Breaking the news. How families first learn about their child's chronic condition

Flashbulb Memories in the Communication of the Diagnosis of Visual Impairment: The Effect of Context and Content

The diagnosis of a child's visual impairment is remembered vividly and intensely by their parents. However, the way in which the diagnosis is communicated may affect the development and persistence of this memory. The aim of this study is to analyze the circumstances in which the first news of the diagnosis of visual impairment in children is given and whether the memory of this event persists over time leading to a flashbulb memory. A longitudinal study was carried out with the participation of 38 mothers. Data were collected on sociodemographics, clinical variables, circumstances surrounding the communication of the diagnosis, and the degree of agreement of the information in the two phases of the research. The diagnosis was, on the whole, given to both parents at the same time, in medical language and with little tact, generally in the office of an ophthalmologist. The mothers would have preferred to have received the news in a different way, and the existence of a flashbulb memory is confirmed, more dependent on the context in which the diagnosis was given and its content than on sociodemographic and clinical factors. The way in which the first news of such a diagnosis is given plays a significant role in how it is remembered. Therefore, an improvement in medical practice regarding the communication of such diagnoses is recommended.

What is Known About Critical Congenital Heart Disease Diagnosis and Management Experiences from the Perspectives of Family and Healthcare Providers? A Systematic Integrative Literature Review

The experience of diagnosis, decision-making and management in critical congenital heart disease is layered with complexity for both families and clinicians. We synthesise the current evidence regarding the family and healthcare provider experience of critical congenital heart disease diagnosis and management. A systematic integrative literature review was conducted by keyword search of online databases, MEDLINE (Ovid), PsycINFO, Cochrane, cumulative index to nursing and allied health literature (CINAHL Plus) and two journals, the Journal of Indigenous Research and Midwifery Journal from 1990. Inclusion and exclusion criteria were applied to search results with citation mining of final included papers to ensure completeness. Two researchers assessed study quality combining three tools. A third researcher reviewed papers where no consensus was reached. Data was coded and analysed in four phases resulting in final refined themes to summarise the findings. Of 1817 unique papers, 22 met the inclusion criteria. The overall quality of the included studies was generally good, apart from three of fair quality. There is little information on the experience of the healthcare provider. Thematic analysis identified three themes relating to the family experience: (1) The diagnosis and treatment of a critical congenital heart disease child significantly impacts parental health and wellbeing. (2) The way that healthcare and information is provided influences parental response and adaptation, and (3) parental responses and adaptation can be influenced by how and when support occurs. The experience of diagnosis and management of a critical congenital heart disease child is stressful and life-changing for families. Further research is needed into the experience of minority and socially deprived families, and of the healthcare provider, to inform potential interventions at the healthcare provider and institutional levels to improve family experience and support.

Communicating Bad News: Insights for the Design of Consumer Health Technologies

Background

As people increasingly receive personal health information through technology, there is increased importance for this information to be communicated with empathy and consideration for the patient’s experience of consuming it. Although technology enables people to have more frequent and faster access to their health information, it could also cause unnecessary anxiety, distress, or confusion because of the sensitive and complex nature of the information and its potential to provide information that could be considered bad news.

Objective

The aim of this study was to uncover insights for the design of health information technologies that potentially communicate bad news about health such as the result of a diagnosis, increased risk for a chronic or terminal disease, or overall declining health.

Methods

On the basis of a review of established guidelines for clinicians on communicating bad news, we developed an interview guide and conducted interviews with patients, patients’ family members, and clinicians on their experience of delivering and receiving the diagnosis of a serious disease. We then analyzed the data using a thematic analysis to identify overall themes from a perspective of identifying ways to translate these strategies to technology design.

Results

We describe qualitative results combining an analysis of the clinical guidelines for sharing bad health news with patients and interviews on clinicians’ specific strategies to communicate bad news and the emotional and informational support that patients and their family members seek. Specific strategies clinicians use included preparing for the patients’ visit, anticipating patients’ feelings, building a partnership of trust with patients, acknowledging patients’ physical and emotional discomfort, setting up a scene where patients can process the information, helping patients build resilience and giving hope, matching the level of information to the patients’ level of understanding, communicating face-to-face, if possible, and using nonverbal means. Patient and family member experiences included internal turmoil and emotional distress when receiving bad news and emotional and informational support that patients and family members seek.

