Good communication with patients receiving bad news about cancer in Japan

Patients' perceptions of patient-centered communication with healthcare providers and associated factors in Japan - The INFORM Study 2020

OBJECTIVE

To describe patients' perceptions of the patient-centeredness of their communication with healthcare providers in Japan, and to examine factors associated with these perceptions.

METHODS

We analyzed the cross-sectional data from the INFORM Study 2020, which is a nationwide survey on health information access in Japan. A total of 3605 respondents completed the survey. Our primary outcome was the nine elements of the patient-centered communication scale (PCCS), which was compiled from 2703 respondents (75.0%) reporting at least one provider visit within 12 months. It was rated on a four-point Likert scale: always, usually, sometimes, and never. We used binary logistic regression to examine the association between sociodemographic and health-related variables, and each element of the PCCS.

RESULTS

For all elements, the percentage of respondents who agreed that their healthcare providers always communicated in a patient-centered way was low (17-31%). Patients with higher age, higher education, poorer general health status and a larger number of visits to providers in the previous 12 months were more likely to have positive perception.

CONCLUSION

Patient-centered communication as reported in a national sample in Japan was low.

CLINICAL IMPLICATIONS

Efforts are needed to improve the patient-centeredness of patient-provider communication in Japan to optimize health outcomes.

The Effect of Practitioner Empathy on Patient Satisfaction : A Systematic Review of Randomized Trials

BACKGROUND

Practitioners who deliver enhanced empathy may improve patient satisfaction with care. Patient satisfaction is associated with positive patient outcomes ranging from medication adherence to survival.

PURPOSE

To evaluate the effect of health care practitioner empathy on patient satisfaction, using a systematic review of randomized trials.

DATA SOURCES

Ovid MEDLINE, CINAHL, PsycInfo, Cochrane Central Register of Controlled Trials, and Scopus to 23 October 2023.

STUDY SELECTION

Randomized trials published in any language that evaluated the effect of empathy on improving patient satisfaction as measured on a validated patient satisfaction scale.

DATA EXTRACTION

Data extraction, risk-of-bias assessments, and strength-of-evidence assessments were done by 2 independent reviewers. Disagreements were resolved through consensus.

DATA SYNTHESIS

Fourteen eligible randomized trials (80 practitioners; 1986 patients) were included in the analysis. Five studies had high risk of bias, and 9 had some concerns about bias. The trials were heterogeneous in terms of geographic locations (North America, Europe, Asia, and Africa), settings (hospital and primary care), practitioner types (family and hospital physicians, anesthesiologists, nurses, psychologists, and caregivers), and type of randomization (individual patient or clustered by practitioner). Although all trials suggested a positive change in patient satisfaction, inadequate reporting hindered the ability to draw definitive conclusions about the overall effect size.

LIMITATIONS

Heterogeneity in the way that empathy was delivered and patient satisfaction was measured and incomplete reporting leading to concerns about the certainty of the underpinning evidence.

CONCLUSION

Various empathy interventions have been studied to improve patient satisfaction. Development, testing, and reporting of high-quality studies within well-defined contexts is needed to optimize empathy interventions that increase patient satisfaction.

PRIMARY FUNDING SOURCE

Stoneygate Trust. (PROSPERO: CRD42023412981).

Investigation of Fertility Preservation Education Videos for Pediatric Patients Based on International and Historical Survey

Purpose: Recently, direct communication with children about cancer seems to have shifted, but little is known about communication regarding discussions of future infertility risk due to cancer therapy. This study conducted cross-cultural comparisons between Japan and the United States to clarify communication patterns about cancer notification and develop appropriate information about fertility issues. Methods: An online survey was distributed to members of the Japanese Society of Pediatric Hematology/Oncology in July 2019 and the American Society of Pediatric Hematology/Oncology in July 2020. Based on the results from the survey, we developed three types of educational videos: a prepubertal version A, B, and a pubertal version. Next, we conducted a survey to assess whether these were appropriate for clinical practice. Results: We analyzed 325 physicians in Japan and 46 in the United States. In Japan, 80.5%, 91.7%, and 92.1% of the physicians notified patients aged 7-9, 10-14, and 15-17 years of their cancer diagnosis directly, respectively, compared within the United States, where the rate was 100%, regardless of age. Further, 9% and 45% of physicians in Japan and the United States, respectively, discuss fertility issues directly with patients aged 7-9 years. In the survey to assess the educational videos, 85% of the physicians preferred to use the educational videos in clinical practice. Conclusion: This is the first step in bringing concordance to communication patters for emerging cancer care around the globe and that this study and its intervention arm provide guidance in ways that ensure global equity in care.

Complexity and function of family involvement in advance care planning: A qualitative study of perspectives from people living with advanced cancer, family members and healthcare professionals

BACKGROUND

Family members can support advance care planning conversations. However, how family involvement in advance care planning operates to achieve goal-concordant care remains unclear.

AIM

To explore how family involvement impacts the process of advance care planning for advanced cancer patients and their family members to achieve goal-concordant care in Japan.

DESIGN

Qualitative study incorporating semi-structured in-depth interviews with thematic analysis informed by Family Systems Theory.

SETTING/PARTICIPANTS

Medical oncology departments at two tertiary hospitals in Japan. A purposive sample of 13 advanced cancer patients, 10 family members and 9 healthcare professionals who cared for them.

RESULTS

Twenty-five interviews were conducted, comprising 7 dyads of patients and their family members and 18 individual interviews. Four themes were identified: characteristics of patients and family members and their views on illness and advance care planning; family context and communication; interactions with healthcare professionals and societal and cultural influences; and family members' acceptance, preparation and confidence. Family involvement was observed as being variable at an individual level and also across generations. Family members provided patients with the instrumental and emotional support that facilitated the advance care planning process. Family involvement enabled family members to better prepare for realising patients' wishes. It increased family members' confidence in surrogate decision-making.

CONCLUSIONS

Two mechanisms of how family involvement may enable goal-concordant care were identified: family members' support provision and their preparation for realising patients' wishes. Healthcare professionals should assess family's readiness to engage in advance care planning, and the time required to prepare them for the process.

