Physicians' attitudes to and problems with truth-telling to cancer patients

Culture and end of life care: a scoping exercise in seven European countries

AIM

Culture is becoming increasingly important in relation to end of life (EoL) care in a context of globalization, migration and European integration. We explore and compare socio-cultural issues that shape EoL care in seven European countries and critically appraise the existing research evidence on cultural issues in EoL care generated in the different countries.

METHODS

We scoped the literature for Germany, Norway, Belgium, The Netherlands, Spain, Italy and Portugal, carrying out electronic searches in 16 international and country-specific databases and handsearches in 17 journals, bibliographies of relevant papers and webpages. We analysed the literature which was unearthed, in its entirety and by type (reviews, original studies, opinion pieces) and conducted quantitative analyses for each country and across countries. Qualitative techniques generated themes and sub-themes.

RESULTS

A total of 868 papers were reviewed. The following themes facilitated cross-country comparison: setting, caregivers, communication, medical EoL decisions, minority ethnic groups, and knowledge, attitudes and values of death and care. The frequencies of themes varied considerably between countries. Sub-themes reflected issues characteristic for specific countries (e.g. culture-specific disclosure in the southern European countries). The work from the seven European countries concentrates on cultural traditions and identities, and there was almost no evidence on ethnic minorities.

CONCLUSION

This scoping review is the first comparative exploration of the cultural differences in the understanding of EoL care in these countries. The diverse body of evidence that was identified on socio-cultural issues in EoL care, reflects clearly distinguishable national cultures of EoL care, with differences in meaning, priorities, and expertise in each country. The diverse ways that EoL care is understood and practised forms a necessary part of what constitutes best evidence for the improvement of EoL care in the future.

Availability of psychiatric consultation-liaison services as an integral component of palliative care programs at Japanese cancer hospitals

OBJECTIVE

Collaboration between psychiatry and palliative medicine has the potential to enhance the quality of medical practice. The integration between palliative care and psychiatry has been attempted only in discrete medical settings and is not yet firmly established as an institution. Our objective was to determine the availability and degree of integration between psychiatric consultation-liaison services and palliative care in Japan.

METHODS

A survey questionnaire was mailed to consultation-liaison psychiatrists at 375 government-designated cancer hospitals regarding their consultation-liaison services.

RESULTS

A total of 375 survey questionnaires were sent to consultation-liaison psychiatrists, with a response rate of 64.8%. Designated cancer hospitals with approved palliative care teams were significantly more likely to have a consultation-liaison psychiatrist in the palliative care team than those in non-approved palliative care teams [80/80 (100%) versus 110/153 (73%); P= 0.008]. Approved palliative care teams had double the number of referrals, conducted rounds more frequently and held conferences more frequently. Psychiatrists of the approved palliative care teams spent more of their time on palliative care consultations, adhered more closely to consultation processes and contributed more actively to the integration of developmental perspectives in treatment plans.

CONCLUSIONS

In Japan, most designated cancer hospitals with approved palliative care teams were more likely to integrate psychiatric consultation-liaison services into their palliative care programs. Systematic strategies for integration between palliative care and consultation-liaison psychiatry would contribute to the provision of appropriate psychosocial care for cancer patients and families at all stages.

Breaking bad news issues: a survey among radiation oncologists

Introduction:

Discussion of bad news and resuscitation in terminal cancer is an important but difficult and often neglected issue in day-to-day oncology practice.

Materials and Methods:

We interviewed 35 radiation oncologists using an indigenous 15-item questionnaire on their beliefs about breaking bad news and resuscitation to terminal cancer patients.

Results:

Most responders had an oncology experience of three to seven years (20/35). Thirty-two were comfortable discussing cancer diagnosis, prognosis and life expectancy-related issues. A similar number believed all cancer-related information should be disclosed, while only four believed in imparting all information in one visit. All agreed that disclosing sensitive information did not affect survival. When requested by relatives to withhold truth from patients, 11 said they would not comply, 22 agreed to tell the truth only if asked and two agreed to avoid difficult questions. Twenty responders denied having been adequately trained in breaking bad news and were keen on dedicated classes or sessions in this area of practice. Most (33/35) believed that Indian patients were keen on knowing their diagnosis and prognosis. Although all agreed to the importance of discussing resuscitation, only 17 believed patients should be involved. Majority (20/35) agreed that the issue needs to be discussed while the patient was conscious. Patients with unsalvageable disease were deemed unsuitable for aggressive resuscitation by 30 responders while the rest believed it should be offered to all. Most (21/35) admitted to feeling depressed after breaking bad news though only seven felt disclosure was more stressful than untruthful statements. Only four knew of a law regarding resuscitation in cancer.

Conclusion:

Observing the widely varied beliefs and practices for disclosing bad news, it is recommended that such training be a regular part of medicine curriculum, especially in the Oncology setting.