Conclusions

The results from this study identify specific strategies for health information technologies to better promote empathic communication when they communicate concerning health news. We distill the findings from our study into design hypotheses for ways technologies may be able to help people better cope with the possibility of receiving bad health news, including tailoring the delivery of information to the patients’ individual preferences, supporting interfaces for sharing patients’ context, mitigating emotional stress from self-monitoring data, and identifying clear, actionable steps patients can take next.

Understanding Effective Delivery of Patient and Family Education in Pediatric OncologyA Systematic Review From the Children's Oncology Group [Formula: see text]

A diagnosis of childhood cancer is a life-changing event for the entire family. Parents must not only deal with the cancer diagnosis but also acquire new knowledge and skills to care safely for their child at home. Best practices for delivery of patient/family education after a new diagnosis of childhood cancer are currently unknown. The purpose of this systematic review was to evaluate the existing body of evidence to determine the current state of knowledge regarding the delivery of education to newly diagnosed pediatric oncology patients and families. Eighty-three articles regarding educational methods, content, influencing factors, and interventions for newly diagnosed pediatric patients with cancer or other chronic illnesses were systematically identified, summarized, and appraised according to the Grading of Recommendations Assessment, Development, and Evaluation criteria. Based on the evidence, 10 recommendations for practice were identified. These recommendations address delivery methods, content, influencing factors, and educational interventions for parents and siblings. Transferring these recommendations into practice may enhance the quality of education delivered by health care providers and received by patients and families following a new diagnosis of childhood cancer.

Cardiovascular Risk Factors in Parents of Food-Allergic Children

Previous studies suggest that chronic stress may induce immune system malfunction and a broad range of adverse health outcomes; however, the underlying pathways for this relationship are unclear. Our study aimed to elucidate this question by examining the relationship between parental cardiovascular risk factors including systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index (BMI), and waist-to-hip ratio (WHR) and maternal psychological stress score (MPSS) relative to the severity of the child's food allergy (FA) and number of affected children. SBP, DBP, BMI, and WHR were measured and calculated at the time of recruitment by trained nurses. MPSS was obtained based on self-report questionnaires covering lifestyle adjustments, perceived chronic stress, and quality of life. General linear models examined whether caregiver chronic stress was associated with FA. For mothers with children under age 5 years, SBP, DBP and number of affected children had strong and graded relationships with severity of the child's FA. MPSS was also significantly and positively associated with child FA severity (P < 0.001). However, no relationships were found between FA severity, BMI, or WHR for either parent. This was also the case for paternal SBP, DBP, and number of affected children of any age. There is a strong and graded link between cardiovascular risk and perceived stress in mothers of food-allergic children under age 5. Findings may have important implications for family-centered care of FA, may generalize to caregivers of children with chronic conditions, and extend the literature on allostatic load.

Emotional reactions of mothers who have babies who are diagnosed with Down syndrome

PURPOSE

The aim of this study was to explore a deeper insight into experiences of Turkish mothers living with/diagnosed with Down syndrome (DS) baby.

METHODS

Individual and audiotaped interviews were carried out with 11 women after amniocentesis in Karaman city of Turkey between August 2012 and February 2013. Transcribed semistructured interviews were qualitatively and analyzed using a thematic analysis approach to code and categorize emerging themes.

RESULTS

Three principal themes emerged from the study: mothers' emotional reaction after diagnosed DS, mother and healthcare professional interactions, and mother's coping with diagnosed DS.

CONCLUSIONS

Understanding the experiences of women living with/diagnosed with DS baby enables nurses to devise appropriate strategies to provide better support at every stage and thus helping them to cope with daily life.

Parent perceptions of the quality of information received about a child's cancer

BACKGROUND

Parents' perceptions of the quality of information communicated by their child's oncologist about the child's cancer are not well understood.

PROCEDURE

We conducted a cross-sectional survey of 194 parents of children with cancer (response rate 70%), treated at the Dana-Farber Cancer Institute and Boston Children's Hospital, Boston, Mass, and the children's physicians. Parents were asked to report the quality of information received about the child's cancer in several domains.