Preferred Communication with Adolescent and Young Adult Patients Receiving Bad News About Cancer

Purpose: Several studies have investigated good communication practices with adult patients receiving bad news about cancer. However, while communication preferences may differ between adults and adolescent and young adult (AYA) patients, these preferences have not been determined for AYA patients. The primary endpoint of this study was to describe the communication preferred by AYA patients with cancer. Methods: The study cohort consisted of 15 patients who received a cancer diagnosis at the age of 15-29 years. Patients were recruited at the National Cancer Center Hospital or through "STAND UP!!," an association of AYA patients with cancer. Semistructured interviews were conducted, and content analysis was performed to analyze the data. Results: For the preferred communication of AYA patients, 80 categories were extracted in the following five domains: (1) "Supportive setting," (2) "Method of disclosure of bad news," (3) "Information given," (4) "Emotional support," and (5) "Support for the patient's decision making." Although more than half of the categories extracted were identical to the preferred communication of adult patients, some categories specific to AYA patients were identified that physicians should consider. Preferences specific to AYA patients included mentioning generation-specific social factors, not showing excessive empathy, and communicating in a manner considering their age and cognitive development that supports their decision making. Conclusion: Although physicians should be mindful of the specific preferences of AYA patients, the basic attitude and communication preferences are similar to those of patients of other generations.

The experience of providing end-of-life care at home: The emotional experiences of young family physicians

Background

End-of-life care is now a major issue in Japan as a result of the rapidly aging population; hence, the need for fostering family physicians to be engaged in end-of-life care at home is increasing. Studies in the United States and the United Kingdom have shown that physicians feel emotional and moral distress in end-of-life care, and that they develop detachment and dehumanizing attitudes toward patients as a coping mechanism. However, few studies have explored the emotional experiences that family physicians have during home-based end-of-life care. The aim of this study is to explore the emotional experiences of young family physicians in such situations.

Methods

We conducted a qualitative analysis of interviews with family medicine residents or family physicians who had just completed their residency. The interviews were audio-recorded and transcripts were prepared. The coded data were analyzed according to thematic analysis using NVivo 10 software.

Results

Study participants were 12 family physicians of PGY 5-11, with experienced end-of-life care cases of 3-20. Thirteen themes were extracted from the data, which were categorized into five domains: difficulties in end-of-life discussion, emotions of physicians, the role of physicians, communicating with the family, and positivity in end-of-life care. The physicians experienced various emotions and struggles within these domains, but they also felt something positive through providing care for the dying patients and their families.

Conclusion

Family physicians experience various emotional difficulties during end-of-life home care. However, positive emotions at the end of life were also experienced through their care.

Geriatric assessment and management with question prompt list using a web-based application for elderly patients with cancer (MAPLE) to communicate ageing-related concerns: J-SUPPORT 2101 study protocol for a multicentre, parallel group, randomised controlled trial

INTRODUCTION

Elderly cancer patients often have ageing-related physical and psychosocial problems that should be fully shared with their oncologists. Geriatric assessment (GA) can assess these ageing-related problems and guide management. Communication support might also facilitate implementation of GA-guided management. We will conduct a multicentre, randomised controlled trial to examine the efficacy of a programme that combines a GA summary, management recommendations and communication support to facilitate ageing-related communications between elderly Japanese patients with cancer and their oncologists, and thus to implement programme-guided management.

METHODS AND ANALYSIS

We plan to recruit a total of 210 patients aged ≥70 years, diagnosed with incurable cancers of gastrointestinal origin, and referred for first-line or second-line chemotherapy. In the intervention arm, a summary of management recommendations based on a GA and question prompt list (QPL) will be provided to patients and shared with their oncologists at the first outpatient visit after randomisation by trained intervention providers. For 5 months after the initial intervention, implementation of GA-guided management recommendations will be reviewed monthly with the patients and their oncologists to implement management as needed. The GA and QPL will be re-evaluated at 3 months, with a summary provided to patients and their oncologists. Those participants allocated to the usual care arm will receive usual oncology care. The primary endpoint is the number of conversations about ageing-related concerns at the first outpatient visit after randomisation.

ETHICS AND DISSEMINATION

This study was approved by the institutional review board of the National Cancer Center Japan on 15 April 2021 (ID: 2020-592). Study findings will be disseminated through peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

UMIN000045428.

Assessing the need for a question prompt list that encourages end-of-life discussions between patients with advanced cancer and their physicians: A focus group interview study

OBJECTIVE

Early integration of palliative and cancer care improves the quality of life and is facilitated by discussions about the end of life after cessation of active cancer treatment between patients with advanced cancer and their physicians. However, both patients and physicians find end-of-life discussions challenging. The aim of this study was to assess the need for a question prompt list (QPL) that encourages end-of-life discussions between patients with advanced cancer and their physicians.

METHODS

Focus group interviews (FGIs) were conducted with 18 participants comprising 5 pancreatic cancer patients, 3 family caregivers, 4 bereaved family members, and 6 physicians. Three themes were discussed: question items that should be included in the QPL that encourages end-of-life discussions with patients, family caregivers, and physicians after cessation of active cancer treatment; when the QPL should be provided; and who should provide the QPL. Each interview was audio-recorded, and content analysis was performed.

RESULTS

The following 9 categories, with 57 question items, emerged from the FGIs: (1) preparing for the end of life, (2) treatment decision-making, (3) current and future quality of life, (4) current and future symptom management, (5) information on the transition to palliative care services, (6) coping with cancer, (7) caregivers' role, (8) psychological care, and (9) continuity of cancer care. Participants felt that the physician in charge of the patient's care and other medical staff should provide the QPL early during active cancer treatment.

SIGNIFICANCE OF RESULTS

Data were collected to develop a QPL that encourages end-of-life discussions between patients with advanced cancer and their physicians.

Evaluation of a Tool that Enables Cancer Patients to Participate in the Decision-Making Process during Treatment Selection

BACKGROUND

Patient participation in decisions related to their treatment is strongly recommended. This study was conducted to develop and evaluate a support tool that can help patients make decisions related to their own treatment.

METHODS

Twenty cancer patients who were hospitalized for first-line treatment were enrolled. Before hospitalization, a 'Check sheet on treatment selection', which contained 14 questions, was distributed to patients and/or their families. After hospitalization, the attending physician explained the treatment while referring to the written check sheet. At discharge, patients' responses to the 'Questionnaire on check sheet and treatment selection' were collected to evaluate the utility of the check sheet. Finally, the 'Questionnaire of the check sheet' was handed to the attending physician to evaluate.

