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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 4  |  Page : 192-198

Physicians' perceptions of breaking bad news to cancer patients and family


1 Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
2 Department of Pediatrics, Dalla Lana School of Public Health, Toronto, Ontario, Canada

Date of Web Publication26-Oct-2017

Correspondence Address:
Sami Ayed Alshammary
King Fahad Medical City, Riyadh
Saudi Arabia
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DOI: 10.4103/jhs.JHS_57_17

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  Abstract 

Background: Breaking bad news to patients with a cancer diagnosis is not an easy task for physicians. The diagnosis must be explicitly stated and understood, and the prognosis must be well-discussed in the most gentle and comfortable manner. It is important that the disclosure is performed in a way that patients will not lose all hope and get very depressed and undergo an abrupt change in their outlook on life.
Objective: The aim of this study was to explore physicians' perceptions and perspectives of breaking the bad news to cancer patients before and after attending training workshops.
Methods and Settings: A quasi-experimental design was performed among physicians working in a comprehensive cancer centre. It compared the performance of the respondents in breaking bad news before and after attending a communication skill workshop. It was conducted from March to April 2017.
Results: Pre-intervention survey result showed 68% responded to the survey. Eighty-four percent were comfortable with breaking bad news, and 70% had training in breaking bad news. Eighty-six percent of the responders (86.3%) stated that patients should be told about their cancer. Almost 30% of the respondents stated that they would still disclose the diagnosis to patients even if it would be against the preference of the relatives. Nearly 61% said that they would only tell the details to the patients if asked. Nearly 67% of them disagreed that patients should be told about the diagnoses only if the relatives consent. About 51% of physicians wanted to discuss the bad news with the family and patient together, whereas 24% stated that the patient alone should be involved in the discussion.
Conclusion: Physicians face a dilemma when families do not wish the patient to know about the cancer diagnosis, and this highlights the necessity of taking into consideration the social circumstances in healthcare. When taking these into consideration, curriculum in the medical school must, therefore, be updated and must integrate the acquisition of skills in breaking bad news early in training.

Keywords: Attitude, breaking bad news, comprehensive cancer centre, perception, psychosocial distress, survey


How to cite this article:
Alshammary SA, Hamdan AB, A. Saleem LM, Ratnapalan S, Duraisamy B. Physicians' perceptions of breaking bad news to cancer patients and family. J Health Spec 2017;5:192-8

How to cite this URL:
Alshammary SA, Hamdan AB, A. Saleem LM, Ratnapalan S, Duraisamy B. Physicians' perceptions of breaking bad news to cancer patients and family. J Health Spec [serial online] 2017 [cited 2017 Nov 19];5:192-8. Available from: http://www.thejhs.org/text.asp?2017/5/4/192/217306


  Introduction Top


Bad news is defined as 'Any news that adversely and severely affects an individual's view of his or her future'. Providing serious case disclosure to anyone needs expertise, experience and compassion.[1] Breaking bad news is no doubt an essential, yet unpleasant and difficult part in daily practice, particularly for those who are dealing with cancer patients. Bad news often pertains to a situation where there is a feeling of no hope, a threat to a person's mental or physical wellbeing, a risk of upsetting an established lifestyle or where a message is given which conveys to individual fewer choices in his or her life.[1] Other source quote, 'any information which negatively and seriously impacts a person's view of his or her future life as bad news'.[2] The news may be a calamitous diagnosis such as advanced cancer with poor prognosis or limited life expectancy. It could be due to treatment failure or adverse effect of a drug.[3] There is a broad spectrum of what can be considered bad news such as: a child who has a congenital defect, an infertility problem, a contagious disease, or any other condition that may alter the life of a patient and his/her family. Regardless of the content or context of bad news, divulging them to the patient and his/her family or guardian is not an easy task.