The validity of self-reported cancer diagnoses and factors associated with accurate reporting in a cohort of older Australian women

Epidemiological research often ascertains cancer history via self-reported questionnaires. We assessed the validity of self-reported cancer diagnoses in women born 1921-1926 recruited to the Australian Longitudinal Study in Women's Health (ALSWH) and determined the factors associated with false positive (FP) and false negative (FN) reporting. 4234 ALSWH cohort members were asked at baseline (1996) and in subsequent three-yearly surveys whether they had been diagnosed with specific cancers, including breast, cervical, lung and colorectal. We linked the cohort to the population-based New South Wales Central Cancer Registry (CCR) from 1972 to 2005 to identify registered invasive cancers. We calculated sensitivity, specificity and positive predictive value (PPV) of self-reported cancer diagnoses overall, at baseline (prevalent cancers) and follow-up (incident cancers) using the CCR diagnosis as the 'gold standard'. We used adjusted logistic regression to examine the determinants of FP and FN reports. Overall sensitivity was 89.2% (95% CI 86.0-91.7%) and exceeded 90% for breast, lung and colorectal cancer at baseline. Overall specificity was 96.9% (95% CI 96.3-97.5%), however, PPV was lower at 66.5% (95% CI 62.7-70.1%). FN reporting of any cancer at baseline was associated with being born overseas. Sensitivity and specificity of self-reported cancer diagnoses in this cohort of older women (aged 70-75 years at baseline) is high but PPV is comparatively lower. Hence, the use of linked data from population-based cancer registries is recommended for studies of cancer epidemiology. Particular attention must also be paid to country of birth in self-reported cancer data, as these findings suggest cancer will be under-reported by this group of women.

Cross-cultural adaptation of an innovative approach to learning about difficult conversations in healthcare

BACKGROUND

The Program to Enhance Relational and Communication Skills (PERCS) was developed at a large hospital in the United States to enhance clinicians' preparedness to engage in difficult conversations.

AIM

To describe the implementation of PERCS in an Italian hospital and assess the program's efficacy.

METHODS

The Italian PERCS program featured 4-h experiential workshops enrolling 10-15 interdisciplinary participants. The workshops were organized around the enactment and debriefing of realistic case scenarios portrayed by actors and volunteer clinicians. Before and after the workshop, participants rated their perceived preparation, communication and relational skills, confidence, and anxiety on 5-point Likert scales. Open-ended questions explored their reflections on the learning. T-tests and content analysis were used to analyze the quantitative and qualitative data, respectively.

RESULTS

146 clinicians attended 13 workshops. Participants reported better preparation, confidence, and communication skills (p < 0.001) after the workshops. The program had a different impact depending on the discipline. Participants valued the emphasis on group feedback, experiential and interdisciplinary learning, and the patient's perspective, and acquired: new communication skills, self-reflective attitude, reframed perspective, and interdisciplinary teamwork.

CONCLUSION

PERCS proved culturally adaptable to the Italian context and effective in improving participants' sense of preparation, communication skills, and confidence.

The psychology of antecedents to adult reproductive disorders in adolescent girls

The normal developmental tasks and roles of adolescence are altered by a diagnosis of a reproductive disorder. The crisis of impaired fertility affects both parent and child, stressing the family system. For the adolescent girl, a reproductive disorder has an impact on her developing sense of self, body-image, and sexuality, which, in turn, can affect her self-esteem and relationships with others. Because of the sexual nature of a reproductive disorder, feelings of embarrassment or protectiveness are often engendered that can make it difficult for families to discuss. Nonetheless, families do best with openness and honesty regarding the condition and should be discouraged from keeping the diagnosis a secret. Adolescence encompasses a broad spectrum of emotional maturity, which needs to be considered by parents and clinicians when communicating information. Understanding that the family is an emotional unit, a family systems approach to deal with health issues is most appropriate. In this context, parents need to first deal with their own feelings about the diagnosis, before they can help their child. Secondly, parents must be provided with tools to build an ongoing conversation with their child that will avoid stigmatizing her condition and handicapping her growth into healthy adulthood. The goal for parent and clinician is to help the adolescent girl formulate positive self-esteem and body image, despite impaired fertility.

Can the caregiver replace his/her elderly cancer patient in the physician-patient line of communication?

GOALS OF WORKS: Only few studies have focussed on the information needs of senior cancer patients. The aim of this study was to evaluate to what extent caregivers perceive their elderly cancer patients' informational needs.

MATERIALS AND METHODS

Between June 2004 and February 2005, at the National Cancer Institute of Aviano (northern Italy), we asked 112 elderly cancer patients naïve for treatments (age >65 years) and their 112 accompanying family members to fill in a self-administered questionnaire exploring the patient's information needs and his/her information-seeking behaviour.

MAIN RESULTS

Elderly patients (60 males and 52 females, mean age 72 years) were mostly affected by genital-urinary (27%) or breast/gynaecological (25%) cancer. Caregivers were usually females (71%), daughters/sons (45%) and/or partners (41%). The interobserver agreement for the information request regarding cancer diagnosis and disease management, for the selected information sources consulted to acquire knowledge and for the reasons for seeking further information between the elderly patients and their caregivers were unsatisfactory to poor.

CONCLUSIONS

Our results show that caregivers misunderstand the informational needs of their patients. Therefore, elderly patient information preferences cannot be predicted accurately by talking to relatives. The recommendation to oncologists is to be more responsive to the needs of both elderly cancer patients and their family members.