RESULTS

Of the fourteen patients who responded to the questionnaire, all indicated that the check sheets were helpful for decision-making and that using the sheets empowered them to ask their doctors questions. Only one person felt uncomfortable with compiling the check sheet. Physicians stated that the check sheet facilitated patient decision-making and improved communication with patients. However, some felt that this activity increased the administrative burden of medical professionals.

CONCLUSION

Almost all patients stated that the present check sheet was useful as a decision support tool and facilitated communication between doctors and patients. Before incorporation into general clinical practice, this increased benefit should be weighed against the potential extra administrative workload imposed on clinicians.

Italian onco-haematological patients' preferences in bad news communication: a preliminary investigation

BACKGROUND

The manner in which bad news is communicated in oncological contexts can affect patients' engagement, their coping strategies and therapeutic compliance. Although this topic has been broadly investigated since the nineties, to the best of our knowledge, little has been written about Italian patients' experiences and preferences concerning what the oncologists should disclose and how they should intimate patients about their health conditions in different stages of oncological disease.

METHODS

In an attempt to fill this gap, an online self-report questionnaire was administered to a sample of Italian onco-haematological patients. Data were analysed both qualitatively (by a content analysis) and quantitatively (by descriptive analysis and Generalized Linear Mixed Model).

RESULTS

While the majority of patients elected to know the truth during their clinical course, a polarisation between those arguing that the truth be fully disclosed and those claiming that the truth be communicated in a personalised way was observed at the attitude level. Among demographic variables accounted for, age seems to most affect patients' preferences. Indeed, younger Italian patients decidedly reject concealment of the truth, even when justified by the beneficence principle. This result could be a reaction to some protective and paternalistic behaviours, but it could even reflect a relation according to which the more the age increases the more the fear of knowing rises, or an intergenerational change due to different ways of accessing the information. The qualitative analysis of the final open-ended question revealed three main sources of problems in doctor-patient encounters: scarcity of time, absence of empathy and use of not-understandable language that makes it difficult for patients to assume a more active role.

CONCLUSIONS

The results of the present study, which represents a preliminary step in the subject investigation, will be deployed for the construction and validation of a more sophisticated questionnaire. Better awareness of the Italian onco-haematological patients' preferences concerning bad news communication and truth-telling could be useful in adopting more suitable medical practices and improving doctor-patient relationships.

Indigenous perspectives on breaking bad news: ethical considerations for healthcare providers

Most healthcare providers (HCPs) work from ethical principles based on a Western model of practice that may not adhere to the cultural values intrinsic to Indigenous peoples. Breaking bad news (BBN) is an important topic of ethical concern in health research. While much has been documented on BBN globally, the ethical implications of receiving bad news, from an Indigenous patient perspective in particular, is an area that requires further inquiry. This article discusses the experiences of Māori (Indigenous peoples of New Zealand) lung cancer patients and their families, in order to investigate the ethical implications of receiving bad news. Data collection occurred through 23 semistructured interviews and nine focus groups with Māori lung cancer patients and their families in four districts in the Midland Region of New Zealand: Waikato, Bay of Plenty, Lakes and Tairāwhiti. The findings of this study were categorised into two key themes: communication and context. Avenues for best practice include understanding the centrality of the HCP-patient relationship and family ties in the healthcare journey, and providing patients with the full range of viable treatment options including hope, clear advice and guidance when the situation calls for it. Overall, the findings of this study hold implications for providing culturally safe and humanistic cancer care when BBN to Māori and Indigenous patients.

Integrated communication support program for oncologists, caregivers and patients with rapidly progressing advanced cancer to promote patient-centered communication: J-SUPPORT 1904 study protocol for a randomised controlled trial

INTRODUCTION

Communication is an essential aspect of care for patients with progressive serious illnesses. This study aims to evaluate the efficacy of a new, integrated communication support program for oncologists, patients with rapidly progressing advanced cancer and their caregivers.

METHODS AND ANALYSIS

The proposed integrated communication support programme is in the randomised control trial stage. It comprises a cluster of oncologists from comprehensive cancer centre hospitals in a metropolitan area in Japan. A total of 20 oncologists, 200 patients with advanced pancreatic cancer and the patients' caregivers are enrolled in this study as of the writing of this protocol report. Oncologists are randomly assigned to the intervention group (IG) or control group (CG). Patients and caregivers are allocated to the same group as their oncologists. The IG oncologists receive a 2.5-hour individual communication skills training, and patients and caregivers receive a half-hour coaching intervention to facilitate prioritising and discussing questions and concerns; the CG participants do not receive any training. Follow-up data will be collected quarterly for 6 months for a year and then annually for up to 3 years. The primary endpoint is the intergroup difference between before-intervention and after-intervention patient-centred communication behaviours during oncology visits.

ETHICS AND DISSEMINATION

This study is conducted in accordance with the ethical guidelines for clinical studies published by Japan's Ministry of Education, Cultural, Sports, Science and Technology, the Ministry of Health, Labour and Welfare, and the ethical principles established for research on humans stipulated in the Declaration of Helsinki and further amendments thereto. The protocol was approved by the Institutional Review Board of National Cancer Center, Japan on 4 July 2018 (ID: 2017-474).

TRIAL STATUS

This study is currently enrolling participants. Enrolment period ends 31 July 2020; estimated follow-up date is 31 March 2023.

TRIAL REGISTRATION NUMBER

UMIN Clinical Trial Registry (UMIN000033612); pre-results.

Negative recollections regarding doctor-patient interactions among men receiving a prostate cancer diagnosis: a qualitative study of patient experiences in Japan

OBJECTIVES

To explore the negative recollections of prostate cancer patients regarding the attitudes and language used by the doctors in delivering their diagnoses in Japan, in order to improve patient-centred communication.

DESIGN AND SETTING

This is a qualitative secondary analysis of the prostate cancer narrative data from the Database of Individual Patients' Experiences-Japan archives. A thematic analysis was conducted regarding negative recollections of doctors' words/attitudes when delivering a cancer diagnosis. Recruitment was based on maximum variation sampling. Participants were recruited from medical institutions, patient associations and through media advertisements.

