical needs, little research exists on what patients who are treated in non-specialized institutions are told about their diagnosis and treatment. We assessed the information that breast cancer patients received about their diagnosis from the perspective of both the patient and the physician, in order to determine whether they agree in their perceptions of communication, and whether the nature of patient-physician communication is associated with patient satisfaction. Questionnaires were completed by 1171 Italian breast cancer patients (representing a 81.5% response rate) and their physicians at the time of surgery for breast cancer. Only a minority of patients (47%) reported having been told that they had cancer. Satisfaction with information was highest among women who had been told the diagnosis. Patient and physician reports of what information was conveyed about the diagnosis differed for over half of patients, with highest satisfaction levels reported when both patient and physician stated that the diagnosis had been conveyed. While comparison of patient and physician reports should not be used to validate either source of information, the degree of patient-physician disagreement found in this research may alert physicians to potential difficulties that can arise in communicating with cancer patients.
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.
(Arch Intern Med. 1991;151:463-468)
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.
In answer to a questionnaire administered in 1961, 90% of responding physicians indicated a preference for not telling a cancer patient his diagnosis. To assess attitudinal changes, the same questionnaire was submitted to 699 university-hospital medical staff. Of 264 respondents, 97% indicated a preference for telling a cancer patient his diagnosis—a complete reversal of attitude. As in 1961, clinical experience was the major policy determinant, but the 1977 population emphasized the influence of medical school and hospital training. Our respondents indicated less likelihood that they would change their present policy or be swayed by research. Clinical experience was the determining factor in shaping two opposite policies. Physicians are still basing their policies on emotion-laden personal conviction rather than the outcome of properly designed scientific studies.(JAMA 241:897-900, 1979)
Objective:
To design a structured curriculum concerning issues of communication with patients and families for use during training of pediatric residents.Background:
The stimulus for this initiative arose from residents' perceived need for such a program and the realization that a structured approach to communication techniques did not currently exist in our residency and, in fact, in many undergraduate and graduate medical education curricula.Methods:
Our program was designed to address complex and difficult areas in physician-patient interaction, including how to deliver "bad news," deal with hostile parents, and speak to children about serious illness; the psychosocial aspects of death and dying were also covered in the program. Various teaching techniques were used. We attempted to assess residents' response and alteration in behavior consequent to the program.Results:
The program was successfully incorporated into the training of our residents and was carried out by using existent personnel; minimal expense was incurred. The residents thought the course was valuable and effective, although no statistically significant change in the communication skills of residents could be demonstrated.Conclusions:
The area of physician-patient communication can be taught in a structured fashion during residency. Programs should be devised to meet the changing needs of training during residency and should incorporate the unique strengths of individual institutions.(Arch Pediatr Adolesc Med. 1996;150:638-642)
A questionnaire and interviews were used to study the policies of 219 physicians about "telling" cancer patients. Ninety per cent indicated a preference for not telling. Although clinical experience was cited by three-quarters as the major policy determinant, the data bear no relation to experience or age. Instead, inconsistencies, opinionatedness, and resistance to change and to research were found which indicated emotion-laden a priori personal judgments as the real determinants. Feared reactions to telling (e.g., suicide) could rarely be substantiated. Equally undocumented assumptions were given as justifications for telling. Underlying were feelings of pessimism and futility about cancer. The strong feelings mobilized by our deep and serious concerns for cancer patients, and our difficulties in helping them, stimulate denial mechanisms. These responses, unfortunately, operate as interferences to progress in cancer therapy.
Examined whether audiotapes of "bad news" consultations improved patients' retention of information given during the interview and whether the provision of tapes has any bearing on psychological morbidity and other post-consultation events. 67 female patients (aged 36–82 yrs) with a diagnosis of breast cancer were interviewed by a consultant surgeon. The consultation was recorded and 1 group of patients were allowed to take the tape away and make reference to it during the preoperative period. Provision of tapes was found to enhance patients' understanding of their treatment and resulted in fewer visits to their general practitioners. Use of tapes did not, however, reduce psychological morbidity. The results also indicate that partners experience comparable degrees of psychological morbidity and that female patients who undergo wide local excisions remain significantly more anxious postoperatively than patients who have mastectomies. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Background:
Discrepancies exist between reported experiences of patients when they have been given a diagnosis of cancer, published guidelines for telling a diagnosis, and patterns of communication patients rate as favorable. Several studies have identified what happened and what is important to cancer patients when told their diagnosis, but no studies have addressed subsequent communications concerning the implications of the diagnosis and treatment choices. This study extended previous research by investigating the experiences and preferences for communication about diagnosis, prognosis, and treatment of patients diagnosed with breast cancer or melanoma.