Indeed, communicating bad news is a daunting process for the physician and excellent communication skills are needed.[4] Unfortunately, this aspect of medical practice did not receive enough attention in medical training in the past, where undergraduate medical education focused mainly on the factual and scientific knowledge, whereas the clinical and communication skills training was supposed to be acquired during postgraduate training which involved learning by observation.[5],[6]

Until the sixties of the last century, the clinical environment was more of a doctor-centred model which is in line with the consensus of the American Medical Association in 1847 that stated: 'The life of a sick person can be shortened not only by the acts but also by the words or the manner of a physician. It is, therefore, a sacred duty to guard himself carefully in this respect, and to avoid all things which have a tendency to discourage the patient and to depress his spirits';[7] it was quite acceptable among physicians to conceal any information if there is any concern it might affect the patient. However, this has been widely replaced by a patient-centred model that fosters skilful communication.[6],[7] There is growing cognisance towards the importance of specific skills needed for this task. The communication skills training, therefore, have become a core part of many Western medical schools' curricula.[6] One more relevant point to mention is that the modern model of medical practice secures patient's autonomy, and his/her right to obtain any information he/she desires to know about his/her own condition. In relation to this, a study of 529 Japanese cancer patient was conducted regarding their preference of disclosure of bad news, which revealed that 90% strongly preferred to discuss their current condition and treatment options with their physician, while 50% preferred to receive information regarding their life expectancy.[8] A systemic review in the same context demonstrates some demographic variation in this area as younger patients, female patients and those with higher education level are more inclined to receive detailed information about their medical condition.[9] However, the setting, time and the way at which the news is to be delivered is extremely important.[10]

Poor communication, especially with cancer patients, has been found to produce unfavourable physical and psychosocial outcomes, such as poor pain control, worse compliance to treatment and patient discontent.[11] On the physician side, however, communication difficulties lead to job dissatisfaction, higher stress levels, affect the doctor-patient rapport. Moreover, it can be a leading cause of iatrogenicity and litigation against the doctor and health facility.[6],[12]

It has been shown that a number of factors influence doctors' communication skills when delivering bad news. Some of these factors include: burnout and fatigue, time restrains, deficiency of experience, individual's barriers, such as spiritual and cultural believes, personal attitudes and fear of harming the patient or fear of being blamed.[13],[14] Conveying bad news is found to be more difficult when the clinician has a long-standing relationship with the patient, when the patient is young, or when hope had been retained for a successful outcome previously.[15]

A systematic review has exhibited that attending communication skills training course does have a role in boosting communication behaviour and attitudes.[16] However, the benefit of these training courses might not be apparent to the health professionals involved.[17] In the same context, one study showed that doctors who had not commenced a proper communication skills training were incapable of establishing requisite communication skills, even after 10 years or more of clinical work.[6] There is evidence that medical students who received structured clinical communication skills training have broader conception of communication, and better understanding of their patients' needs.[18]

Communication is a two-way process and how the news is understood depends on patients' expectations, previous experience, the overall stress and emotional state at the time of communication.[19] The physician should be able to deal with the stress generated by the impact of the bad news, acknowledge the patient's emotions while supporting patients and family in making informed decisions that are harmonious with their individual situation and to the best of their interest.

There have been protocols and frameworks created to facilitate breaking bad news. 'SPIKES' (Setting, Perception, Invitation, Knowledge, Empathy, Strategy and Summary) is a well-known six-step protocol that has been shown to boost the confidence of doctors who use it in communicating bad news with cancer patients.[2] Others have produced similar framework designed to aid the physicians such as, 'BREAKS' (Background, Rapport, Explore, Announce, Kindle, Summarize),[20] the 'Calgary-Cambridge framework' for breaking bad news (Beginning the session, Sharing the information, Being sensitive to the patient, Planning and support, Follow-up and closing)[21] and ABCDE protocol (Advance preparation, Build therapeutic relationship, Communicate, Deal with reactions, Explore patient's understanding).