PARTICIPANTS

Men with a diagnosis of prostate cancer (n=51).

FINDINGS

Of the 51 participants, 17 had negative recollections of the doctors' words/attitudes during the delivery of the cancer diagnosis. After thematic analysis, 11 categories emerged: 'Surprised by the abrupt disclosure of the diagnosis', 'Displeased by the direct disclosure of the diagnosis to the patient in the absence of family members', 'Unable to accept the doctor's negative words in the explanations', 'Unable to understand the doctor's technical jargon', 'Distrust due to failure in diagnosis based on previous examinations', 'Aggrieved at the doctor's unwillingness to allow questions', 'Dissatisfied with explanations involving facts only', 'Indignant over the unexpected disclosure of life expectancy', 'Unable to accept the doctor's blame for the delay in the initial hospital visit', 'Uncomfortable with the usage of inappropriate metaphors' and 'Pessimistic thoughts despite optimistic explanations'.

CONCLUSIONS

It is clear that patients have recollections of a variety of negative experiences regarding the words/attitudes of their doctors at the time they received their prostate cancer diagnosis. Thus, the use of narrative data would facilitate the appropriate application of commonly used guidelines for the delivery of cancer diagnoses tailored to individual patients in clinical practice.

Association Between the Communication Skills of Physicians and the Signing of Do-Not-Resuscitate Consent for Terminally Ill Patients in Emergency Rooms (Cross-Sectional Study)

Background

The signing of do-not-resuscitate (DNR) consent is mandatory in providing a palliative approach in the end-of-life care for the terminally ill patients and requires an effective communication between the physician and the patients or their family members. This study aimed to investigate the association between the communication skills of physicians who participated in the SHARE (supportive environment, how to deliver the bad news, additional information, reassurance, and emotional support) model course on the patient notification and the signing of do-not-resuscitate (DNR) consent by the terminally ill patients at emergency rooms.

Methods

Between May 1, 2017 and April 30, 2018, a total of 109 terminally ill patients were enrolled in this study, of which 70 had signed a DNR and 39 had not. Data regarding the patients’ medical records, a questionnaire survey completed by family members, and patient observation forms were used for the assessment of physicians’ communication skills during patient notification. The observation form was designed based on the SHARE model. A multivariate logistic regression model was applied to identify the independent significant factors of the patient and family member variables as well as the four main components of the observation form.

Results

The results revealed that knowing how to convey bad news and providing reassurance and emotional support were significantly correlated with a higher rate of signing DNR consent. Additionally, physician-initiated discussion with family members and a predicted limited life expectancy were negative independent significant factors for signing DNR consent.

Conclusion

This study revealed that good communication skills help to increase the signing of DNR consent. The learning of such skills from attendance of the SHARE model course is encouraged for the physicians in the palliative care of terminally ill patients in an emergency room.

The training in SHARE communication course by physicians increases the signing of do-not-resuscitate orders for critical patients in the emergency room (cross-sectional study)

BACKGROUND

Communication skills may be an important skill for the front-line emergency physicians.

AIM

This study aimed to investigate the effect of training in a SHARE communication course by emergency physicians on patient notification and signing of do-not-resuscitate (DNR) orders for critical patients in the emergency room.

DESIGN

From a total of 29 attending physicians in the emergency department, 19 physicians had been trained in the SHARE communication course. An observation form designed based on the SHARE training was completed by two observers who noted the communication process between physicians and patients and family members during patient notification and signing a DNR order. To assess the influence of physicians trained in a SHARE communication course on the signing of DNR orders, a propensity score-matched population was created to reduce the potential selection bias of patients and family members.

SETTING

Level 1 trauma medical center in southern Taiwan.

RESULTS

There were 145 individuals enrolled in the study, of which 93 signed the DNR order, and 52 did not sign it. Analysis from 23 matched pairs from this population revealed that significantly more family members would sign a DNR order if the physician had been trained in the SHARE communication course than when they did not receive this training (78.3% vs. 39.1%, respectively, p = 0.017). The overall score of the observation form for physicians was higher in those individuals who had signed a DNR order than in those who did not sign it (29.48 ± 3.72 vs. 26.13 ± 3.52, respectively, p = 0.003), especially when the physician had chosen a quiet environment (1.35 ± 0.65 vs. 0.87 ± 0.69, respectively, p = 0.020), understood the patient's wishes and confirmed them (1.78 ± 0.42 vs. 1.30 ± 0.70, respectively, p = 0.008), and expressed concern (1.48 ± 0.79 vs. 0.96 ± 0.77, respectively, p = 0.028). In addition, a feedback survey about the feelings experienced by these physicians during the process of patient notification did not reveal a significant difference during the communication with those who had or had not signed DNR orders.

CONCLUSION

The training in a SHARE communication course can improve the communication skills of emergency physicians in patient notification and signing of DNR orders for critical patients.

Breaking Bad News: An Evidence-Based Review of Communication Models for Oncology Nurses

BACKGROUND

A diagnosis of cancer is a stressful, difficult, and life-altering event. Breaking bad news is distressing to patients and families and is often uncomfortable for the nurse delivering it. Evidence-based communication models have been developed and adapted for use in clinical practice to assist nurses with breaking bad news.

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OBJECTIVES

The purpose of this article is to provide an overview on breaking bad news and to review the utility of the SPIKES and PEWTER evidence-based communication models for oncology nurses.
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METHODS

Perceptions of breaking bad news from the nurse and patient perspectives, as well as barriers and consequences to effective communication, will be presented. Clinical examples of possible situations of breaking bad news will demonstrate how to use the SPIKES and PEWTER models of communication when disclosing bad news to patients and their families.
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FINDINGS

By using the evidence-based communication strategies depicted in this article, oncology nurses can support the delivery of bad news and maintain communication with their patients and their patients' families in an effective and productive manner.