Different attitudes of Chinese patients and their families toward truth telling of different stages of cancer

OBJECTIVE

Cancer patients and their families differed in their attitude toward truth telling. The objective is to investigate different attitudes of Chinese patients or families toward whether and how to disclose diagnosis to patients with different stages of cancer and to examine the difference between the two groups.

METHODS

A questionnaire was delivered to 1023 participants.

RESULTS

Three hundred and eighty-two patients and 482 families completed the questionnaire. Cancer patients were more likely than families to believe that patient should be informed of the diagnosis (early-stage, 90.8 vs 69.9%, P<0.001; terminal stage, 60.5 vs 34.4%, P<0.001), and that doctor-in-charge was the appropriate person to disclose the diagnosis. Most participants thought that patient should be disclosed immediately after the diagnosis. Nearly half of participants reported that patient should be disclosed in a quiet and undisturbed room. When the hypothetic diagnosis changed from early-stage cancer to terminal illness, the number of participants, who wanted patient to know the diagnosis, decreased significantly.

CONCLUSION

Our findings indicated that Chinese cancer patients and their families differed in their attitude toward truth telling and the attitudes toward such a disclosure were influenced by disease stage. Physicians should realize this phenomenon and pay more attention to the skills of how to disclose the cancer diagnosis.

Cultural aspects of communication in cancer care

Cultural competence in oncology requires the acquisition of specific knowledge, clinical skills, and attitudes that facilitate effective cross-cultural negotiation in the clinical setting, thus, leading to improved therapeutic outcomes and decreased disparities in cancer care. Cultural competence in oncology entails a basic knowledge of different cultural attitudes and practices of communication of the truth and of decision-making styles throughout the world. Cultural competence always presupposes oncology professionals' awareness of their own cultural beliefs and values. To be able to communicate with cancer patients in culturally sensitive ways, oncologists should have knowledge of the concept of culture in its complexity and of the risks of racism, classism, sexism, ageism, and stereotyping that must be avoided in clinical practice. Oncologists should develop a sense of appreciation for differences in health care values, based on the recognition that no culture can claim hegemony over others and that cultures are evolving under their reciprocal influence on each other. Medical schools and oncology training can teach communication skills and cultural competence, while fostering in all students and young doctors those attitudes of humility, empathy, curiosity, respect, sensitivity, and awareness that are needed to deliver effective and culturally sensitive cancer care.

Palliative care in amyotrophic lateral sclerosis, Parkinson's disease, and multiple sclerosis

BACKGROUND

Amyotrophic lateral sclerosis, Parkinson's disease, atypical parkinsonian syndromes, and multiple sclerosis are progressive neurologic disorders that cumulatively afflict a large number of people. Effective end-of-life palliative care depends upon an understanding of the clinical aspects of each of these disorders.

OBJECTIVES

The authors review the unique and overlapping aspects of each of these disorders with an emphasis upon the clinical management of symptoms.

DESIGN

The authors review current management and the supporting literature.

CONCLUSIONS

Clinicians have many effective therapeutic options to choose from when managing the symptoms produced by these disorders.

Ways to obtain a breast cancer diagnosis, consistency of information, patient satisfaction, and the presence of relatives

GOALS OF WORK

What physicians told breast cancer patients about their diagnosis, who informed them, and how this information was conveyed were examined in this study. Finally, the relatives' role in this communication process was considered.

MATERIALS AND METHODS

Women with primary breast cancer (N = 222) below the age of 70 were interviewed after surgery and after they were informed about their diagnosis.

MAIN RESULTS

One hundred twenty-one women consulted their primary gynecologist first, then they were referred to a radiologist, and finally to the secondary care gynecologist. Forty-seven women omitted the radiologist and only five went directly to the hospital for treatment. In most cases (N = 199), the general practitioner was not involved. Receiving inconsistent information was associated with patient dissatisfaction. This also applies to women who received their diagnosis on the phone. Women awaiting a worse diagnosis were more likely to be accompanied by another person.

CONCLUSIONS

Future studies should focus on the possible involvement of family doctors and relatives during the diagnostic process. Giving inconsistent information should be avoided.

Communication Strategies and Cultural Issues in the Delivery of Bad News

Good communication is a fundamental skill for all palliative care clinicians. Patients present with varied desires, beliefs, and cultural practices, and navigating these issues presents clinicians with unique challenges. This article provides an overview of the evidence for communication strategies in delivering bad news and discussing advance care planning. In addition, it reviews the literature regarding cultural aspects of care for terminally ill patients and their families and offers strategies for engaging them. Through good communication practices, clinicians can help to avoid conflict and understand patients' desires for end of life care.

Anxiety and depression in patients with gastrointestinal cancer: does knowledge of cancer diagnosis matter?

Background

Gastrointestinal cancer is the first leading cause of cancer related deaths in men and the second among women in Iran. An investigation was carried out to examine anxiety and depression in this group of patients and to investigate whether the knowledge of cancer diagnosis affect their psychological distress.

