Breaking bad news in genetic counseling—problems and communication tools

Psychosocial barriers and facilitators for cascade genetic testing in hereditary breast and ovarian cancer: a scoping review

Despite increased awareness and availability of genetic testing for hereditary breast and ovarian cancer (HBOC) syndrome for over 20 years, there is still significant underuse of cascade genetic testing among at-risk relatives. This scoping review synthesized evidence regarding psychosocial barriers and facilitators of family communication and/or uptake of cascade genetic testing in relatives from HBOC families. Search terms included 'hereditary breast and ovarian cancer' and 'cascade genetic testing' for studies published from 2012-2022. Through searching common databases, and manual search of references, 480 studies were identified after excluding duplications. Each article was reviewed by two researchers independently and 20 studies were included in the final analysis. CASP, RoBANS 2.0, RoB 2.0, and MMAT were used to assess the quality of included studies. A convergent data synthesis method was used to integrate evidence from quantitative and narrative data into categories and subcategories. Evidence points to 3 categories and 12 subcategories of psychosocial barriers and facilitators for cascade testing: (1) facilitators (belief in health protection and prevention; family closeness; decisional empowerment; family support, sense of responsibility; self-efficacy; supportive health professionals); (2) bidirectional concepts (information; perception of genetic/cancer consequences; negative emotions and attitude); and (3) barriers (negative reactions from family and negative family dynamics). Healthcare providers need to systematically evaluate these psychosocial factors, strengthen facilitators and alleviate barriers to promote informed decision-making for communication of genetic test results and uptake of genetic testing. Bidirectional factors merit special consideration and tailored approaches, as they can potentially have a positive or negative influence on family communication and uptake of genetic testing.

Early Experiences of Parents of Children With Craniofacial Microsomia

OBJECTIVE

To describe the early health care experiences of parents of children with craniofacial microsomia (CFM), a congenital diagnosis often identified at birth.

DESIGN

Qualitative descriptive.

SETTING

Homes of participants.

PARTICIPANTS

Parents of 28 children with CFM from across the United States.

METHODS

We interviewed participants (27 mothers individually and one mother and father together) via telephone or teleconference and used reflexive thematic analysis to derive themes that represented early health care experiences of parents of children with CFM.

RESULTS

Participants' narratives included detailed recounting of their birth and early care experiences. We identified two overarching themes. The first overarching theme, Stressors, included four subthemes that represented difficulties related to emotional reactions and negative experiences with health care providers. The second overarching theme, Finding Strength, included four subthemes that represented participants' positive adjustment to stressors through independent information seeking about CFM, adaptive coping, positive experiences with health care providers, and drawing on external supports.

CONCLUSION

Participants often described early experiences as challenging. Findings have implications for improving early care, including increasing open and supportive communication by health care professionals, expanding access to CFM information, screening for mental health concerns among parents, strengthening coping among parents, and linking families to resources such as reliable online CFM information and early intervention programs.

Do parents get what they want during bad news delivery in NICU?

OBJECTIVES

Little is known about parents' preferences in breaking bad news (BBN) in neonatology. The study was aimed at comparing parents' experiences with their first BBN discussion with a neonatologist/pediatric surgeon to their personal preferences.

METHODS

We conducted a quantitative survey amongst 54 parents of hospitalized preterm or term infants with severe diseases in two medium-size and one small German neonatal units. Parents answered self-rated questions on how they perceived BBN during their infant's hospital stay, asking for procedure and perception of BBN, their preferences and satisfaction with BBN.

RESULTS

Overall satisfaction with BBN was moderate to high (median (min-max): 8 (1-10) on a 1-10-Likert scale). A compassionate way of disclosure correlated highest with overall satisfaction with BBN. Thorough transmission of information in an easy to understand manner emerged as another crucial point and correlated significantly to satisfaction with BBN, too. The study revealed that it was highly important for parents, that physicians had good knowledge of the infant and the course of his/her disease, which was only met in a minority of cases. Moreover, there was a major discrepancy between expected and observed professional competence of the delivering physicians. Additionally, physicians did not set aside sufficient time for BBN and parents reported a lack of transporting assurance and hope.