The Experience of Persons With Hematological Malignancy When Communicating With Health Care Professionals

This study aimed to elucidate the experiences of Japanese persons with hematological malignancy (PHMs) in communicating with health care professionals (HCPs), from diagnosis to the end of life, as recalled by their families. We interviewed 14 bereaved families and analyzed the data using the basic techniques of grounded theory. We found that PHMs lived to the fullest possible when they experienced ownership of their illness process despite their disease. The ownership was made possible by active communication from HCPs: first, acknowledging the PHM's way of life, including reaching out from the HCPs and appreciating sincerely PHMs' hopes and will; and second, paving the way ahead, including giving prospects and offering choices. The study underlines that rather than just providing information about the disease, HCPs need to actively ask about and show respect for the PHM's way of life. Only after achieving this can HCPs communicate possible future pathways with PHMs.

Elderly cancer patients’ preferences regarding the disclosure of cancer diagnosis. Experience of a single institution in Italy

The disclosure of a diagnosis of cancer is complex, particularly in older patients for reasons related to the wishes of the family, fear of discouraging the patient, or the patient's inability to understand the information. So our insight into older people's perspectives regarding the disclosure of their cancer diagnosis is fragmentary and inadequate. To examine the views of older adults regarding this issue, we performed a prospective observational study in an inpatient oncology clinic. From January 2006 to June 2006, a sample of 132 consecutive cancer patients aged over 70 years with a variety of solid tumors, recently diagnosed and mainly at an advanced stage, agreed to take part in a survey about the disclosure of the diagnosis of their disease. Of the 132 patients who verbally agreed to participate and were given questionnaires, 106 returned data. The majority of patients (64.1%) in this study wanted to be informed about the diagnosis of their disease also if it was cancer, and 58.5% were in fact informed about the exact nature of their disease. Male patients were more keen to know the diagnosis than female patients (P = 0.002) and they were in fact more informed about their diagnosis than female patients (P = 0.005). Patients with more formal education were more informed than patients with less formal education (P = 0.035). This study demonstrates that the preferences of older patients regarding cancer diagnosis disclosure are highly similar to those of younger people. Male patients and patients with more formal education were more informed than female patients and patients with less formal education.

Dynamic axes of informed consent in Japan

Scholarship in cross-cultural bioethics routinely frames Japanese informed consent in contrast to informed consent in North America. This contrastive analysis foregrounds cancer diagnosis disclosure and physician paternalism as unique aspects of Japanese informed consent that deviate from American practices. Drawing on in-depth interviews with 15 Japanese medical professionals obtained during fieldwork in Japan from 2013 to 15, this article complicates the informed consent discourse beyond East-West comparisons premised on Anglo-American ethical frameworks. It expands professional perspectives to include nurses, medical social workers, clinical psychologists, and ethicists and it addresses informed consent for a broad range of conditions in addition to cancer. The results suggest that division of affective labor is an under-theorized dimension of informed consent that is perceived as at odds with principled demands for universal informed consent. These practical tensions are conceptualized as cultural differences, with Japan identified in terms of omakase as practical and supportive and the United States identified in terms of jiko kettei as principled and self-determining. These results have implications for the methodology of cross-cultural bioethics as well as for theories and practices of informed consent in both Japan and the United States. I conclude that responsible cross-cultural work in bioethics must begin from the ground up, incorporating all relevant stakeholder perspectives, attitudes, and experiences.

Factors associated with patient preferences for communication of bad news

OBJECTIVE

Communication based on patient preferences can alleviate their psychological distress and is an important part of patient-centered care for physicians who have the task of conveying bad news to cancer patients. The present study aimed to explore the demographic, medical, and psychological factors associated with patient preferences with regard to communication of bad news.

METHODS

Outpatients with a variety of cancers were consecutively invited to participate in our study after their follow-up medical visit. A questionnaire assessed their preferences regarding the communication of bad news, covering four factors-(1) how bad news is delivered, (2) reassurance and emotional support, (3) additional information, and (4) setting-as well as on demographic, medical, and psychosocial factors.

RESULTS

A total of 529 outpatients with a variety of cancers completed the questionnaire. Multiple regression analyses indicated that patients who were younger, female, had greater faith in their physician, and were more highly educated placed more importance on "how bad news is delivered" than patients who were older, male, had less faith in their physician, and a lower level of education. Female patients and patients without an occupation placed more importance on "reassurance and emotional support." Younger, female, and more highly educated patients placed more importance on "additional information." Younger, female, and more highly educated patients, along with patients who weren't undergoing active treatment placed more importance on "setting."

SIGNIFICANCE OF RESULTS

Patient preferences with regard to communication of bad news are associated with factors related to patient background. Physicians should consider these characteristics when delivering bad news and use an appropriate communication style tailored to each patient.

Poor-prognosis disclosure preference in cancer patient-caregiver dyads and its association with their quality of life and perceived stress: a cross-sectional survey in mainland China

BACKGROUND

This study attempted to examine the discordance between family caregivers and cancer patients in their poor-prognosis disclosure preferences in mainland China and then ascertained the associations between quality of life (QoL), perceived stress, and poor-prognosis disclosure preferences.

METHODS

Six hundred fifty-one pairs of inpatients and their matched caregivers (participation rate = 92.2%) were recruited in this cross-sectional survey. A set of paired self-administered questionnaires were completed independently by patient-caregiver dyads.

RESULTS

Fewer family caregivers than cancer patients felt that poor prognosis should be disclosed to patients (61.2% vs. 90.0%, p < 0.001). Patients' positive poor-prognosis disclosure preference was associated with patients' better QoL (p < 0.05) and caregivers' reduced perceived stress levels (p = 0.013). However, caregivers' poor-prognosis disclosure preference correlated only with their own physical state (p = 0.028). Moreover, the caregivers who concurred with patients in positive poor-prognosis disclosure preference were more likely to experience a better QoL (p < 0.05) and lower perceived stress levels (p = 0.048) in the III-IV stage subgroup.

CONCLUSIONS

There was a significant discrepancy in poor-prognosis disclosure preference between cancer patients and caregivers in China. The caregivers' preference of concealing poor prognosis from patients was not related to cancer patients' QoL or perceived stress. In addition, caregivers had better QoL and lower stress levels when they held the same positive poor-prognosis disclosure preference as the patients. Copyright © 2015 John Wiley & Sons, Ltd.

Breaking bad news to cancer patients in palliative care: A comparison of national cross-sectional surveys from 2006 and 2012

OBJECTIVE

Most cancer patients experience the time when a doctor must "break the bad news" to them, a time when it is necessary for patients to call upon their self-determination to aid in the battle with cancer. The purpose of our study was to clarify the percentage of times doctors deliver bad news to patients at the end of life in each of four different situations, and to define the most common recipients of this bad news. We compare these results for two timepoints: 2006 and 2012.