Methods

This was a cross sectional study of anxiety and depression in patients with gastrointestinal cancer attending to the Tehran Cancer Institute. Anxiety and depression was measured using the Hospital Anxiety and Depression Scale (HADS). This is a widely used valid questionnaire to measure psychological distress in cancer patients. Demographic and clinical data also were collected to examine anxiety and depression in sub-group of patients especially in those who knew their cancer diagnosis and those who did not.

Results

In all 142 patients were studied. The mean age of patients was 54.1 (SD = 14.8), 56% were male, 52% did not know their cancer diagnosis, and their diagnosis was related to esophagus (29%), stomach (30%), small intestine (3%), colon (22%) and rectum (16%). The mean anxiety score was 7.6 (SD = 4.5) and for the depression this was 8.4 (SD = 3.8). Overall 47.2% and 57% of patients scored high on both anxiety and depression. There were no significant differences between gender, educational level, marital status, cancer site and anxiety and depression scores whereas those who knew their diagnosis showed a significant higher degree of psychological distress [mean (SD) anxiety score: knew diagnosis 9.1 (4.2) vs. 6.3 (4.4) did not know diagnosis, P < 0.001; mean (SD) depression score: knew diagnosis 9.1 (4.1) vs. 7.9 (3.6) did not know diagnosis, P = 0.05]. Performing logistic regression analysis while controlling for demographic and clinical variables studied the results indicated that those who knew their cancer diagnosis showed a significant higher risk of anxiety [OR: 2.7, 95% CI: 1.1–6.8] and depression [OR: 2.8, 95% CI: 1.1–7.2].

Conclusion

Psychological distress was higher in those who knew their cancer diagnosis. It seems that the cultural issues and the way we provide information for cancer patients play important role in their improved or decreased psychological well-being.

Illness Awareness of Patients in Hospice: Psychological Evaluation and Perception of Family Members and Medical Staff

BACKGROUND

Despite the widespread belief that patients should be given full information about their disease and prognosis, they actually they know very little. The purpose of this study was to evaluate the awareness of 100 patients (from the Hospices of Rimini and Savignano-Rubicone) about their diagnoses and prognoses. It is also investigated staff and relatives perceptions of patients' awareness.

METHODS

A semistructured interview of patients was performed by psychologists to evaluate their awareness about diagnosis and prognosis. Then psychologists completed a questionnaire about their own evaluation of patients' disease awareness. Moreover, the same questionnaire was completed by family members and by staff members (doctors and nurses) about their perceptions of patients' awareness. Doctors and nurses gave their answers based on their routine interactions with patients.

RESULTS

Despite the fact that patients in hospice were in the terminal phase of disease, 30% of patients had no diagnosis awareness, and an even higher percentage of patients (62%) who had no prognosis awareness.

Factors related to truth-telling practice of physicians treating patients with cancer in Turkey

BACKGROUND

In the practice of oncology, effective communication between physician and patient is very important. Although many studies have indicated that a large majority of physicians, especially from Western countries, tell the truth about diagnosis and prognosis, little is known about attitudes of physicians in Turkey toward truth-telling.

OBJECTIVE

In this study, we tried to determine the truth-telling practice of physicians and explore potential related factors with a self-reported questionnaire.

DESIGN

Using a questionnaire, 131 cancer specialists were interviewed during the 15th National Oncology Meeting in April 2003.

RESULTS

The percentage of physicians who never, rarely, generally, and always prefer truthtelling about a cancer diagnosis were 9%, 39%, 45%, and 7%, respectively. In univariate logistic regression analysis for the truth-telling practice, significant variables included "do not tell" requests from family, experiences from medical training and clinical practice, and medical specialty. In the multivariate analysis, "do not tell" requests from relatives and medical training factors retained their significance.

CONCLUSION

Professional training in breaking bad news is important and is associated with the self-reported truth-telling practices of physicians.

Telling the truth to patients with cancer: what is the truth?

Attitudes and practices of truth-telling to people with cancer have shifted substantially in the past few years. However, cultural and individual differences persist, and some difficulties common to all medical specialties are magnified in oncology. In this Personal View, I review and analyse data for attitudes and practices of truth-telling worldwide. I also assess ethical justifications, with special reference to interpersonal aspects of patients' autonomy and the dynamic nature of truth in the clinical context. Examples are provided to show how this ethical perspective can help oncologists to frame the discourse on truth-telling and to find solutions to the dilemmas of whether, when, and how to tell the truth to their patients in clinical practice. Finally, I identify future targets for research.

Is doctors' ability to identify cancer patients' worry and wish for information related to doctors' self-efficacy with regard to communicating about difficult matters?

The aims were to investigate whether: (A) doctors' ability to identify patients' worry about prognosis/wish for information about disease and treatment is related to doctors' self-efficacy with regard to communicating about difficult matters and patients' satisfaction with a consultation/hope to live a good life in spite of the disease; and (B) patients and doctors agree on how much worry/wish for information a patient experiences/wishes. Sixty-nine patients with carcinoid and 11 doctors participated. Ability to identify worry/wish for information was estimated by posing questions to doctors/patients concerning how much worry/information a patient experienced/wished during a consultation. Doctors' self-efficacy was measured by nine questions, patients' satisfaction and hope by two questions. When doctors show good ability to identify wish for information, they report higher self-efficacy (t = 3.5, d.f. = 67, P < 0.001) than when they show less good ability. Patients finding the consultation very satisfying meet doctors reporting higher self-efficacy than patients finding the consultation satisfying (t = 2.26, d.f. = 65, P < 0.05). Doctors fail to identify patients who report less worry/wish more information than the average patient. The findings underscore the importance of further enhancing doctors' self-efficacy with regard to communicating about difficult matters and ability to identify patients who are less worried/wish more information than the average patient.