Methods:
A self-report questionnaire was designed for this study based on previous research and qualitative data generated from focus groups. Patients with breast cancer or melanoma answered questions about their experiences with communication at the time of diagnosis and concerning prognosis, treatment and related issues. Comparisons were made between patient experiences, preferences and published guidelines. Differences between the experiences of breast cancer and melanoma patients were tested and the relationship between communication and subsequent psychological adjustment to cancer was assessed.
Results:
Patient preferences for communication during diagnostic consultation were not always consistent with published guidelines. Type of cancer did not significantly affect patient preferences. Psychological adjustment was related to patient ratings of the quality of doctor discussion about treatment options, but not about the diagnosis of cancer and its implications. Patients who wanted more emotional support at the time of diagnosis subsequently experienced poorer psychological adjustment.
Conclusions:
The differences in patient preferences show that a list of prescriptions for how to disclose a cancer diagnosis is too simplistic. Guidelines for clinicians should be derived from patient-based data rather than be limited only to clinical opinion. Guidelines concerning communication at the time of diagnosis also need to address discussions concerning the implications of the diagnosis and making treatment decisions.
Physicians view enhancing patient hopefulness as a critical aspect of cancer treatment, yet little is known about how the circumstances of the initial disclosure of a cancer diagnosis affects this important psychosocial variable. The authors examined the extent to which various forms of physician disclosure of a cancer diagnosis are seen by patients as more or less hopeful and as favorable or unfavorable.
Statements describing various circumstances of diagnostic disclosure were generated from interviews with 10 physicians and 10 patients with cancer. Fifty-seven statements were rated on two bipolar rating scales describing hopefulness and favorability by an additional 56 patients with recent onset of cancer. To determine if overall emotional adjustment to the illness affected these ratings, scores on the Mental Adjustment Scale were also obtained.
Results revealed that patients had clear ideas about which procedures were most and least hopeful and favorable or unfavorable, that the ratings demonstrated clear factorial validity suggesting broad areas of diagnostic disclosure procedure where physicians may make efforts to enhance hope, and that ratings of hopefulness and favorability were related to overall emotional adjustment to the illness.
There was consensus among patients that certain procedures enhanced hopefulness and certain procedures reduced it. Physicians would do well to attend carefully to this aspect of treatment and continually seek patient input concerning their preferences for the conduct of the treatment relationship.
Studies which apply content analysis techniques to the cancer consultation are few. This descriptive study examines the structure and content of the bad news cancer consultations of 117 outpatients newly referred to the Medical Oncology Department of a large London teaching hospital. From previous communication research three main hypotheses are formed: (i) the cancer consultation is clinician-dominated rather than patient-centred; (ii) the level of psychosocial discussion between clinicians and patients is low and (iii) patient characteristics such as sex, age and prognostic category influence clinician behaviours. Each patient had two consultations with one of 5 oncologists. Both these were audiotaped with the patients' consent. The tapes were content coded using the Roter Interaction Analysis System. Results showed that clinicians tended to use closed rather than open questions. Patients asked few questions and were seldom given space to initiate discussion. Thus, the level of patient-centredness was low. Despite the fact that consultations concerned life threatening disease and often contained information regarding toxic treatment which is known to provoke psychological dysfunction, the number of questions relating to patients' psychological health were few. The amount of discussion concerning medical topics from both parties was 2.5 times greater than the amount of psychosocial discussion. Although there was a suggestion in the data that 3 clinicians showed variations in behaviour according to patient age and prognostic group, the number of patients for each doctor was small. Patients were well informed about their diagnosis, prognosis and treatment options, but their emotional well-being was rarely probed.
One hundred patients on four general surgical wards in a large teaching hospital were interviewed about the information they had received about their illness and what they had been told about the investigations they had undergone. Fifty-five of them expressed some dissatisfaction and 14 were strongly dissatisfied. The way in which ward rounds were conducted was heavily criticised, but most patients did not object to the teaching of medical students at the bedside. Twenty-four patients would have liked more explanation about why investigations were performed, and 38 though that they had not been told enough about the results of their investigations. This lack of information led to anxiety and fear. The findings suggest that more effort is needed to improve communication between doctors and patients.