METHODS

The study had a national cross-sectional design consisting of self-completed questionnaires sent to all hospitals that provide cancer care. We mailed them to hospital directors in January and February of 2012, requesting a reply. The results of the same survey in 2006 were employed as a point for comparison.

RESULTS

A total of 1224 questionnaires were returned during 2012. 1499 responses collected in 2006 were employed as reference data. Some hospital characteristics had changed over that interval; however, the new data obtained were representative for patients being treated in Japanese cancer care hospitals. In hospitals with 300-499, there were significant differences between 2006 and 2012 in the providing information about ("disclosure of cancer diagnosis," "therapeutic options for treatment," and "a life-prolonging treatment"). In addition, the likelihood of doctors delivering bad news to patients and family members (as opposed to family members only) at the end of life increased from 2006 to 2012.

SIGNIFICANCE OF RESULTS

Our results suggest that the overall incidence of bad news being disclosed has increased, especially in hub medical institutions for cancer care. Advanced treatment options or domestic legislation may have influenced the frequency or type of bad news.

Effect of communication skills training program for oncologists based on patient preferences for communication when receiving bad news: a randomized controlled trial

PURPOSE

The aim of this study was to identify the effects of a communication skills training (CST) program for oncologists, developed based on patient preferences regarding oncologists' communication.

PARTICIPANTS AND METHODS

Thirty oncologists were randomly assigned to either an intervention group (IG; 2-day CST workshop) or control group (CG). Participants were assessed on their communication performance during simulated consultation and their confidence in communicating with patients at baseline and follow-up. A total of 1,192 patients (response rate, 84.6%) who had consultations with the participating oncologists at baseline and/or follow-up were assessed regarding their distress using the Hospital Anxiety and Depression Scale, satisfaction with the consultation, and trust in their oncologist after the consultation.

RESULTS

At the follow-up survey, the performance scores of the IG had improved significantly, in terms of their emotional support (P = .011), setting up a supportive environment (P = .002), and ability to deliver information (P = .001), compared with those of the CG. Oncologists in the IG were rated higher at follow-up than those in the CG in terms of their confidence in themselves (P = .001). Patients who met with oncologists after they had undergone the CST were significantly less depressed than those who met with oncologists in the CG (P = .027). However, the CST program did not affect patient satisfaction with oncologists' style of communication.

CONCLUSION

A CST program based on patient preferences is effective for both oncologists and patients with cancer. Oncologists should consider CST as an approach to enhancing their communication skills.

Giving bad news: a qualitative research exploration

BACKGROUND

The manner in which healthcare professionals deliver bad news affects the way it is received, interpreted, understood, and dealt with. Despite the fact that clinicians are responsible for breaking bad news, it has been shown that they lack skills necessary to perform this task.

OBJECTIVES

The purpose of this study was to explore Iranian mothers' experiences to receive bad news about their children cancer and to summarize suggestions for improving delivering bad news by healthcare providers.

MATERIALS AND METHODS

A qualitative approach using content analysis was adopted. Semi-structured interviews were conducted with 14 mothers from two pediatric hospitals in Iran.

RESULTS

Five major categories emerged from the data analysis, including dumping information, shock and upset, emotional work, burden of delivering bad news to the family members, and a room for multidisciplinary approach.

CONCLUSIONS

Effective communication of healthcare team with mothers is required during breaking bad news. Using multidisciplinary approaches to prevent harmful reactions and providing appropriate support are recommended.

Development and preliminary evaluation of communication skills training program for oncologists based on patient preferences for communicating bad news

Objective:

The purposes of this study were to develop a communication skills training (CST) workshop program based on patient preferences, and to evaluate preliminary feasibility of the CST program on the objective performances of physicians and the subjective ratings of their confidence about the communication with patients at the pre- and post-CST.

Methods:

The CST program was developed, based on the previous surveys on patient preferences (setting up the supporting environment of the interview, making consideration for how to deliver bad news, discussing about additional information, and provision of reassurance and emotional support) and addressing the patient's emotion with empathic responses, and stressing the oncologists' emotional support. The program was participants' centered approach, consisted a didactic lecture, role plays with simulated patients, discussions and an ice-breaking; a total of 2-days. To evaluate feasibility of the newly developed CST program, oncologists who participated it were assessed their communication performances (behaviors and utterances) during simulated consultation at the pre- and post-CST. Participants also rated their confidence communicating with patients at the pre-, post-, and 3-months after CST, burnout at pre and 3 months after CST, and the helpfulness of the program at post-CST.

Results:

Sixteen oncologists attended a newly developed CST. A comparison of pre-post measures showed improvement of oncologists' communication performances, especially skills of emotional support and consideration for how to deliver information. Their confidence in communicating bad news was rated higher score at post-CST than at pre-CST and was persisted at 3-months after the CST. Emotional exhaustion scores decreased at 3-months after CST. In addition, oncologists rated high satisfaction with all components of the program.

Significance of results:

This pilot study suggests that the newly developed CST program based on patient preferences seemed feasible and potentially effective on improving oncologists' communication behaviors what patients prefer and confidence in communicating with patients.

Psychosocial care in cancer: an overview of psychosocial programmes and national cancer plans of countries within the International Federation of Psycho-Oncology Societies

We report data from representatives of national professional psycho-oncology societies on the integration of psychosocial care into national cancer programmes or cancer plans. To date information on how, or whether, psychosocial care has been recognized and integrated into comprehensive cancer care internationally has been extremely limited. The value of the current survey, whilst not comprehensive, lies with the fact that it is the first to report on the current status of psychosocial care for cancer patients and their families from a global perspective. Representatives of 29 countries that are members of the Federation of National Psycho-Oncology Societies, coordinated under the aegis of the International Psycho-Oncology Society (IPOS), participated in a survey aimed at clarifying access to psychosocial care. Results indicate that while psychosocial oncology has grown over the last decade, it is either not established or not completely established, or not an integral part of care in some countries, especially developing countries, where basic care is sometimes not provided to cancer patients. Future targets need to focus on the integration of psychosocial oncology programmes into comprehensive cancer care and their coordination within multidisciplinary teams.