Materials for teaching the skill of breaking bad news may comprise lectures, group discussions, role-playing and teaching in the context of patient care.[22] A survey from North Italy among 674 doctors from different backgrounds, found that 86% of the responding physicians prefer guidelines to assess breaking bad news to patients.[23] Another study showed that standardised patient intervention for breaking bad news improves healthcare professionals' performance when comparing pre- and post-intervention scores.[24]

Currently, up to the researchers' knowledge, there is no evidence supporting superiority of one protocol of breaking bad news over another.


  Methods Top


The objectives of this study were to evaluate the effect of multimodal teaching workshops on Cancer physician's interdisciplinary teams' knowledge of communication skills, and their beliefs relating to breaking bad news. The Comprehensive Cancer Centre (CCC) encompasses departments of Medical Oncology, Radiation, Haematology and Palliative care; it provides service for adults and paediatrics patients from all over the Kingdom of Saudi Arabia through referral system. At present, there are 95 beds for inpatient, and an average of 1500 outpatients visits monthly.

Study design

This study was a questionnaire survey of physicians working at CCC in order to compare the physicians' perceptions of communicating bad news before and after attending a communication skills workshop. The workshop included didactic lectures, microteaching, small group teaching and interactive discussions. All participants completed a pre and post-test questionnaires which was handed out before and after their training session.

Study population

All physicians (Consultant, Assistant Consultant, Fellows and Residents) who were working at the CCC during the time of the study (n = 75) were included in the study. Doctors who did not come into lineal contact with patients for example; pathologist, clinical pharmacists and forensic physicians were excluded from the study population.

Questionnaire development

A validated questionnaire was used which was composed of two sections;

  • Section I: Included demographic inquiry such as: age, gender, speciality and rank, as well as year of graduation
  • Section II: Was designed to extract the participant's concept and performance in communicating bad news.


Statistical analysis procedure

All categorical variables: age group, speciality, job title, etc., were presented as numbers and percentages. Chi-square/Fisher's exact test was used according to whether the cell expected frequency was smaller than 5; and furthermore, to determine the significant relationship between training in professional breaking bad news and survey responses as well as other categorical variables; a P < 0.05 was considered as statistically significant. All data were entered and analysed through statistical package SPSS (IBM Corp. 1989, 2013. IBM SPSS Statistics, Version 22.0.)

The response rate for physicians completing pre- and post-workshop surveys was 68% (n = 51/75) and all of them were included in the analysis. Haematology and Oncology speciality were the most common respondents in the survey, 31% (n = 16) of respondents were from the Oncology Department, and 27.5% (n = 14) from Haematology. Seventy percent of responders had previous training in breaking bad news. Please see [Table 1] for demographic information.
Table 1: Pre-interventional survey demographic data

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Comfort with disclosing breaking bad news

In the pre-workshop survey 84% stated they were comfortable with breaking bad news. Eighty-six percent of responders stated that patients should be told about their cancer status. About 30% of the respondents reported that they would still disclose the diagnosis to patients even if it would be against the preference of the relatives and 61% said that they would only tell the details to the patients if asked. About 67% disagreed that patients should be told about their diagnoses only if their relatives consent. About 51% of physicians wanted to discuss the bad news with the family and patient together, whereas 24% stated that the patient alone should be involved in the discussion.

There was no significant difference in the comfort level of breaking bad news after the workshop (post-test). A slight decrease was found whether physicians would tell the patients their cancer diagnosis (82.4% from 86%, not statistically significant) in post-interventional survey. Furthermore, 15 (29.4%) of the respondents stated that they would still disclose the diagnosis to patients even if it would be against the preference of the patient's relatives of not saying so. [Table 2] illustrates the statistical interpretation of the responses from physicians related to breaking bad news.
Table 2: Comparative analysis of pre- and post-survey responses of breaking bad news

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Perceptions of withholding information from patients

About 61%, both in the pre- and post-survey, preferred only to tell the details to the patients if they were asked to. Meanwhile, 67% (34) chose to disagree that patients should be told about the diagnoses only with the relatives' consent in the pre-training survey and 78% (40) after the training, which was not statistically significant (P = 0.391). There was a significant increase in physicians stating that it is more appropriate to talk to the patient first, after the training (24%–45%; P = 0.027).