RESULTS

Most parents reported that information about their child's cancer had been excellent (49%) or good (41%) overall, and ratings were similar for information about diagnosis (P = 0.62) and treatment (P = 0.59). Fewer parents felt they received high quality information about how cancer treatment is working (P < 0.001), likelihood of cure (P < 0.001), what the diagnosis means for the future (P < 0.001), and whether there is a cause for the child's cancer (P < 0.001). In multivariable models, parents were more likely to consider information of high quality when they also rated physician communication style highly. The accuracy of their knowledge on likelihood of cure and the child's future limitations, however, was not associated with quality ratings.

CONCLUSIONS

Although parents feel that they have received high quality cancer information overall, parents feel they receive lower quality information about issues relating to the child's future. Yet quality ratings are not associated with their actual knowledge. Parent perceptions of quality represent one, but not the only, facet of communication quality.

Understanding Pediatric Palliative Care

Advancing pediatric palliative care is desperately needed to support the physical, emotional, cultural, spiritual, and psychosocial needs of children and families who live with life-threatening illnesses. Although educational resources and standards of practice related to this topic have been developed, dissemination and implementation of programs have been slow to progress. The purpose of this case study is to present the lived experiences of an adolescent with leukemia and his family to illustrate how health care providers may benefit from receiving enhanced palliative and end-of-life care education.

Egyptian mothers' preferences regarding how physicians break bad news about their child's disability: a structured verbal questionnaire

Background

Breaking bad news to mothers whose children has disability is an important role of physicians. There has been considerable speculation about the inevitability of parental dissatisfaction with how they are informed of their child’s disability. Egyptian mothers’ preferences for how to be told the bad news about their child’s disability has not been investigated adequately. The objective of this study was to elicit Egyptian mothers’ preferences for how to be told the bad news about their child’s disability.

Methods

Mothers of 100 infants recently diagnosed with Down syndrome were interviewed regarding their preferences for how to be told bad news. Mothers were recruited through outpatient clinics of the Pediatric Genetics Department at Fayoum University Hospital (located 90 km southwest of Cairo, Egypt) from January to June 2011.

Results and discussion

Questionnaire analyses revealed nine themes of parental preferences for how to be told information difficult to hear. Mothers affirmed previously reported recommendations for conveying bad medical news to parents, including being told early, being told of others with a similar condition, and being informed of the prognosis.

Conclusions

Mothers affirmed communication themes previously discussed in the literature, such as being told early, and being informed of the prognosis. Although more research is needed in this important area, we hope that our findings will stimulate future search and help health care providers in different societies establish guidelines for effectively communicating bad news.

Managing the delivery of bad news: an in-depth analysis of doctors' delivery style

OBJECTIVE

The purpose of this study was to identify and describe the delivery styles doctors typically use when breaking bad news (BBN).

METHODS

Thirty one doctors were recruited to participate in two standardised BBN consultations involving a sudden death. Delivery styles were determined using time to deliver the bad news as a standardised differentiation as well as qualitative analysis of interaction content and language style. Communication performance was also assessed.

RESULTS

Analysis of BBN interactions revealed three typical delivery styles. A blunt style characterised by doctors delivering news within the first 30 s of the interaction; Forecasting, a staged delivery of the news within the first 2 min and a stalling approach, delaying news delivery for more than 2 min. This latter avoidant style relies on the news recipient reaching a conclusion about event outcome without the doctor explicitly conveying the news.

CONCLUSION

Three typical bad news delivery styles used by doctors when BBN were confirmed both semantically and operationally in the study. The relationship between delivery style and the overall quality of BBN interactions was also investigated.

PRACTICE IMPLICATIONS

This research provides a new template for approaching BBN training and provides evidence for a need for greater flexibility when communicating bad news.

The nursing dimension of providing palliative care to children and adolescents with cancer

Palliative care for children and adolescents with cancer includes interventions that focus on the relief of suffering, optimization of function, and improvement of quality of life at any and all stages of disease. This care is most effectively provided by a multidisciplinary team. Nurses perform an integral role on that team by identifying symptoms, providing care coordination, and assuring clear communication. Several basic tenets appear essential to the provision of optimal palliative care. First, palliative care should be administered concurrently with curative therapy beginning at diagnosis and assuming a more significant role at end of life. This treatment approach, recommended by many medical societies, has been associated with numerous benefits including longer survival. Second, realistic, objective goals of care must be developed. A clear understanding of the prognosis by the patient, family, and all members of the medical team is essential to the development of these goals. The pediatric oncology nurse is pivotal in developing these goals and assuring that they are adhered to across all specialties. Third, effective therapies to prevent and relieve the symptoms of suffering must be provided. This can only be accomplished with accurate and repeated assessments. The pediatric oncology nurse is vital in providing these assessments and must possess a working knowledge of the most common symptoms associated with suffering. With a basic understanding of these palliative care principles and competency in the core skills required for this care, the pediatric oncology nurse will optimize quality of life for children and adolescents with cancer.