CONCLUSIONS

In BBN physicians should draw greatest attention to ensure understanding in parents, with good knowledge of child and disease and sufficient time in a trustworthy manner. Physicians should focus on transporting competence, trust and gentleness.

Acceptability and Usability of the Family Gene Toolkit for Swiss and Korean Families Harboring BRCA1/BRAC2 Pathogenic Variants: A Web-Based Platform for Cascade Genetic Testing

The study adapted the Family Gene Toolkit and developed a customized web application for Swiss and Korean families harboring BRCA1 or BRCA2 pathogenic variants to support family communication of genetic testing results and promote cascade genetic testing among at-risk relatives. In the first step, narrative data from 68 women with BRCA1/BRCA2 pathogenic variants and clinician feedback informed a culturally sensitive adaptation of the content consistent with current risk management guidelines. In the second step, the Information Technology team developed the functions and the interface of the web application that will host the intervention. In the third step, a new sample of 18 women from families harboring BRCA1/BRCA2 pathogenic variants tested the acceptability and usability of the intervention using "think-aloud" interviews and a questionnaire. Participants expressed high levels of satisfaction with the intervention. They provided positive feedback for the information regarding active coping, strategies to enhance family communication, interactive elements, and illustrative stories. They reported that the information was useful and the web application was easy to navigate. Findings suggest that the Family Gene Toolkit is well-designed and can increase rates of cascade testing among at-risk relatives. Its efficacy will be tested in a subsequent randomized trial.

Developing an effective and comprehensive communication curriculum for undergraduate medical education in Poland - the review and recommendations

BACKGROUND

The recognition of the importance of effective communication in the healthcare system has been growing. Given that communication courses must be adjusted to the specificity of a particular culture, language, and other contextual issues, many countries and communities sharing a common language have proposed their recommendations for a communication curriculum for undergraduate medical education. To date, no recommendations have been developed for either any Central and Eastern Europe countries or for regions where Slavic languages are spoken. Their specificity of post-communist transformation should be acknowledged. This study aims to review communication curriculums and offer recommendations for medical communication training for undergraduate medical students in Poland.

METHODS

The recommendations were developed through an iterative consultation process with lecturers, faculty members of medical schools, and education coordinators. PubMed and Google Scholar databases were searched to identify full text English and Polish language articles on communication curriculum for undergraduate medical education. Additionally, the new Regulation of the Polish Minister of Science and Higher Education, defining educational standards for undergraduate medical education was analysed in search of learning outcomes that could be applied in communication skills teaching. The authors extracted the most relevant communication skill competencies, as determined by the process participants, discussed current challenges, including those of the COVID-19 pandemic era, and indicated best practices.

RESULTS

A review was conducted, and a set of recommendations was developed pertaining to the scope and methodology of teaching communication skills. The study included: (1) definition, (2) education content, (3) learning outcomes, (4) the recommended teaching methods. The recommendations are in concord with the graduate profile, as well as the current structure of medical studies. The authors listed and discussed the basic communication competencies expected of medical graduates, as well as medical communication course content viewed from different perspectives, including clinical, psychological, sociological, legal, and linguistic.

CONCLUSIONS

Detailed recommendations aimed at integrating best practices into a comprehensive communication curriculum may promote successful teaching, learning, and assessment of medical communication.

What matters to parents? A scoping review of parents' service experiences and needs regarding genetic testing for rare diseases

Patient care experiences are key to promoting better outcomes and are an essential consideration for successful implementation of genomics in paediatric care. To understand parents' service experiences and needs regarding testing of their child for rare diseases, we conducted a scoping review. Five databases were searched (2000-2022), with 29 studies meeting the inclusion criteria. Experiences of care wholly delivered by genetic services were most commonly reported (n = 11). Results were synthesised by mapping extracted data to adapted Picker principles of person-centred care. Parents especially valued and emphasised the importance of feeling 'cared for', continuous relationships with clinicians, empathic communication, being kept informed while awaiting genetic test results, linkage with informational and psychosocial resources following results disclosure, and follow-up. Strategies were often proposed by authors to address long-standing unmet needs but evidence from the literature regarding their potential effectiveness was rarely provided. We conclude that 'what matters' to parents regarding genetic testing is not dissimilar to other aspects of care. Paediatric medical specialists have existing skill sets, trusted relationships and can apply familiar principles of 'good' care to enhance experiences of genetic testing. The lack of evidence for service improvement strategies highlights the pressing need to undertake rigorous design and testing of interventions alongside mainstreaming of genomics into paediatric care.