Timing of disclosure

In both the surveys, 47 (92.2%) and 48 (92.7%) agreed that information regarding the patient's case could be given over multiple visits to facilitate a more comprehensive disclosure of the information to be conveyed.

Physicians' perceptions of patients' reaction to bad news

More than half of them believe that breaking bad news will not take away the patient's hope 26 (51.0%) or lessens his/her survival. Post-test, this number rose to 64.7%.

The intervention was efficient in improving the number of physicians who felt they have had training to handle difficult disclosure from 70.6% to 90.2% (P = 0.013).

Thirty-nine (76.5%), 36 (70.6%) of the respondents in the pre-and post-tests believed that patients were keen on knowing about their disease.

Physicians' self-reported reaction after breaking bad news

About 21 (41.2%) of the respondents agreed that they felt depressed after disclosing bad news to patients. There was no improvement with this percentage after the training workshop. A similar number of 21 (41.2%) did not report having any particular feeling on breaking bad news, but after the training workshop, this percentage became 33.3%.[17] Interestingly, 43 (80.3%) in pre-, and 36 (70.6%) in post-survey result considered giving false hope to patients was more stressful than disclosure of diagnosis.

The results indicated that issues about physicians' beliefs in resuscitation were varied. The physicians were divided about when discussions of resuscitation should occur, and more than half of them were depressed after such discussions. The majority of the respondents 43 (84.3%) in pre-, and 47 (92.2%) in post-survey identified the discussion of resuscitation with patients and relatives as important. More than half in both surveys stated that having both patients and relatives, together, is the preferred set-up when resuscitation is being discussed, and only 11.8% in pre-survey result and 21.3% said that patients alone should be involved in this discussion.

The best time for DNR discussion is when the patient is conscious and oriented according to 86.3% (n = 43) in pre, and 87.2% (n = 45) of post-test responders; while 9.8% (n = 5) in the pre, and 8.5% (n = 4) in post-test stated this discussion should take place only when the patient is comatose, and requirement of resuscitative measures are imminent.

Almost all of the participants (47/51) stated that resuscitation should be discouraged in uncontrolled or metastatic disease; one physician (2.0%) in pre-survey, and 3 (5.9%) in post-survey reported that aggressive resuscitation should be offered to all irrespective of stage or cause. Only 16 (31.4%) were aware that there is a hospital protocol addressing the issue of resuscitation in terminal patients, however, this percentage changed to 35 (68.6%) in the post-test (P = 0.001).


  Discussion Top


The rates of the comfort among the physicians while breaking bad news was higher than the rest of the previous studies and the training programme had mild-to-moderate effects on physicians' attitudes and perceptions. This could be due to the fact that King Fahad Medical City is a tertiary medical hospital which has exposed the participants in this study to the most relevant patient factors encountered in daily clinical practice. Significant changes found, after the training programme, were that more physicians stated that the patient should receive the information first and more became aware of the institutional policies. Physicians' views of honouring family wishes in the sociocultural environment of the Middle East is not surprising, and this practice may be explored further by interviewing patients and families.

In the previous eras, doctors were the ones who decided the fate of their sick patients. It is in contrary to the majority of the concerned patients who are more eager to know about their condition and their health status. Furthermore, they even want to get involved in the decision-making, wherein (pre 76.5%, post 90.2%) of the respondents confirmed that their patients were eager to know about their illness.

Moreover, this also concurs with the international guidelines that patients should be aware of their disease. However, the manner of disclosure must not be at one interview setting. The information about a patient's disease must be informed in a gradual manner to prevent patient's emotional downfall and promote more comprehension.[25]

It is common to the populace's perception that cancer, as a diagnosis, means death.[26] In this context, the responsibility lies on the treating physicians. She/he must be able to assess the patients' capability to accept information in order for them to act accordingly or else, he/she will just be striking them unnecessarily or reassuring them falsely.