Truth telling in medical practice: students' opinions versus their observations of attending physicians' clinical practice

OBJECTIVE

Truth telling or transmitting bad news is a problem that all doctors must frequently face. The purpose of this cross-sectional study was to investigate if medical students' opinions of truth telling differed from their observations of attending physicians' actual clinical practice.

METHODS

The subjects were 275 medical clerks/interns at a medical center in northern Taiwan. Data were collected on medical students' opinions of truth telling, their observations of physicians' clinical practice, students' level of satisfaction with truth telling practiced by attending physicians, and cancer patients' distress level when they were told the truth.

RESULTS

Students' truth-telling awareness was significantly higher than the clinical truth-telling practice of attending physicians (p<0.001), and the means for these parameters had a moderate difference, especially in three aspects: method, emotional support, and providing additional information (p<0.001). Regardless of this difference, students were satisfied with the truth telling of attending physicians (mean ± SD=7.33 ± 1.74). However, our data also show that when cancer patients were informed of bad news, they all experienced medium to above average distress (5.93 ± 2.19).

CONCLUSIONS

To develop the ability to tell the truth well, one must receive regular training in communication skills, including experienced attending physicians. This study found a significant difference between medical students' opinions on truth telling and attending physicians' actual clinical practice. More research is needed to objectively assess physicians' truth telling in clinical practice and to study the factors affecting the method of truth telling used by attending physicians in clinical practice.

Breaking bad news in a Southeast European population: a survey among cancer patients in Albania

OBJECTIVE

The purpose of this study was to explore the attitudes of cancer patients, their family, and community members in Albania, a post-communist country in Southeast Europe, regarding breaking bad news.

METHODS

One hundred and fifty consecutive cancer patients, 150 respective relatives, and an age-sex-residence matched sample of 150 individuals in Tirana district were interviewed from September 2009-January 2010 about attitudes related to diagnosis disclosure. Logistic regression was used to assess the association of diagnosis disclosure with demographic characteristics.

RESULTS

Community members were the most in favor, whereas the patients' relatives were the least in favor of diagnosis disclosure. Most of the patients, who were aware of their diagnosis, were not satisfied with the disclosure approach employed by the medical staff. The odds of favoring diagnosis disclosure were significantly higher among younger, male, urban, and more educated patients.

CONCLUSION

This survey identified important characteristics of cancer patients, their relatives, and a community-based sample in Albania that could predict the willingness to disclose a fatal diagnosis. Establishment of a formal training of health professionals regarding breaking bad news should be considered in order to ensure a proper approach of communicating diagnosis to cancer patients in transitional Albania.

Illness experience in patients with hepatocellular carcinoma: an interpretative phenomenological analysis study

AIMS

Hepatocellular carcinoma (HCC) is common in Asia and has implications for compromised health-related quality of life. We report a qualitative study to explore the impact of HCC on patients' lives and the adjustment process.

METHODS

Thirty-three adult patients with HCC in Taiwan (age from 31 to 76 years) took part in a semistructured interview. The interview guide included illness experience, strategies used to deal with the disease, and any significant concerns in their current life. Data were analyzed using interpretative phenomenological analysis.

RESULTS

Three main themes were identified. These included: (a) the impact of disease: HCC was associated with physical symptoms and psychosocial stress, as well as positive changes; (b) illness perceptions: patients perceived HCC as a long-term and chronic disease that could not be cured but might be controlled; and (c) coping strategies: these included focusing on managing HCC and its symptoms, emotional responses, and leading a normal life.

CONCLUSION

Patients' physical condition, their illness perceptions, and coping strategies all contributed to their disease adjustment. Our results suggest that patients in Taiwan are as keen for information about their disease as described in Western cultures. Cross-cultural work is needed to enhance our understanding about how the social or cultural contexts shape individuals coping with cancer.

Breaking bad news: the patient's viewpoint

The objective of this study was to ascertain how patients judge the acceptability of physicians' communication of bad news. Two hundred forty-five adults, who had in the past received bad medical news, indicated the acceptability of physicians' conduct in 48 vignettes of giving bad news to patients. Vignettes were all combinations of five factors: level of bad news (infection with hepatitis C, cirrhosis of the liver, or liver cancer); request or not to the patient to come with spouse or partner; attempt or not by the physician to find out the patient's expectations about the test results; presence or absence of emotional supportiveness; and provision or not of complete and understandable information. In addition, nine physicians rated the same vignettes. Quality of information and emotional supportiveness explained more than 95% of the variance in patients' acceptability judgments, while the degree of badness of the news had no impact. In addition, for patients, low emotional supportiveness could not be fully compensated by high quality of information, nor the inverse. Physicians, in contrast, responded as if such compensations were possible. Physicians must appreciate that patients expect high levels of both empathy and information quality, no matter how bad the news.

An experimental investigation of the dilemma of delivering bad news

OBJECTIVE

This randomly controlled experiment tested a theory of how experienced physicians solve the dilemma of communicating bad news by using implicit language.

METHODS

8 physicians delivered both bad and good news to 16 analogue patients. Microanalysis of their news delivery reliably identified departures from explicit language.

RESULTS

As predicted, the physicians used implicit language at a significantly higher rate when delivering bad news than good news. For bad news, they tended to use alternative terms for the diagnosis, to qualify their evaluation, to underemphasize certainty, and to subtly separate the patient from the disease. The evidence both within and after the interview indicated that recipients still understood the bad news.

CONCLUSION

(1) The skilful use of implicit language is a solution to the dilemma of honest but not harsh communication of bad news. (2) Experimental methods can complement surveys and qualitative studies for investigating bad news delivery by providing a theoretical foundation and controlled conditions.

PRACTICE IMPLICATIONS

Physicians can deliver bad news honestly without being blunt by skilfully incorporating implicit language. The theory, data, and examples presented here provide insights into the nature and functions of implicit language, from which students and practitioners can develop their individual styles.