Teaching perspectives on the communication of difficult news of genetic conditions to medical students

Informing parents that their child has a diagnosis of Down syndrome (DS) is a common example of the delivery of unexpected or difficult news. Expectations and life planning will change, and if detected prenatally, discussions might include the option of pregnancy termination. Medical school curricula currently include training in breaking unexpected news; however, it is difficult to teach and assess. We use the perspectives of clinicians, educators, and a medical student who is the parent of a child with DS to frame a discussion on teaching, practicing, and assessing communication of difficult news in human genetics during medical school.

Overcoming therapeutic nihilism. Breaking bad news of amyotrophic lateral sclerosis—a patient-centred perspective in rare diseases

Amyotrophic lateral sclerosis (ALS) is a rare, incurable, and fatal neurodegenerative disease with median survival time from onset to death ranging from 20 to 48 months. Breaking bad news about ALS diagnosis is a challenging task for physicians and a life-changing experience for patients. Several protocols for delivering difficult information are available, including SPIKES and EMPATHY. Our goal was to assess to what extent these guidelines are followed in Polish ALS patients’ experience as well as to identify any other patients’ preferences not addressed by the guidelines. Participants of our study were recruited via a neurology clinic. Twenty-four patients with confirmed ALS diagnosis were interviewed using in-depth interview and a self-constructed questionnaire: 9 females, 15 males in age ranging from 30–39 to 60–69. The analysis showed a pattern of shortcomings and fundamental violations of available protocols reported by ALS patients. Patients also had to deal with therapeutic nihilism, as they were perceived as “hopeless cases”; unlike in oncological setting, their end-of-life needs were not accommodated by some standard schemes. As a conclusion, we recommend using extended breaking bad news protocols with special emphasis on preparing a treatment plan, giving the patient hope and sense of purpose, offering psychological support and counselling directed to patients and caregivers, and providing the patient with meaningful information about the disease, social support, treatment options, and referral to appropriate health care centres.

Opportunities to enhance parental well-being during prenatal counseling for congenital heart disease

Prenatal diagnosis of congenital heart disease (CHD) can be a life-altering and traumatic event for expectant parents. Parental anxiety, depression, and traumatic stress are common following a prenatal cardiac diagnosis and if untreated, symptoms often persist long-term. During prenatal counseling, parents must try to manage psychological distress, navigate uncertainty, process complex medical information, and make high-stakes medical decisions for their unborn child and their family. Physicians must deliver the diagnosis, describe the expected perinatal management plan, discuss short and long-term prognoses and introduce elements of uncertainty that may exist for the particular diagnosis. Physican training in these important skills is highly variable and many in our field acknowledge the need for improved guidance on best practices for counseling and supporting parents during pregnancy and early parenthood after prenatal diagnosis, while also sustaining physicians' own emotional well-being. We describe these challenges and the opportunities that exist to improve the current state of prenatal counseling in CHD.

The "CONNECT" Protocol: Delivering Bad News by Phone or Video Call

The COVID-19 pandemic has changed the principles of communication within the health-care setting. Communication skills as developed for use in the context of a direct and personal encounter have become insufficient. As a result, numerous health professionals came to believe they were not sufficiently prepared to deliver bad news in relation to medical care. The CONNECT protocol is a tool designed to help health-care professionals in the delivery of such messages. The name of the protocol is an acronym derived from C – context, O – organization, NN – near and niceties, E - emotions, C – counseling, T – taking care. The objective of the protocol is to improve the effectiveness of the delivery of bad news in relation to medical care by ensuring proper organization of the key elements of the encounter with the patient and/or their family.

