Communicating bad news in oncology: the medical oncologist’s perspective

Abstract

Nowadays cancer has become one of the most common diseases, due to its high incidence and mortality. Because this diagnosis has a major impact on the patient’s psychological perception and quality of life, the Medical Oncologist should develop an individual approach to every patient. From our clinical experience, in collaboration with our psychologist, we have sum up some of the most important objectives, which the doctor should follow in order to improve the communication skills. First of all, we have to be aware of the sequences of the adaptation process towards the diagnosis of cancer, which are merely common for most of the patients. Secondly, we have to improve our communication skills by respecting some principles such as: the proper timing and place (each with particularities) and our personal communication criteria. The efficacy of the doctor’s communication skills is reflected in the maintenance of a good patient-doctor relation, reflected also by the trust and the continuous addressability of the patient and the therapy compliance. The aim of this paper is to enlighten and optimize the communication of bad news in the Oncology field.

 

Tablet of Contents:

1. Introduction

2. Material and method

3. Results

4. Conclusion

 

1. Introduction

Nowadays cancer has become one of the most common diseases, due to its high incidence and mortality. It is estimated that it is the second cause of death worldwide and the sites with the top incidence are the lung, female breast and colorectum [1]. This statistical data, which can be easily accessed by anyone, establishes cancer as one of the most feared diagnosis.

Because it has a major impact on the patient’s psychological perception and quality of life, the Medical Oncologist should develop an individual approach to every patient but in out daily practice we have to face many obstacles in order to apply the theoretical skills.

Throughout the years, delivering bad news to cancer patients has been a topic of great interest, which is revealed by the many medical articles from the specialty literature, which we have further summarized. First of all, we have to state the definition of bad news, described as any news that affects adversely and severely an individual’s view of the future, as mentioned in the literature [2]. One of the earliest communication protocols was implemented by Buckman in his book, and included criteria such as: finding out how much the patient wants to know, delivering the bad news personally, making sure the message is understood, etc [3]. Later on, a protocol with five phases was created by Fine, which focused on doctors’ preparation, the acquisition, sharing and reception of the information by the patient and finally, the patient’s response [4]. By far the most popular protocol, approved in many countries as a standard, is the SPIKES protocol, developed by Baile et al., Each letter represents an abbreviation from the main subjects, as follows: S is addressed to the doctor and stands for setting up the interview, P is also attributed to the medical oncologist and consists of assessing the patient’s perception, I refers to obtaining the patient's invitation, K symbolizes the knowledge given to the patient, E describes the emphatic response to the patient’s emotions and S illustrates the strategy and summary [5]. Also, another model entitled ABCDE was proposed by Rabow and McPhee and focuses on the following aspects: the doctor’s preparation in advance of the discussion, building a therapeutic relationship or environment, a good communication, dealing with the patient’s reactions and the ones of his family and encouraging and validating emotions [6]. Although we have access to this medical data, many physicians especially those at the beginning of their career, feel unprepared and have a lack of communication skills, when it comes to delivering bad news to their patients.

Our medical preparation does not include an effective training programme on breaking bad news and the doctors fear of being blamed, not knowing all the answers, which can further disengage them emotionally from their patients [7]. An important solution should include the acknowledgement offered by the protocols previously mentioned and a patient-centered approach, adjusted to the physician's personal experiences.

 

2. Material and method

From our daily practice, we have sum up some of the most important objectives, which the Medical Oncologist should follow in order to improve the communication skills. We are grateful to have in our Department a clinician psychologist, who offers a very important support to our patients. First of all, we have to understand that the adaptation at the diagnosis of cancer is a complex procedure, which varies from one patient to another and it is differentiated by the patient’s personality features, life experiences and expectancy. Still, this process is gradual and contains common features which can be identified at almost all the patients and have been described as the Kubler-Ross stages. This includes five steps which the patient goes through, beginning with the negation. In this phase the patient refuses to admit the diagnosis and considers it a mistake and the consequences derive in not continuing the further medical investigations. Related to it, is the fury phase in which the patient passes the responsibility of the diagnosis on another person, except from itself and may lead to aggressive behavior. In the negotiation phase, the patient begins to partially admit the diagnosis but takes no further action. This translates into the depression phase, in which the patient feels hopeless and abandoned and adopts a negative behavior. Despite the steps described, in this period of time, which is different at each patient, the disease in progressing.