Preferences of cancer patients regarding communication of bad news: a systematic literature review

Most physicians regard the communication of bad news to be a difficult issue in clinical oncology practice. The optimal manner of communicating bad news to patients so that physicians can create maximal understanding in patients and facilitate their psychological adjustment is unknown. A systematic review of the literature was conducted to clarify available knowledge on patient preferences regarding the communication of bad news and associated factors. A comprehensive computer search of databases (MEDLINE and PsychINFO) and a manual search identified 24 studies. The above issue has been discussed mainly in Western countries. Most studies used different measures to obtain information on patient preferences and have provided mostly descriptive evidence. The findings in this review suggest that patient preferences with regard to the communication of bad news by physicians consist of four components: setting, manner of communicating bad news, what and how much information is provided and emotional support, and that patients' preferences are associated with demographic factors. Younger patients, female patients and more highly educated patients consistently expressed a desire to receive as much detailed information as possible and to receive emotional support. Asian patients were shown to prefer that relatives be present when receiving bad news more than Westerners do and to prefer to discuss their life expectancy less than Westerners. Physicians need to recognize these preferences to help patients understand.

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.

Barriers to providing palliative care and priorities for future actions to advance palliative care in Japan: a nationwide expert opinion survey

OBJECTIVES

Palliative care specialists are faced with extensive barriers to providing effective palliative care. We carried out a survey to identify existing barriers from the point of view of palliative care experts in Japan and determine the priorities for future actions to overcome these barriers.

METHODS

We conducted a cross-sectional mail survey in December 2004. We sent out 2607 questionnaires to members of the Japanese Society of Palliative Medicine and Hospice Palliative Care Japan. We asked all respondents two open-ended questions regarding barriers and future actions in the context of palliative care in Japan. In total, 426 questionnaires were returned (response rate of 16%).

RESULTS

We identified 95 different answers concerning barriers to providing effective palliative care. The three most frequent answers were "general medical practitioners' lack of interest, knowledge, and skills" (n = 203), "general population's lack of knowledge and misunderstandings about palliative care" (n = 122), and "general medical practitioners' failure to provide information and lack of communication skills" (n = 89). We identified 136 different answers concerning future actions required to improve palliative care. The three most frequent answers were "organize study sessions on palliative care or case conferences in hospitals" (n = 122), "provide information about palliative care to the general population" (n = 117), and "in undergraduate education, make palliative care a compulsory course" (n = 88).

CONCLUSIONS

We identified numerous barriers to providing effective palliative care, related to not only medical practitioners, but also economic factors and the general population. These findings suggest that to overcome these barriers, we need to take action on many fronts, including increasing social awareness and effecting political change, as well as addressing problems relating to practitioners. We prioritized the future actions. The most frequent urgent problems were identified. We hope that collaborative efforts by the relevant organizations will improve palliative care in Japan.

Japanese cancer patients' communication style preferences when receiving bad news

This study describes the communication style preferences of Japanese patients when receiving bad news, examines the factor structure of the measure for patients' preferences (MPP) in a Japanese population, and explores variables that may be associated with patients' communication style preferences. Five hundred twenty-nine cancer outpatients completed several psychosocial measures including the Japanese version of the MPP (MPP-J), the Mental Adjustment to Cancer Scale (MAC), and the Hospital Anxiety and Depression Scale (HADS). The patients desired detailed information and a supportive environment when receiving bad news. The MPP-J demonstrated a 5-factor structure: support, facilitation, medical information, clear explanation, and encouraging question-asking. Regression analyses indicated that a female gender, the fighting spirit and anxious preoccupation dimensions of the MAC were positively associated with all 5 MPP-J factors. In conclusion, Japanese cancer patients' preferences for communication when receiving bad news differ somewhat from those of American patients. Japanese physicians should encourage patients to ask questions and should consider the demographic (e.g. gender), medical (disease status) and psychosocial characteristics (fighting spirit and anxious preoccupation) of patients when delivering bad news.

Preferences of cancer patients regarding the disclosure of bad news

To understand patients' preferences regarding the disclosure of bad news is important in the clinical oncology setting. The aim of this study was to clarify descriptively the preferences of cancer patients. Five hundred and twenty-nine Japanese cancer outpatients were surveyed regarding their preferences regarding the disclosure of bad news, and several psychosocial and medical demographic variables were analyzed. In a descriptive analysis, more than 90% of the patients strongly preferred to discuss their current medical condition and treatment options with their physician and to have their physicians take the feelings of their family into consideration as well. While half of the patients preferred to receive information regarding their life expectancy, 30% preferred not to receive it. Multiple regression analyses indicated the preferences showing interindividual variations were associated with the level of education and the mental adjustment to cancer scores. A factor analysis revealed four preferences factors: method of disclosure of the bad news, provision of emotional support, provision of additional information, and setting. These four factors had good internal consistency reliability (Cronbach's alpha = 0.93-0.77). Providing emotional support, including the desire for the physician to show consideration for the patient's family, and understanding an individual's communication preferences may be useful for promoting patient-physician communication.

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.

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.

Telling children and adolescents about their cancer diagnosis: cross-cultural comparisons between pediatric oncologists in the US and Japan

PURPOSE

Over the last 50 years, direct communication about cancer with adults has shifted from an approach of not telling to one of telling. Less is known about communication practices with children. The purpose of this study is to (1) describe patterns of communication at diagnosis between pediatric oncologists and children with cancer and (2) compare cultural differences in these practices in the US and Japan.

METHODS

This 2003 survey, developed in English and translated into Japanese was mailed to members of the American Society of Pediatric Hematology/Oncology and the two Japanese Societies of Pediatric Hematology and Oncology; there were 350 US and 362 Japanese respondents. Descriptive statistics and logistic regressions were performed.

RESULTS

US physicians had a consistent pattern of telling children (65% always told the child; less than 1% rarely or never told). Japanese physicians had greater variability in their patterns of telling (with only 9.5% always telling, 34.5% rarely or never telling). Direct communication with the child was influenced by personal attitudes, patient factors, and work culture in both countries. Many more variables emerged as influencing Japanese physicians' communication practices than for US physicians. US physicians were influenced by their own sense of responsibility for telling, while Japanese physicians were more influenced by personal attitudes, patient factors, and work culture.

CONCLUSIONS

US and Japanese physicians differed when communicating directly with the child about his or her cancer. The impact of these practices on children and their parents should be explored and the parent and child's perspectives elicited. This information will help facilitate culturally sensitive patient and family centered communication.