Hope and Related Variables in Italian Cancer Patients

Hope, long considered an essential element for life, has been shown to be important among cancer patients in coping, perceived control over the illness, and psychologic adjustment to the illness. The purpose of this study was (a) to describe the level of hope in Italian cancer patients; (b) to compare the levels of hope during and after hospitalization; (c) to determine whether hope was correlated with quality of life and several symptoms; and (d) to determine whether the variables from the international literature also pertain to Italian cancer patients. A descriptive correlational design using repeated measures was chosen to study 80 Italian cancer patients during hospitalization and then at home. The following instruments were used: a Sociodemographic Questionnaire, the Hope Related Variable Questionnaire, the Nowotny Hope Scale, the Rotterdam Symptom Checklist, and the Hospital Anxiety and Depression Scale. Overall, patients were moderately hopeful and the level of hopefulness was similar in the hospital and at home. Hope was positively correlated with quality of life, self-esteem, coping, adjustment to the illness, well-being, comfort in the hospital, satisfaction with information received, relationship with, and support from family, healthcare professional, and friends. Hope was negatively correlated with anxiety, depression, and boredom during hospitalization. Time since diagnosis, illness stage, and knowing or not knowing the diagnosis and treatment were not correlated with hope. Similarities and differences with the international literature are discussed, and implications for caring for Italian cancer patients are drawn.

What elderly cancer patients want to know? Differences among elderly and young patients

THE AIMS OF OUR STUDY WERE

(1) to evaluate the information needs of Italian elderly cancer patients (age > or =65 years), (2) to compare them with those of young patients (age 18-40 years). Between June 2004 and February 2005 we asked 122 elderly (mean age 72 years) and 52 young (mean age 33 years) cancer patients naïve for treatment to fill in two self-administered questionnaires exploring their needs for information and their psychological distress. The needs for information of elderly patients differed significantly from those of the young patients (p<0.0001); on contrast, both groups showed a similar psychological distress and the same reasons for seeking further information. Our results demonstrate that, more frequently than expected, Italian elderly cancer patients do not want complete information on their disease. Assessing to what extent elderly patients require information is essential for giving them tailored information.

Ethical decision making on truth telling in terminal cancer: medical students' choices between patient autonomy and family paternalism

INTRODUCTION

The effect of medical education is often hard to evaluate. We tried to assess whether a 2-hour, small-group discussion could alter student perspectives on truth telling. Currently, in Taiwan it is common practice to consult with the family of a terminally ill patient before telling the truth to the patient, which may be in conflict with patient autonomy.

METHODS

The study was based on content analysis of self-reflective written texts after a 2-hour group discussion on a clinical case describing a truth-telling situation. The changes in decision patterns regarding the emphasis placed on patient autonomy versus family paternalism and the connection to related moral reasoning were subjected to focus analysis.

RESULTS

The students' initial attitudes regarding the subject of truth telling were categorised into 4 patterns, namely, patient-centred (n = 46), family-centred (n = 20), simultaneous informing (n = 1), and situational informing (n = 5) modes. The discussion stimulated perspective changes in many of the students and their attitudes were then regrouped as patient-comprehensive (n = 35), family-centred (n = 1), and family-comprehensive (n = 36) modes. It was found that variations on 'common sense' and moral reasoning existed prior to the class and the students initially tended to overlook the complexity of truth telling in terminal cancer. Through the discussion and reflective learning, they were enabled to acknowledge the vulnerability of both the patient and his or her family, and to make decisions based on more comprehensive considerations.

CONCLUSION

Group discussion seemed to be able to enhance ethical consideration. Further research is required to determine whether the benefits of this approach can be translated into behavioural changes in practice.

Different attitudes of oncology clinicians toward truth telling of different stages of cancer

OBJECTIVES

To investigate different attitudes of oncology clinicians toward whether and how to disclose diagnosis to patients with different stages of cancer.

MATERIALS AND METHODS

A questionnaire investigating physician's demographic information and attitude toward truth telling was delivered to 256 Chinese oncology clinicians.

RESULTS

Two hundred thirty-two (90.6%) physicians completed the questionnaire. Of these oncology clinicians, 87.5% reported that a patient with early-stage cancer should be informed of the diagnosis, while only 40.5% believed that a patient with terminal illness should know the truth (P<0.001). Physicians who preferred to tell the truth reported that patients with early or terminal stage of cancer should be informed by the doctor-in-charge (81.3 vs 77.7%, respectively; P>0.05), immediately after the diagnosis (83.7 vs 87.2%, respectively), and in a quiet and undisturbed room (63.5 vs 68.1%, respectively; P>0.05). In stepwise multiple logistic regression analyses, no demographic information showed association with truth telling of early-stage cancer. Women doctors [odds ratio (OR), 2.25; 95% CI, 1.31 to 3.89; P=0.004] were more likely than men to want the patient to be informed of the terminal illness. Physicians with cancer relatives (OR, 0.55; 95% CI, 0.31 to 0.97; P=0.04) were less likely than physicians without cancer relatives to want the patient to be informed of the terminal illness.