The latest step is the acceptance, when the patient becomes more optimistic and eager to fight with the disease and accepts the medical treatment and investigations [8]. One of the most important aspects of an efficient communication is the proper timing and there are some key points which should be taken in consideration. The physician should deliver the information in the suspicion phase, when the patient undergoes the medical investigations, in the certainty phase, at the beginning of the oncological treatment (chemotherapy or radiotherapy) before signing the consent. Also, the patient should be informed when the disease is evolving (when it metastasizes or relapses), when the active treatment must be resumed or in the palliative stage. Most importantly, the patient must be kept updated whenever we discover new medical information upon his disease. According to the ethical grounds, we should not inform the patient about his diagnosis or prognosis when he particularly requests not to find out, when the death is imminent (but the family is informed), or when he is not autonomous [9]. Another major part is how we communicate with the patient and as medical oncologists we have to exercise some abilities such as the active listening, adopting an emphatic attitude towards the patient. Also, we should be aware of the patient’s personality features and adjust our dialogue to his level of understanding and provide an open communication with clarifying questions and feedback. We aim to provide a sincere and positive communication, based on realistic objectives, with simple and logical terms. The final aspect we want to approach is the location. The environment factors may affect the patient’s trust towards the hospital and the physician’s reputation. We should provide an intimate setting, by choice in our personal office, where the patient and his family can feel comfortable. Because of the emotional impact of this diagnosis, we should not deliver bad news when other people are around, in places such as the hospital hallway. As a form of respect shown to the patient, we should provide our personal office as the proper location for this task and allocate sufficient time.

 

3. Results

From our daily routine we have identified that one of the major key points identified above is not sufficiently developed. The lack of time is considered our greatest impediment in communication. From our daily programme we can assess 10-15 minutes/patient, which are merely not enough. In most of the cases, after communicating the diagnosis, the family wants separate explanations, aside of the patient and this requests more time. Also, the patient is not convinced by the information we have delivered and if we do not clarify his answers, he will look up for a second opinion at another physician which delays the further treatment and examinations. Our help comes from the collaboration with the clinician psychologist in our Department, who provides a great benefit for the patient. Although this support is essential, the major role in communicating bad news is attributed to the physician, which has the moral duty to inform the patient about the prognosis, treatment options and the side effects. As mentioned before, each patient needs time to understand and accept the diagnosis and decide upon the treatment option. We should inform about the consequences of the treatment delay, but we must never rush the patient into taking a decision because this is his personal decision.

After we have established a patient-doctor relationship and we gained the patient’s trust, we have observed that diagnosis of cancer remains the most feared of the medical specter because of its bad prognosis associated with high mortality. Also, patients are afraid of the side-effects of the therapy, especially those visible, such as alopecia and rash. Subsequently, during chemotherapy or radiotherapy the capacity of work is often affected so the patients are frightened of losing their independence and become a burden for their family. In their opinion, the diagnosis of cancer confers a social stigma and subsequently interferes with their social lives. Offering support to cancer patients is vital and it begins from the physician, psychologist, nurses and medical staff, family members, friends and support groups.

 

4. Conclusion

To sum up, a proper delivery of bad news in the key in the future patient-doctor relationship. Gaining the patient’s trust is essential and requires good communication skills as those mentioned above. In spite of the major challenge that we have to encounter, the lack of time, we should find solutions to adapt the theoretical data into our daily practice. The treatment compliance is based on our relationship with the patient, and because is it a major part of his diagnosis with a changing impact on his life, we should offer him explanations every time he comes at the hospital to perform it. Also, the young doctors should be provided by their mentor with some efficient communication skills to become confident in this task.

 

The Authors:

MIHUȚIU Simona [1] [2]

PĂTCAȘ Adela [3]

LUPĂU Corina [1]

VLAD Camelia [1]

[1] Clinical County Hospital “Dr. Gavril Curteanu” Oradea (ROMANIA)

[2] Faculty of Medicine and Pharmacy Oradea (ROMANIA)

[3] Institute of Oncology “Prof. Dr. I. Chiricuta” Cluj Napoca (ROMANIA)

 

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