Breaking bad news during prenatal care: a challenge to be tackled

Communicating an unfavorable diagnosis during prenatal care is a growing challenge in clinical practice, as more and more tests are being performed to screen for the main conditions affecting the pregnant woman and her fetus. The way patients receive and subsequently deal with bad news is directly influenced by how the news is communicated by the attending physician. Unfortunately, physicians receive little or no training in communicating bad news, and they generally feel quite uncomfortable about doing so. Although many physicians consider the saying that "there's no good way to break bad news" to be the truth, the maxim does not reflect the true picture. The scope of this article is to discuss, in light of the scientific literature and the experience of fetal medicine services, some recommendations that can help to deal with these difficult moments and improve patient care for the remainder of the pregnancy.

Factors associated with emotional response of parents at the time of diagnosis of Down syndrome

PURPOSE

The purpose is to describe factors associated with emotional responses of parents at the time of diagnosis of Down syndrome.

DESIGN AND METHODS

Using a survey design, data on attitudes of healthcare providers, content of information, and emotional responses were collected from 131 parents in Korea.

RESULTS

There were positive relationships between healthcare providers' attitudes and the content of information (r = .622; p < .0001), and content of information and parents' responses (r = .271; p = .002).

PRACTICE IMPLICATIONS

By providing positive information, healthcare providers can help parents to develop a more optimistic outlook on their children's future.

A failing medical educational model: a self-assessment by physicians at all levels of training of ability and comfort to deliver bad news

OBJECTIVE

Patient surveys consistently show physician communication remains less than ideal. While previous studies have demonstrated a lack of trainee confidence in delivering bad news, our study explores communication skills at all levels of practice and highlights potential barriers to improvement.

METHODS

Pediatric residents, fellows, and attendings involved in direct patient care at a major academic center participated in a voluntary questionnaire, consisting of self-assessed scales of comfort level, knowledge level, amount of training, and attitudes towards communication education. We also elicited barriers to learning and teaching as well as significant experiences.

RESULTS

Eligible responses (n = 253) were evenly divided between trainees and faculty. Almost half of attendings and two thirds of fellows did not feel sufficiently knowledgeable to deliver bad news. Many attendings felt disproportionately more comfortable than they felt knowledgeable. All trainees felt insufficiently knowledgeable for independent practice of this skill. Educational barriers centered on time constraints, a deemphasis, a lack of positive modeling, and minimal awareness of existing resources. Poor experiences revolved around inappropriate language and settings as well as insufficient empathy or preparedness. Positive anecdotes highlighted the importance of education and the impact of role models.

CONCLUSION

Independent of level of training, this study reveals a lack of self-assessed preparedness from many responsible for delivering bad news to patients and families. A significant barrier to improvement is the disproportionate level of self-assessed comfort versus knowledge level. Educational models should include both didactics to learn the skills and practice-based learning to refine the techniques.

Evaluation of an Information Resource for Parents of Children with Autism Spectrum Disorder

This study sought to evaluate a newly created information resource book for parents of children newly diagnosed with Autism Spectrum Disorder entitled Autism Spectrum Disorder: Information for Parents. A purposive sample of 13 participants (comprised of mothers of children with ASD and ASD service providers) participated in 1 of 3 focus groups. Focus group participants provided their feedback regarding the accessibility, usefulness, content accuracy and tone of the resource book. Findings reveal that concise yet comprehensive and hopeful information targeted to parents at diagnosis, has been lacking in ASD practice. This supportive informational resource book addresses this gap in supporting family adaptation and mobilization at the key juncture of diagnosis. Suggestions for resource refinement and future development of similar diagnostic-related literature to support families of newly-diagnosed children are outlined.

Postnatal diagnosis of Down syndrome: synthesis of the evidence on how best to deliver the news

CONTEXT

Many parents of children with Down syndrome (DS) have expressed dissatisfaction with how they learned about their child's diagnosis. DS remains the most common chromosomal condition, occurring in 1 of every 733 births, with the majority of children still diagnosed postnatally.