Disclosing Adverse Events in Clinical Practice: The Delicate Act of Being Open

Practicing a "safe" disclosure of adverse events remains challenging for healthcare professionals. In addition, knowledge on how to deliver a disclosure is still limited. This review focuses on how disclosure communication may be practiced based on the perspectives of patients and healthcare professionals. Empirical studies conducted between September 2008 and October 2019 were included from the databases PubMed, Web of Science and Psychinfo. After full text analysis and quality appraisal this scoping review included a total of 23 studies out of 2537 studies. As a first step, the needs of patients and the challenges of healthcare professionals with the practice of providing an effective disclosure were extracted from the empirical literature. Based on these findings, the review demonstrates that specific disclosure communication strategies on the level of interpersonal skills, organization, and supportive factors may facilitate healthcare professionals to provide optimal disclosure of adverse events. These may be relevant to provide patients with a tailored approach that accompanies their preferences for information and recognition. In conclusion, healthcare professionals may need training in interpersonal (verbal and nonverbal) communication skills. Furthermore, it is important to develop an open (organizational) culture that supports the communication of adverse events and disclosure as a standard practice.

'Difficult Conversations with Patients'-A Modified Group Objective Structured Clinical Experience for Medical Students

This study presents a modified Group Objective Structured Clinical Experience (GOSCE) focused on difficult conversations, in which, due to limited time and financial resources, only some students could actively participate in scenarios. We aimed to evaluate the intervention, including differences between them and observers. The intervention was organized for sixth-year medical students at a Polish medical university. The study protocol assumed a pre-post analysis of students' attitudes and self-efficacy of communication skills and their opinions about the intervention. Complete questionnaire pairs were returned by 126 students. The pre-post analysis revealed a significant improvement in their self-efficacy levels of almost all skills as well as their affective attitudes and belief in outcomes of communication learning. The improvement was significant among both the active participants and observers. It also showed a decrease in the motivation score, significant only in females. Regardless of their roles, students had positive opinions about the course and its particular aspects. The modified GOSCE may be an enjoyable and effective learning experience for students, especially in the light of limited resources. However, changes in their motivation score suggest the necessity to increase the importance of communication learning in the curriculum.

The SPIKES protocol does not influence the tolerance or effectiveness of intra-articular corticosteroid injection in the knees of osteoarthritis patients: A prospective, controlled, randomized single-blinded trial

BACKGROUND

Patient user embracement involves behaviours of including and listening to the patient, appreciating their complaints, and identifying their needs, whether individual or collective. The aim of this study was to evaluate the influence of a user embracement protocol (SPIKES protocol) for patients with knee osteoarthritis (OA) immediately before intra-articular injection (IAI) relative to procedure tolerance and its effectiveness in the immediate, short and medium terms.

METHODS

This was a randomized controlled trial. Patients received IAIs with triamcinolone hexacetonide (40 mg) preceded or not by the SPIKES protocol. The outcomes measured were: visual analogue scale for pain at rest, pain on movement and joint swelling; morning stiffness; Western Ontario McMaster Universities Index Functional Questionnaire (WOMAC); pain catastrophizing scale; McGill pain questionnaire; SF-36 questionnaire on quality of life; Trace State Anxiety Inventory (IDATE); and a Timed Up and Go functional test.

RESULTS

One hundred patients were randomized in the user embracement group (n = 50) or the control group (n = 50); 89% were women and 60% white, mean age was 67.1 (±7.3) years, and mean disease time was 6.3 (±6.2) years. No statistically significant differences were found between the groups for any variables at pre-procedure time, nor did the groups differ in their tolerance to the procedure or during the 12 weeks of follow up for any evaluated variables.

CONCLUSIONS

No benefit was identified by applying a user embracement protocol to patients with knee OA prior to IAI with corticosteroid, neither to tolerance at the time of the procedure nor to its effectiveness in the immediate, short, and medium terms.