In answer to a questionnaire administered in 1961, 90% of responding physicians indicated a preference for not telling a cancer patient his diagnosis. To assess attitudinal changes, the same questionnaire was submitted to 699 university-hospital medical staff. Of 264 respondents, 97% indicated a preference for telling a cancer patient his diagnosis--a complete reversal of attitude. As in 1961, clinical experience was the major policy determinant, but the 1977 population emphasized the influence of medical school and hospital training. Our respondents indicated less likelihood that they would change their present policy or be swayed by research. Clinical experience was the determining factor in shaping two opposite policies. Physicians are still basing their policies on emotion-laden personal conviction rather than the outcome of properly designed scientific studies.
To investigate the importance of a sympathetic approach to breaking bad news in the doctor-patient relationship.
Worldwide surveys of views on truth disclosure by health care professionals, the public, and patients with cancer and other diseases.
Surveys using a Medline Computer Search were identified.
Twenty-two questionnaire studies.
The data obtained demonstrate trends of an increasing wish since 1950 on the part of patients, the public and doctors for more openness.
The skills necessary for breaking bad news well can be acquired through organised undergraduate and postgraduate education which emphasises a good working doctor-patient relationship.
Numerous studies have shown that patients are usually dissatisfied with the information they receive during clinical consultations with medical specialists. Therefore, a randomised study design has been used to assess the role of personal letters to patients outlining their cancer consultation. Compared with the control group, patients receiving letters were more satisfied with the amount of information given, and tended to have greater and more accurate recall of the consultation. A survey of referring doctors revealed general support for the idea of sending to cancer patients letters that outline the substance of their consultations. The study shows that letters to patients are a useful method of improving patient satisfaction and recall in clinical consultations. They also provide a permanent record of the consultation, which can be kept for future reference, and encourage greater patient involvement in their care.
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.
'Not being told what is wrong' is the most frequent complaint patients make (Fletcher, 1980). In cancer a lack of information greatly increases the stress and anxiety experienced. In this report, 46 patients with cancer were given audiotape recordings of their 'bad news' consultations to take home. Analysis of subsequent questionnaire data revealed that both patients and their families benefited enormously from the opportunity to hear the details of their diagnosis and treatment again.
Teaching on the theme of ‘breaking bad news’ was selected for special development as part of an introductory course on communication skills for preclinical medical students in 1987. Eight parents of handicapped children and three patients terminally ill with neoplastic diseases cooperated in a series of semi-structured group discussions in which students were encouraged to interact with patients and children. The patients/parents readily assumed the role of teachers and where it was possible, they participated in similar sessions the following year.
Analysis of questionnaires indicated that the plan had proved acceptable to patients, relatives and students. Follow-up of student opinion one year later indicated that students felt they had derived benefit from these opportunities to learn first-hand from patients and parents of handicapped children.
The effects of an intervention consisting of information, referral, counseling, and follow-up care individualized to patient and spouse needs on satisfaction and coping were determined from data gathered from 30 recently diagnosed male cancer patients and their spouses. A control group of 30 recently diagnosed cancer patients and their spouses received routine information, referral, counseling, and follow-up care. All participants were assessed for their informational needs using the Informational Needs Assessment instrument, and all self-rated their satisfaction with information received using the Satisfaction (SAT) instrument. Couples in the experimental groups received formal individualized intervention as described earlier. Two weeks after the initial testing but before medical intervention, all participants again self-rated their satisfaction using the SAT instrument. The results of a repeated measures analysis of variance test indicated that the experimental groups gained more information and were more satisfied with that information when compared with their counterpart control groups.
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The diagnosis and treatment of cancer is associated with a substantial psychiatric morbidity including anxiety, depression, sexual difficulties, body image problems, illness behaviour, and conditioned responses. Active enquiry is worthwhile since most problems are alleviated by treatment once they have been elicited.
A survey of a representative sample of 62 parents of Down's syndrome infants revealed a high level (58 per cent) of dissatisfaction with the procedure for disclosing the diagnosis and with the immediate counselling services. From the replies and previous reports, a ‘model procedure’ was set up in one Area Health Authority to test the hypothesis that dissatisfaction is inevitable. Parents receiving the ‘model procedure’ reported 100 per cent satisfaction, compared with 20 per cent in a control group. It was concluded that dissatisfaction is not inevitable but results directly from organisational difficulties in not providing the necessary service.
RÉSUMÉ
Mongolisme: la révélation du diagnostic entraine‐t‐elle inévitablement une insatisfaction?