OBJECTIVE

Our goal was to review systematically all available evidence regarding how physicians should approach the conversation in which they explain DS for the first time to new parents.

METHODS

We searched online databases from 1960 to 2008, including Medline and PsychInfo, as well as Web sites maintained by academic organizations (eg, American Academy of Pediatrics) and other nonprofit or private organizations (eg, the National Down Syndrome Society), by using the terms "Down syndrome," "trisomy 21," "mongolism," "prenatal diagnosis," "postnatal care," and "delivery of health care." Articles were selected that answered > or =1 research question, established a priori: (1) Who is the best person to communicate the news? (2) When is the best time to share the news? (3) Where is the best place or setting to deliver the news? (4) What information should be delivered? and (5) How should the news be communicated? All studies were evaluated for quality according to the method outlined by the US Preventative Services Task Force. Final recommendations were based on the strength of evidence.

RESULTS

Parents prefer to receive the diagnosis together in a joint meeting with their obstetrician and pediatrician. The conversation should take place in a private setting as soon as a physician suspects a diagnosis of DS. Accurate and up-to-date information should be conveyed, including information about local support groups and resources.

CONCLUSION

By implementing a few cost-neutral measures, physicians can deliver a postnatal diagnosis of DS in a manner that will be deemed by new parents as sensitive and appropriate.

Perceptions of the concept of mutation among family members of patients receiving outpatient genetic services and university students

Our objectives were to investigate: (1) relationships between perceptions of various terms regarding mutation and the depth of knowledge regarding mutation among family members of patients receiving genetic outpatient services, and (2) differences in perceptions of the term "gene mutation" for family members versus university students. Fifty-eight family members and 178 university students responded to two questionnaires: Impressions regarding the term, and Knowledge about the concept of mutation. Factor analyses were conducted to determine the factor structure of ratings of the terms, and two-way analyses of variance [(1)Term, (2)Group x Knowledge] were conducted to examine differences in perceptions of the terms as measured by scores for each extracted factor. Family members had a significantly more negative perception of the term "gene mutation" than "gene change" and a less negative perception of the term "gene mutation" than "gene lesion"; they had significantly more negative perceptions of the term "gene mutation" than did university students.

Communicating with children and families: from everyday interactions to skill in conveying distressing information

Health care communication is a skill that is critical to safe and effective medical practice; it can and must be taught. Communication skill influences patient disclosure, treatment adherence and outcome, adaptation to illness, and bereavement. This article provides a review of the evidence regarding clinical communication in the pediatric setting, covering the spectrum from outpatient primary care consultation to death notification, and provides practical suggestions to improve communication with patients and families, enabling more effective, efficient, and empathic pediatric health care.

Recognizing the role of parents in developmental outcomes: a systems approach to evaluating the child with developmental disabilities

When developmental concerns arise in children, a clinical assessment focuses on the child's developmental profile to achieve three goals (1) determine diagnosis, (2) develop interventions, and (3) evaluate progress. Parents often have needs during this time that are not addressed by professionals because of the exclusive focus on the child during the evaluation. In this article, we suggest that clinicians take a "systems" approach to the assessment process by recognizing how the well being of family members can impact a child with a developmental disability. We review systems theory and its conceptualization of individual functioning and discuss how parental well-being differs according to child diagnosis. Finally we suggest a systems-based model to use during the assessment process.

Breaking difficult news in a newborn setting: Down syndrome as a paradigm

Breaking the difficult news of an unexpected diagnosis to parents in the newborn setting is a common occurrence in genetic counseling. Many clinical geneticists and genetic counselors have had the challenge of delivering a postnatal diagnosis of Down syndrome to parents of newborns. Down syndrome is a common chromosome condition occurring in approximately 1 in 800 live births. Presenting the diagnosis to families must be accomplished in a supportive, positive, caring, and honest manner. However, there are few scientific data and little instruction in training programs on how best to convey this news in an appropriate manner. Several articles in the literature over the last three decades have proposed various guidelines for the so-called informing interview. Discussions of parents' preferences and experiences in receiving this news have also been documented. Few reports, however, have focused on breaking difficult news of the diagnosis of a genetic condition to parents in a newborn setting in the genetics literature. In this paper, we will review the medical literature on delivering difficult news, specifically focused on that regarding the diagnosis of Down syndrome in the newborn setting. We propose a theoretical framework from which the informing interview can be planned and future outcome data can be measured. In this way, researchers of this theme can investigate the process, including the healthcare professionals' delivery of difficult news and make recommendations for continued improvement of the process. Our model can be generalized to breaking difficult news for a variety of other congenital conditions.