An effective strategy is to first relay encouraging words to patients before exposing the bad news which contributes to feelings of hopelessness.[27] In this study, the majority of the physicians believed that sick patients gave importance to the presence of family members during the 'bad news' interview. In the previous studies, it was the patient who determined the amount of information needed to be disclosed.[16],[28] Furthermore, the disclosure of patients' clinical information should best rely on the patients' preference.[29],[30] She/he has the right not to let his/her relatives know the details of his/her condition, and this is a vital ethical principle that all doctors must bear in mind.[31] However, in this communication, the doctor must be at his/her modest condition for him/her to appear as very approachable and not provoking at all. Assertively, he/she needs to explain to the patient's relatives in the most comprehensive manner the ethical purpose of keeping information from the patient as it may lead to some effects such as confusion and loss of confidence. He/she must also give assurance that he/she would be able to set the discussion with the patient with high sensitivity while limiting the information as to what the patient prefers to share.[32],[33] One of the previous studies showed that 66.7% of its respondents preferred not to let the patient know their very real health condition to prevent intense negative emotions such as downfall and heartbreak.[34] However, 64.7% of the respondents in the current study concur that breaking bad news does not automatically take away hope and does not decrease survival. Interestingly, 32 (62.7%) of the physicians will not voluntarily disclose unless the patient requested full information.

Discussing resuscitation with cancer patients and their relatives has remained a complex and challenging task. Identifying who, among the patients, needs resuscitation is one of the most serious concerns in cancer care. This study has revealed that, 5.9% in pre-, 2% in the post-tests of the respondents, believe that patients with controlled primary or with acute and reversible causes must be the only ones to receive resuscitation.

Our study found that most physicians who responded believe that resuscitation should be discouraged in medically incurable cases. However, physician's knowledge about the information, any law for resuscitation and institutional policies remains very low, and this has lead to a low level of legal awareness regarding resuscitation concerns which affects Oncology practitioners on a day-to-day basis.

As mentioned from the previous research, attitudes and behaviours of professional caregivers may vary widely, as they can be affected by several factors, such as conscience, religion, culture, personal experience and education.[35],[36],[37] While this may be true, physicians must extend their efforts in providing disclosure about patient's resuscitation status in a matter that suffices their needs about the explanation of its information.

It is important for physicians to inform patients and their families about desired outcomes of Cardiopulmonary Resuscitation and its potential associated risks. Furthermore, if the patient's condition indicates, and if the need arises the option for Do Not Resuscitate (DNR) should be discussed with them. It is vital that families should actively participate in the decision-making. There are ethical and moral concerns that need to be taken into consideration regarding resuscitation and the DNR concept.

The study shows that the majority wish to have DNR discussion early led by the consultants attending to the patient. We believe that inappropriate resuscitations add stress to the 'code team' consisting of junior doctors who would call if the patient arrests. We also hope to implement simulation training for DNR discussion to provide physicians some practice and increase their comfort levels.

Although most doctors working in the cancer centre felt that they were just comfortable in breaking bad news to patients, some statements showed that the physicians felt depressed after disclosure and need ongoing training and support.


  Conclusion Top


Resuscitation remains a challenging area with disagreements on patient's involvement and final decision-making. The social context in the Middle East where there is an extended family set-up and family support during illness, the relatives' attitudes and beliefs versus patients' wishes remain a tricky area as shown in our study. It is, therefore, vital to incorporate breaking bad news training in medical school curriculum focusing more on ethical and legal issues in cancer patients. In connection with the various beliefs and practices observed, it is recommended that breaking bad news education should be part of the medicine residency curriculum, especially in the Oncology, Haematology, Paediatric Oncology and Radiation Oncology fields. Availability of guidelines from some professional organisations (i.e., Saudi Association of Palliative Care or Saudi Oncologists Society) in this would go a long way in resolving some of these issues to a large extent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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