Une étude d'un échantillon représentatif de 62 parents de nourrissons mongoliens a révélé un haut niveau d'insatisfaction (58 pour cent) sur la façon dont avaient été révélés le diagnsotic et les conseils immédiatement associés. D'après les réponses et des analyses antérieures, un “procédé modèle” a étéétabli dans un département de santé pour évaluer I'hypothèse selon laquelle l'insatisfaction est inévitable. Les parents ayant bénéficié du “procédé modèle” ont donné un taux de satisfaction de 100 pour cent alors qu'un groupe contrôle accordait 20 pour cent. Les auteurs concluent que l'insatisfaction peut être évitée, mais résulte directement des difficultés d'organisation qui ne fournissent pas les services nécessaires.
ZUSAMMENFASSUNG
Down Syndrom: ist es unumgänglich, daß die Mitteilung der Diagnose Unzufriedenheit hervorruft?
Eine Befragung einer repräsentativen Gruppe von 62 Eltern von Kindern mit Down Syndrom ergab, daß ein großer Teil (58 Prozent) sehr unzufrieden war mit der Art, wie ihnen die Diagnose mitgeteilt wurde, und mit der anschließenden Beratung. Anhand der Angaben und früherer Berichte wurde in einem Gesundheitsamt eine Modellberatung eingerichtet mit dem Ziel, die Hypothese zu prüfen, die besagt, daß Unzufriedenheit unumgänglich sei. Eltern, die diese Modellberatung bekamen, waren zu 100 Prozent zufrieden, verglichen mit nur 20 Prozent einer Kontrollgruppe. Man schließt daraus, daß Unzufriedenheit nicht unumgänglich ist, sondern direkt aus organisatorischen Schwierigkeiten resultiert, durch die nicht die notwendige Beratung erfolgt.
RESUMEN
Sindrome de Down: és inevitable la insatisfacción debida a comunicar el diagnóstico?
El estudio de una muestra representativa de 62 padres de niños con sindrome de Down reveló un alto nivel (58 por ciento) de insatisfacción con el procedimiento de dar a conocer el diagnóstico y con los servicion consejeros inmediatos. Con las respuestas y de los informes previos se ideó“un modelo de procedimiento” en una área de salud mental para verificar la hipótesis de que la insatisfacción es inevitable. Los padres que recibieron el “procedimiento modelo” mostraron un 100 de satisfacción en comparación con el 20 por ciento del control. Se concluyó que la insatisfacción no era inevitable pero que era el resultado directo de las dificultades de organización al no proporcionar el servicio necesario.
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 present study explored the degree to which patients prefer to become informed about and to participate in their medical care. A total of 256 cancer patients completed an Information Styles Questionnaire and the Beck Hopelessness Scale. Patients' behavior and beliefs were found to incorporate the contemporary standard of informed and active involvement. Significant age trends were found: The younger the patients, the more closely they conformed to the well-informed participant standard of patient behavior; the older the patients, the more likely they were to prefer the older, nonparticipatory patient role. Patients who wanted to be involved in treatment decisions were significantly more hopeful than others. Most patients in each age group displayed high levels of hope, preferences for open communication about their illness, and a desire for maximum amounts of information.
When asked before admission to hospital 74% of 640 surgical patients suffering from various abdominal diseases stated that they wanted to be told if examinations revealed they were suffering from cancer. A prospective study of 58 patients confirmed this wish and no regrets were noted 3 days and 3 months later. The immediate reactions to information were moderate and almost all patients adjusted well to the situation after a short, varying, initial phase with anxiety. No severe, untoward reactions were seen. In contrast to the traditional attitude in surgical wards this study suggests that generally cancer patients should be given the diagnosis.
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.
Recent decisions in Australian courts affirm three important principles relating to consent to therapy. First, patients must be appropriately and adequately informed. Second, the scope and detail of the information supplied should be based on the reasonable patient's need to know rather than on the actions of the reasonable doctor. Third, the doctor must take care to ensure that the information imparted is understood by the patient. This publication reviews the basis of informed consent and traditional beneficent-style consent. The occasions when beneficence is more appropriate are outlined.