Resident Physiciansʼ Competencies and Attitudes in Delivering a Postnatal Diagnosis of Down Syndrome

OBJECTIVE

This study responded to the need expressed by physicians and parents alike for improved medical information and support to families upon the initial diagnosis of Down syndrome at birth. The purpose was to assess obstetrics and gynecology and pediatrics residents' cognitive knowledge about Down syndrome and comfort in counseling parents with a newborn child with Down syndrome before and after intervention (resident viewing and interaction with the educational material).

METHODS

A team of physicians, parents, and educational specialists developed an interactive CD-ROM that asked resident physicians to read and view virtual patient-doctor sessions, and provide their own responses to critical situations related to Down syndrome diagnoses. The research tested both knowledge and attitude change, as well as the effectiveness of an interactive CD-ROM as a pedagogical tool.

RESULTS

Our effectiveness study yielded positive and significant improvement in knowledge and level of comfort changes with both obstetrics and gynecology and pediatric physicians in residence at the University of Kentucky. Residents also found the technologically based interactive type of instruction to be usable and valuable.

CONCLUSION

Teaching physicians to impart accurate and balanced information about Down syndrome at the initial point of diagnosis can be achieved, in part, through training with the CD-ROM. From a broader perspective, this effectiveness study suggests the potential applications of these communication strategies not only to families who have a child with Down syndrome, but also to those with other life-altering disabilities.

LEVEL OF EVIDENCE

II-3.

Postnatal support for mothers of children with Down syndrome

Delivering and receiving a postnatal diagnosis of Down syndrome is not an easy experience for most physicians or parents. In this study, 467 mothers of children with Down syndrome in Spain completed a survey about the postnatal support services they received immediately following the diagnosis of their child. Mothers reported feeling anxious, frightened, guilty, angry, and, in rare cases, suicidal. According to most mothers, physicians did not give adequate amounts of information about Down syndrome and rarely did they give enough printed materials or make referrals to parent support groups. Little seems to have changed since 1972. Mothers provided recommendations on how the Spanish medical system could be improved, with implications for other countries including the United States.

Parenting a young person with mental health problems: temporal disruption and reconstruction

The article explores the experiences of parents living with a young person with mental health problems. Qualitative interviews were conducted with 25 parents (18 mothers and 7 fathers) whose child had a diagnosed psychiatric condition. It is argued that the parents engaged in a form of narrative reconstruction of their dual roles as parents and carers as they tried to make sense of the illness in their lives by reconstructing their past, present and future experiences. The concept 'responsibility' was threaded through the parents' narratives and is discussed in relation to three key dimensions - moral responsibility; causal responsibility; and responsibility for self. It is argued that the moral imperative to care for their child was the dominant theme in the parents' narratives but that this was challenged by their lack of knowledge of psychiatric conditions; their interactions with healthcare professionals; their relationships with their child; and their difficulties in coping with the extended parental responsibility that arose from their caring role.

Mothers of children with Down syndrome reflect on their postnatal support

OBJECTIVE

Since 1964, researchers have been examining the ways in which physicians deliver a postnatal diagnosis of Down syndrome (DS). Almost all of the studies, however, have been limited to reflections or very small sample sizes. The objective of this study was to document, in the most robust comprehensive way, the reflections of mothers in the United States who received diagnoses of DS for their children.

METHODS

An 11-page survey was mailed to 2945 persons on the membership lists of 5 DS parent organizations. The survey gathered both quantitative and qualitative data with yes/no questions, open-ended questions, and a series of statements asking the mothers to rate their level of agreement on a Likert scale of 1 to 7.

RESULTS

Of the 1250 responses (42.4%), 985 were from mothers who received postnatal diagnoses of DS for their children. The majority of these mothers reported being frightened or anxious after learning the diagnosis, and very few rated the overall experience as a positive one. Mothers reported that their physicians talked little about the positive aspects of DS and rarely provided enough up-to-date printed materials or telephone numbers of other parents with children with DS. Improvement has been made with time, albeit slowly.