CONCLUSION

Oncology clinicians differed in their attitudes toward truth telling of different stages of cancer. Physicians reported that the doctor-in-charge should be the ones to disclose the condition of the patient, immediately after the diagnosis, and in a quiet and undisturbed room.

Medical students' views of undergraduate Oncology education: A comparative study

CONTEXT

An ongoing concern of undergraduate medical education regarding oncology has been intensified in Patras Medical School, Greece, aiming at a more comprehensive teaching approach.

OBJECTIVE

A second-step research project was conducted to examine medical students' views of their undergraduate education in oncology, six years after the first investigation, and to assess the impact of the changes on the curriculum.

METHODS

The same questionnaire used in the previous study was again distributed to 210 different medical students.

FINDINGS

Our study revealed that although the quality of education in Oncology has been improved, it has not as yet reached high standards. The improvements over the last six years were mainly attributed to the increased presence of specialized oncology staff and their coordination with other basic and clinical scientists, as well as to the increased focus on research issues. Most of the students suggested putting more emphasis on psychosocial aspects of cancer care and ethical topics.

DISCUSSION

Despite the progress made in the curriculum, there is still a need for further improvements in the students' undergraduate education so as to meet current demands. Medical education in Greece still pays lip service to communication and ethical issues while remaining disease-oriented in its approach. Therefore, the target of undergraduate education in Oncology should not only be the provision of updated medical knowledge, but also the development of a proper attitude towards all cancer-related issues.

Cultural aspects of communication in cancer care

Cancer is increasing in incidence and prevalence worldwide, and the WHO has recently included cancer and its treatments as a health priority in developed and developing countries. The cultural diversity of oncology patients is bound to increase, and cultural sensitivity and competence are now required of all oncology professionals. A culturally competent cancer care leads to improved therapeutic outcome and it may decrease disparities in medical care. Cultural competence in medicine is a complex multilayered accomplishment, requiring knowledge, skills and attitudes whose acquisition is needed for effective cross-cultural negotiation in the clinical setting. Effective cultural competence is based on knowledge of the notion of culture; on awareness of possible biases and prejudices related to stereotyping, racism, classism, sexism; on nurturing appreciation for differences in health care values; and on fostering the attitudes of humility, empathy, curiosity, respect, sensitivity and awareness. Cultural competence in healthcare relates to individual professionals, but also to organizations and systems. A culturally competent healthcare system must consider in their separateness and yet in there reciprocal influences social, racial and cultural factors. By providing a framework of reference to interpret the external world and relate to it, culture affects patients' perceptions of disease, disability and suffering; degrees and expressions of concern about them; their responses to treatments and their relationship to individual physicians and to the healthcare system. Culture also influences the interpretation of ethical norms and principles, and especially of individual autonomy, which can be perceived either as synonymous with freedom or with isolation depending on the cultural context. This, in turn, determines the variability of truth-telling attitudes and practices worldwide as well as the different roles of family in the information and decision-making process of the cancer patient. Finally, culture affects individual views of the patient-doctor relationship in different contexts.

Deception, catholicism, and hope: understanding problems in the communication of unfavorable prognoses in traditionally-catholic countries

The doctor's use of deception in appropriate circumstances has commonly been considered a necessity of the medical art. Resistance to full and frank communication is typical of many traditionally Catholic countries, and particularly of Italy, a western country where Catholicism remains particularly influential. The Catholic teaching on truth and lies, and the problem of telling the truth to a severely ill patient is discussed. It is suggested that the contemporary Catholic model of gradually telling a terminal patient the truth, which looks reasonable and feasible in theory, is rarely followed in practice, as in the majority of cases the truth is not told tout court. Problems stem from the way in which medicine is currently practiced in Italy; from the synergism between Catholicism and the medical tradition's grounded paternalism; and from the ambiguity of the term 'hope'. Catholic ethics in fact recommends that the truth must be told without destroying hope, but the Catholic meaning of 'hope' is very different from its meaning in current language.