Therapeutic options for breast cancer, particularly for early-stage disease, and increased patient participation in medical decision-making have oriented state legislatures toward ensuring that women with breast cancer have adequate information about treatment alternatives. Currently, 18 states have enacted statutes regarding physician disclosure of treatment alternatives to breast cancer patients. This paper reviews these statutes in the context of the requirements imposed on the physician as health care provider and the content of medical information presented to the patient as a consequence of the laws. State statutes were identified through the National Cancer Institute's State Cancer Legislative Database, and the statutory requirements were analyzed. For statutes requiring development of a written summary of treatment alternatives, the most recent summary was obtained through the responsible state agency, and informational content was analyzed for relevance to treatment decisions in early-stage disease. As a group, these laws address informed consent for treatment, physician behavior within the patient-physician relationship, and the medical information upon which treatment decisions are based. Individual statutes vary in the scope of the issues addressed, particularly in the responsibility placed on physicians, and treatment option summaries developed in response to this legislation vary widely in content and scope. Despite broad implications of these statutes in oncology practice, little is known about their effects on breast cancer care. Additional research is needed to define the impact of these statutes on breast cancer care, as such legislation is considered by other states for this and other diseases.
Breaking bad news is neither an easy nor a popular task. Properly handled, however, it can be given in a positive way that the individual can both accept and understand. There may be a range of emotions and concerns following the telling of bad news. These need to be explored and worked through with each individual. This flow diagram describes the steps in this important process.
To evaluate, in a long-term follow-up study of consecutive patients (N = 99), the impact of surgery--breast-conserving treatment (BCT) versus mastectomy (MT)--on psychosocial adjustment among women with breast cancer, pTNM stage I/II.
Semistructured interviews were conducted at a median of 6 years (range, 5.8 to 8.1) after primary surgery. Sixty-six women were available for the long-term follow-up study. Twenty-six women had been treated with BCT and 40 with MT.
No statistically significant differences were found between the two groups concerning psychosocial adjustment, as measured by the Social adjustment Scale (SAS). In general, the levels of maladjustment were lower than at 13 months postoperatively, but 10% still showed maladjustment. Sixty percent of the women were unwilling to show themselves naked, and 22% felt that they had become less attractive because of the surgical treatment. In an explorative part of the interview, 68% of the women complained about how they had been informed of the diagnosis. A tendency toward a significant difference was found in the relation between previous maladjustment and a negative experience at the time of diagnosis (P = .07).
Few data are available on long-term follow-up results with regard to psychosocial adjustment among women after breast cancer surgery. This study provides the important information that there are no differences in patient psychosocial adjustment that can be ascribed to the type of surgery at 6-year follow-up evaluation.
Studies of tape recordings of cancer consultations have produced conflicting results. At the same time, audiotapes containing general information about cancer are poorly evaluated and are distributed to patients in an ad hoc manner. We compared the effects of both interventions on patient satisfaction, psychologic adjustment, and recall of information following their first consultation with a medical oncologist.
Patients (n = 142) were randomized to receive (1) an audiotape of their consultation, (2) an audiotape describing cancer in general terms, or (3) no tape. Recall of information was assessed in a structured interview 4 to 20 days after the consultation.
Satisfaction with the consultation increased linearly from no tape to general tape to consultation tape. Satisfaction with the tape itself was higher in patients who received the consultation tape (satisfaction score, 61%) compared with those who received the general tape (43%). Average recall for all groups was 6.4 of the 25 items of information presented, and 2.4 of the six points identified as particularly important by the oncologist. The consultation tape did not improve recall over the no tape control, but the general tape caused a decrease of almost two items in total recall. Spontaneous (ie, unprompted) recall was significantly poorer with the general information tape. Psychologic adjustment to cancer was unaffected.
We conclude that individual audiotapes have a limited potential to increase recall of information from the oncology consultation. General information tapes about cancer appear to inhibit recall actively.
To design a structured curriculum concerning issues of communication with patients and families for use during training of pediatric residents.
The stimulus for this initiative arose from residents perceived need for such a program and the realization that a structured approach to communication techniques did not currently exist in our residency and, in fact, in many undergraduate and graduate medical education curricula.
Our program was designed to address complex and difficult areas in physician-patient interaction, including how to deliver "bad news," deal with hostile parents, and speak to children about serious illness; the psychosocial aspects of death and dying were also covered in the program. Various teaching techniques were used. We attempted to assess residents' response and alteration in behavior consequent to the program.
The program was successfully incorporated into the training of our residents and was carried out by using existent personnel; minimal expense was incurred. The residents thought the course was valuable and effective, although no statistically significant change in the communication skills of residents could be demonstrated.
The area of physician-patient communication can be taught in a structured fashion during residency. Programs should be devised to meet the changing needs of training during residency and should incorporate the unique strengths of individual institutions.