CONCLUSION

Mothers have called on physicians to improve the way in which postnatal diagnoses are delivered. Specific recommendations are offered.

Communicating sad, bad, and difficult news in medicine

In every medical specialty bad, sad, and difficult information must be given to patients and their families. An insensitive approach increases the distress of recipients of bad news, may exert a lasting impact on their ability to adapt and adjust, and can lead to anger and an increased risk of litigation. Many doctors also find these interactions stressful, and in the absence of much effective training they may adopt inappropriate ways of delivering bad news and coping with the emotional fall-out. Recognition of these difficulties has led to many initiatives, ranging from increased communication skills training to the development of guidelines and protocols. We review some of the research on the impact that giving sad, bad, and difficult news has on doctors and patients, and assess whether interventions are helping. We focus mainly on difficulties encountered involving parents in an obstetric or paediatric setting, people in acute trauma situations such as accident and emergency departments, and patients with cancer.

Parental evaluation of informing interviews for cleft lip and/or palate

OBJECTIVE

This study was conducted to record subjective information concerning parental experiences and preferences with regard to informing interviews for cleft lip and/or palate. The analysis of these data was intended to help informants improve the way in which such conversations are conducted.

METHODS

The study used a self-administered questionnaire. Study participants were the biological parents of children who had cleft lip and/or palate and were seen in the University of Pittsburgh Cleft Palate-Craniofacial Center.

RESULTS

Results revealed that parents wanted informing health professionals to be in greater control of the informing conversation, to show more caring and confidence, to show more of their own feelings, to give parents more of an opportunity to talk and show feelings, to make a greater effort to comfort parents, to provide more information, to initiate more of a discussion about the association between clefts and mental retardation/learning disabilities, and to provide more referrals to other parents during the informing interview. A positive association between the degree to which parents reported knowing the health professionals and reported satisfaction was identified for 10 dimensions of health professional behavior.

CONCLUSIONS

Parents are dissatisfied with several aspects of informing interviews for cleft lip and/or palate. The results of this study suggest ways to improve informing interviews for oral-facial clefts and other congenital anomalies.

First information and support provided to parents of children with Down syndrome in Sweden: clinical goals and parental experiences

When parents are informed that their newborn child has Down syndrome (DS), they often respond with a traumatic crisis reaction. The aims of this study were to assess the clinical goals regarding the first information and support provided to parents of newborn children with DS at the Swedish paediatric departments, and to analyse the parents' experiences of how they were first informed and treated. Data were collected during 1992-1993 from all of the 51 departments of paediatrics in Sweden. Information on the parents' experiences, collected retrospectively in 1996, was based on recollection by 165 parents of 86 children with DS born between 1989 and 1993 at 10 of the paediatric departments considered representative for Sweden. Seventy-five percent of the families were informed about the diagnosis within 24 h post partum. Some parents felt they were informed too late, and a few parents that they were told too soon. Half of the parents were satisfied with the timing. About 70% of the parents considered the information insufficient and 60% felt that they had been unsupported. Seventy percent would have liked more frequent information. Parental criticisms concerning the way in which the information was provided were that they received too much negative information about DS and that both the communication skills and the basic knowledge of DS on the part of the professionals could have been better.

CONCLUSION

The Swedish paediatric departments fall short of their reported strong clinical goals regarding the initial information in Sweden, and improvements in this area are desirable.

Parents' responses to their child's diagnosis of neurofibromatosis 1

Eighteen unaffected families with an affected child were interviewed in their homes to chronicle the experiences of parents in receiving their child's diagnosis of neurofibromatosis (NF) 1. Families were recruited through NF support groups and the Genetics Departments of two metropolitan hospitals in Northern California. Characteristics of disclosures were often at variance with suggestions made in recent years for the giving of "bad news." Disclosures typically were made "helter-skelter" during regular examinations. Parents in 16 of the families described shock, upset, and subsequent depression as their responses to the diagnosis. The overriding issues, which dominated in the disclosure, were the uncertainty of the condition, the possibility of many diverse symptoms, and its historic misdiagnosis as "The Elephant Man's Disease." However, physicians' attention to the setting and style of disclosure, imparting appropriate and positive information, allowance of additional time for careful explanation, and rescheduling a follow-up appointment, may be able to more effectively assist parents in receiving and more positively adapting to their child's diagnosis.