Physician-patient communication among Southern European cancer physicians: the influence of psychosocial orientation and burnout

Physician-patient communication is a critical factor for comprehensive care in oncology. Although a number of studies have been carried out in Northern Europe and the US on this subject, no data are available in Southern European countries. As a part of a multicenter Southern European Psycho-Oncology study (SEPOS), the present investigation was conducted to examine communication skills and related variables (i.e. psychosocial orientation, and burnout) among 125 physicians from Italy, Portugal, and Spain. The Self-Confidence in Communication Skills (SCCS) scale was given to assess physicians' perception of their communication skills and the Expected Outcome of Communication (EOC) scale was administered to examine the physicians' expectations about the effects of communicating with their patients. Doctors' psychosocial orientation was measured by using the Physician Belief Scale (PBS) and burnout was measured by using the Maslach Burnout Inventory (MBI). Although the physicians reported receiving minimal training in communication during their education, they tended to perceive themselves as skilled in patient communication, apart from some areas (e.g. dealing with denial, managing uncertainty, assessing anxiety and depression, and promoting patient-family openness). Low psychosocial orientation and burnout symptoms (i.e. emotional exhaustion, depersonalization, and poor personal accomplishment in their job) were associated with lower confidence in communication skills and higher expectations of a negative outcome, following physician-patient communication. The results suggest that there is a need for training cancer physicians in communication and for increasing a more definite psychosocially oriented approach in cancer care in Mediterranean countries.

Information needs of recently diagnosed cancer patients in Brazil

OBJECTIVE

The communication and disclosure of medical information to cancer patients has been an important issue in oncology, reflecting changes in the physicians' approach when dealing with the patients' ethical right to receive information. The aim of this study was to assess the general and specific information desired by cancer patients regarding their health conditions and to evaluate minor psychiatric symptoms.

METHOD

Two-hundred and ninety-eight patients were examined at an oncological cancer center in São Paulo, Brazil, using a questionnaire designed to investigate patients' preferences about cancer information and evaluate minor psychiatric symptoms.

RESULT

Ninety-five percent of the patients were interested in obtaining information on their health condition, with regard to whether they had cancer (95%), the chances of recovery (89%), and the side effects during treatment (94%). Younger patients tended to show more interest in obtaining information than the elderly. The Self-Reporting Questionnaire classified 25.8% of the sample as a probable psychiatric case, but no correlation was found between Self-Reporting Questionnaire scores and patients' desires for medical information.

CONCLUSION

The majority of patients wished to be informed about their illness condition, and no correlation was found between psychiatric morbidity and desire for information.

Communicating with realism and hope: incurable cancer patients' views on the disclosure of prognosis

PURPOSE

To identify preferences for the process of prognostic discussion among patients with incurable metastatic cancer and variables associated with those preferences.

PATIENTS AND METHODS

One hundred twenty-six (58%) of 218 patients invited onto the study participated. Eligible patients were the consecutive metastatic cancer patients of 30 oncologists, who were diagnosed within 6 weeks to 6 months before recruitment, over 18 years of age, and without known mental illness. Patients completed a postal survey measuring patient preferences for the manner of delivery of prognostic information, including how doctors might instill hope.

RESULTS

Ninety-eight percent of patients wanted their doctor to be realistic, provide an opportunity to ask questions, and acknowledge them as an individual when discussing prognosis. Doctor behaviors rated the most hope giving included offering the most up to date treatment (90%), appearing to know all there is to know about the patient's cancer (87%), and saying that pain will be controlled (87%). The majority of patients indicated that the doctor appearing to be nervous or uncomfortable (91%), giving the prognosis to the family first (87%), or using euphemisms (82%) would not facilitate hope. Factor analysis revealed six general styles and three hope factors; the most strongly endorsed styles were realism and individualized care and the expert/positive/collaborative approach. A range of demographic, psychological, and disease factors were associated with preferred general and hope-giving styles, including anxiety, information-seeking behavior, expected survival, and age.

CONCLUSION

The majority of patients preferred a realistic and individualized approach from the cancer specialist and detailed information when discussing prognosis.

Patient-professional communication research in cancer: an integrative review of research methods in the context of a conceptual framework

This paper uses the conceptual framework of Feldman-Stewart et al. to organize and review the types of research methodologies used to investigate various aspects of patient-health care professional communication in the context of cancer. Research methods employed are classified as either non-experimental or experimental. Non-experimental designs include naturalistic observational studies (e.g. participant observation, audio- or videotaping of interactions) and retrospective introspective descriptions (e.g. self-report questionnaires, qualitative interview methods). Experimental designs often involve interventions aimed at improving communication, such as physician or patient training, and the use of technology to enhance communication (e.g. audiotapes, computers). Using the conceptualization of the communication framework description, we argue that the outcome measures used in these studies address either primary goals, enabling goals, or secondary communication outcomes. Outcomes that are related to primary goals of the communication exchange include assessing the level of understanding of information conveyed, aspects of decision making, planning around treatments, or general provision of care. Outcomes related to enabling goals focus on elements that affect the ability to achieve primary goals. Outcomes secondary to the communication do not relate directly to what the communication is attempting to achieve. We conclude by identifying priority areas for further research, such as identifying the goals of both participants, understanding how particular aspects of the communication process affect their ability to achieve their goals, and examining the external environment in which communication takes place.

Evolution of truth-telling attitudes and practices in Italy

The debate on truth telling is at the core of contemporary biomedical ethics. Differences in truth telling arise from the delicate interplay between autonomy and beneficence in medicine, under the influence of cultural variables. Recently, a trend toward evolution of truth-telling practices has been noticed in countries previously known for non-disclosure. Italy is among them. This article analyzes in detail the different factors that have been influential in the Italian context, focusing on cancer patients. Medical profession, public discourse, medical deontology and legislators played an important role in Italy's shift toward the western autonomy predicament. A review of the scanty published data on informed consent and truth telling in Italy, however, consistently shows that partial or non-disclosure are still present. This seems to represent a general trend in nations traditionally centered on family and community values. The article explores these issues to achieve a better understanding of the specific Italian cultural context, while avoiding common stereotyping. The subject treated contributes to the growing debate on cultural diversity in medicine and in oncology.

Psychosocial morbidity and its correlates in cancer patients of the Mediterranean area: findings from the Southern European Psycho-Oncology Study

BACKGROUND

A few and partial data are available on psychosocial morbidity among cancer patients in Mediterranean countries. As a part of a more general investigation (Southern European Psycho-Oncology Study-SEPOS), the rate of psychosocial morbidity and its correlation with clinical and cultural variables were examined in cancer patients in Italy, Portugal and Spain.

METHODS

A convenience sample of cancer outpatients with good performance status and no cognitive impairment were approached. The Hospital Anxiety-Depression scale (HAD-S), the Mini-Mental Adjustment to Cancer scale (Mini-MAC), and the Cancer Worries Inventory (CWI) were used to measure psychological morbidity, coping strategies and concerns about illness.

RESULTS

Of 277 patients, 34% had pathological scores ("borderline cases" plus "true cases") on HAD-S Anxiety and 24.9% on HAD-S Depression. Total psychiatric "caseness" was 28.5% and 16.6%, according to different HAD cut-offs (14 and 19, respectively). Significant relationships of HAD-S Anxiety, HAD-S Depression, HAD-S Total score, with Mini-MAC Hopeless and Anxious Preoccupation, and CWI score were found. No differences emerged between countries on psychosocial morbidity, while some differences emerged between the countries on coping mechanisms. Furthermore, Fatalism, Avoidance and marginally Hopeless were higher compared to studies carried out in English-speaking countries.

LIMITATIONS

The relatively small sample size and the good performance status prevent us to generalize data on patients with different cancer sites and advanced phase of illness.

CONCLUSIONS

One-third of the patients presented anxiety and depressive morbidity, with significant differences in characteristics of coping in Mediterranean countries in comparison with English-speaking countries.

The attitude toward truth telling of cancer in Taiwan

OBJECTIVE

This study examined a group of Taiwanese subjects at a medical university hospital regarding their attitudes toward truth telling of cancer.

METHOD

Self-report survey with convenience sampling of 195 participants admitted for a 3-day comprehensive health examination in a medical university hospital in Taiwan. Three instruments used to collect the data included the Brief Psychiatric Symptom Rating Scale (BPSRS), Chinese Health Questionnaire (CHQ), and the Attitude Toward Truth Telling of Cancer List.

RESULTS

Once diagnosed with cancer, 92.3% of the participants preferred being told the truth about their diagnosis and 7.7% did not. Age, education, and employment were found to differ between disclosure and nondisclosure groups. The latter group also tended to have higher depression and hostility scores on the BPSRS and higher minor psychiatric morbidity scores. A total of 62.6% of the participants preferred that doctors tell a relative the truth about their cancer diagnosis, while 37.4% preferred that doctors not tell a relative the truth. The distributions of demographic data and mental status did not significantly differ between disclosure and nondisclosure groups if a relative was to be the cancer victim.

CONCLUSIONS

A majority of subjects in Taiwan would prefer to know the truth if victimized by a cancer disease, despite the supposed influence of Chinese culture. Furthermore, attitudes toward truth telling of cancer differed between relatives of patients and the patients themselves. Relatives of cancer patients were more likely to follow to the principle of beneficence, whereas the patients themselves were more likely to follow to the principle of autonomy.

Cancer patient preferences for communication of prognosis in the metastatic setting

PURPOSE

To identify preferences for and predictors of prognostic information among patients with incurable metastatic cancer.

PATIENTS AND METHODS

One hundred twenty-six metastatic cancer patients seeing 30 oncologists at 12 outpatient clinics in New South Wales, Australia, participated in the study. Patients were diagnosed with incurable metastatic disease within 6 weeks to 6 months of recruitment. Patients completed a survey eliciting their preferences for prognostic information, including type, quantity, mode, and timing of presentation; anxiety and depression levels; and information and involvement preferences.

RESULTS

More than 95% of patients wanted information about side effects, symptoms, and treatment options. The majority wanted to know longest survival time with treatment (85%), 5-year survival rates (80%), and average survival (81%). Words and numbers were preferred over pie charts or graphs. Fifty-nine percent (59%) wanted to discuss expected survival when first diagnosed with metastatic disease. Thirty-eight percent and 44% wanted to negotiate when expected survival and dying, respectively, were discussed. Patients with higher depression scores were more likely to want to know shortest time to live without treatment (P =.047) and average survival (P =.049). Lower depression levels were significantly associated with never wanting to discuss expected survival (P =.03). Patients with an expected survival of years were more likely to want to discuss life expectancy when first diagnosed with metastases (P =.02).

CONCLUSION

Most metastatic cancer patients want detailed prognostic information but prefer to negotiate the extent, format, and timing of the information they receive from their oncologists.