Disclosure of developmental disability: a study of parent satisfaction and the determinants of satisfaction

OBJECTIVE

To investigate the level of parent satisfaction with the first communication of a diagnosis of developmental disability in their child ('disclosure') and the determinants of this satisfaction.

METHODOLOGY

Interviews with parents of children with developmental disabilities regarding their experiences at the time of disclosure and their level of satisfaction with the process were carried out.

RESULTS

Parent satisfaction with disclosure overall was found to be high (82.6%). Parents were more likely to be satisfied if they received a large amount of information. Parent satisfaction was found to be higher when the disclosing professional communicates well with the parents, has an understanding of parental concerns, and is direct in manner. Having both parents, the child or support people present were not found to have any significant relationship to parent satisfaction.

CONCLUSIONS

The high level of satisfaction with disclosure in this study supports the claim made by earlier researchers that parental dissatisfaction with the disclosure process is not inevitable. The major determinants of parental satisfaction with disclosure are directness, understanding of parental concerns and good communication on the part of the disclosing professional, and receiving a large amount of information.

Maternal perceptions of family-provider relationships and well-being in families of children with Down syndrome

The purpose of this study was twofold: (a) to describe parental perceptions of family-provider relationships, and (b) to explore links between parental perceptions of family-provider relationships and well-being in families with children who have Down syndrome. Mailed questionnaires were used to collect data from 94 families that include a child with Down syndrome. Data from 89 mothers are the focus of this report. The results indicate that when mothers of children with Down syndrome believe that their family's relationship with health care providers is positive and family-centered, they feel more satisfied with the care that their child is receiving and they are more likely to seek help from health care providers. In addition, when a discrepancy exists between what mothers want the family-provider relationship to be and what they believe the relationship is, mothers feel less satisfied with the care that their child is receiving. Finally, higher levels of individual and family well-being are reported by mothers who (a) want, and believe they have, positive family-centered relationships with providers, and (b) feel more satisfied with care received. Results of this study contribute to a better understanding of the role that health care providers play in individual and family adaptation to chronic conditions.

Parents-as-teachers: design and establishment of a training programme for paediatric residents

OBJECTIVES

To improve the training of paediatric residents in general and to provide more meaningful insights into family functioning.

DESIGN

The programme is one facet of a 1-month developmental disabilities rotation for paediatric PL2 residents. It incorporates elements of family-centred care whereby physicians learn through home and community site visits about the importance of developing partnerships with parents and service providers in order to give better care to children with chronic conditions.

SETTING

Gillette Specialty Health Care Center, St Paul, Minnesota.

SUBJECTS

Paediatric PL2 residents and a parent group.

RESULTS

Of 18 residents, 11 completed written and 18 completed oral feedback evaluations. There were infrequent but consistent complaints relating to logistics; more positive comments were made about the programme and individuals involved.

CONCLUSIONS

In the minds of all participants, the Parents-as-Teachers (PAT) programme has been highly successful, as documented by short-term objective and subjective parent and resident feedback. The PAT experience represents a unique opportunity for parents and physicians-in-training to improve their mutual understanding. While not analysed in this report, the inclusion of a complementary programme involving on-site teaching in various community agencies also appears to be of value.

Benign familial neonatal convulsions; psychosocial adjustment to the threat of recurrent seizures

Forty families have experienced benign familial neonatal convulsions (BFNC) since it was first described by Rett and Teubel in 1964. [Rett, A. and Teubel, R. Neugeborenen Krampfe im Rahmen einer epileptisch belasten Familie. Wiener Klinische Wochenschrift 1964; 76: 609-613.] Diagnosis is based on a benign neonatal course, family history, and seizures which usually end spontaneously by six months of age. The absence of subsequent epilepsy makes BFNC a retrospective diagnosis. Consequently there is a considerable length of time during which parents may anxiously follow their child's development. We describe a child with BFNC whose family has experienced five generations of BFNC yet chose to react to the myths and misconceptions of epilepsy and circumvent updated experience supported by the recent medical literature. We have identified three areas in which appropriate physician intervention and patient education may reduce the magnitude of psychosocial disruptions: at the initial seizure, during childrearing and parenting, and in preparation of the patient for future independent decision making. By recognizing the magnitude of social, psychological, and economic disruptions affecting the child and family and by addressing communication issues during the initial diagnosis and follow-up period, we maximize our opportunity to break the cycle of mis-information and anxiety surrounding "benign' seizures.