Bridging the Gap between Scientific Advancement and Real-World Application: Pediatric Genetic Counseling for Common Syndromes and Single-Gene Disorders

Screening and diagnostic testing for single-gene disorders and common syndromes in the pediatric setting frequently generate data that are challenging to interpret, and the ability to diagnose genetic conditions has outpaced the development of successful treatments or cures. Genetic testing is now integrated purposefully into a variety of primary and specialty care clinics, creating an increased requirement for genetic literacy among providers and patients, as well as a growing need to incorporate genetic counseling services into mainstream clinical practice. The practice of pediatric genetic counseling encompasses a unique combination of skills and training designed to address the evolving psychological, social, educational, medical, and reproductive concerns of patients and their families, which complements the multidisciplinary services of physicians, nurses, and other allied health professionals caring for patients with pediatric-onset genetic conditions. The potential range of genetic counseling needs in the pediatric setting transcends the diagnostic period. The sustained nature of pediatric care presents opportunities for development of trusting and longstanding professional relationships that permit the evolving genetic counseling needs of patients and families to be met. A discussion of cystic fibrosis, a common autosomal recessive single-gene disorder with an increasingly broad clinical spectrum and genotype-phenotype variability, serves as a useful case study to illustrate the current and emerging genetic counseling practices, goals, and challenges impacting patients and their families.

Using patient perspectives to inform communication training materials for health care professionals discussing BRCA mutation testing

Purpose

As demand for genetic testing grows and a wide range of health care professionals (HCPs) are potentially involved in discussions about testing and delivering results, we developed an educational package to help HCPs with these conversations.

Methods

To inform the content of training materials, we conducted interviews with 11 women four of whom had BRCA1 and seven with BRCA2 mutations. Five women had or were currently receiving breast cancer treatment. Ages ranged from 38 to 77 years. Interviews were audio-recorded, transcribed verbatim and analysed using the Framework approach to thematic analysis.

Results

We identified 18 themes and 12 subthemes across the interviews, encompassed by six overarching themes: risk, decision-making, information and understanding, communication and improvement, accessing the system: process and frustration, emotional and social drivers.

Conclusions

The findings informed the didactic components of an educational communication workshop and a summary document for attendees. Qualitative interviews provide an important way of incorporating the patient perspective into communication training materials for HCPs by highlighting key issues that matter most to the patient.

A systematic review of communication interventions to help healthcare professionals discuss genetic testing for breast cancer

Purpose

This systematic review examined educational training interventions for healthcare professionals (HCPs) discussing genetic testing and risk for hereditary breast cancer. There was a particular focus on the presence, and content, of communication elements within these packages.

Methods

Searches were run via CINAHL, EMBASE, PUBMED, and PsychInfo in February 2019 to identify training interventions available to HCPs with reference to communication skills. Studies were assessed for quality, with relevant intervention and outcome data extracted and synthesized. This review followed the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statement and was registered on the PROSPERO database (CRD42019124010).

Results

Of 3,988 items, seven papers, two of which were linked, were eligible for inclusion. There was a mix of randomized and single arm studies with web-based and face-to-face interventions. Content included an overview of genetics, hereditary and familial background, and recommended practice techniques. Outcomes focused on communication, self-efficacy, knowledge, and satisfaction. Interventions were designed for genetic counselors, physicians, primary care physicians (PCPs), medical students, and nurses. None of the papers featured oncologists or surgeons.

Conclusions

This review revealed an overall lack of publications which evaluated interventions to assist HCPs discussing hereditary breast cancer risk and testing. Studies failed to operationalize which ‘communication skills’ they included, nor did they consistently report randomization, outcome measures, or analysis.

Discussing the need for, and management of, genetic testing for inherited cancer risk with individuals and their families can be challenging. As genetic testing in breast cancer becomes more common, the provision of specific communication-based training programs, with reference to genetic testing, risk assessments, and counseling skills is warranted.

Electronic supplementary material

The online version of this article (10.1007/s10549-020-05741-z) contains supplementary material, which is available to authorized users.

BREAKING BAD NEWS IN A NEONATAL INTENSIVE CARE: THE PARENT'S EVALUATION

OBJECTIVE

To describe the reports of parents of newborns (NB) with congenital malformations hospitalized in a Neonatal Intensive Care Unit (NICU) who received bad news, in order to identify the issues related to the perception of bad news given adequately or inadequately.

METHODS

A cross-sectional study was conducted from January to October 2018, in which parents of newborns with congenital malformations hospitalized in NICUs were interviewed at visiting hours, according to inclusion criteria. The questionnaire had semi-structured questions related to reception of bad news. Analysis of the data was descriptive.

RESULTS

28 mothers and two fathers were interviewed and 16 (53.3%) reported having had at least one bad news in the NICU. Of those, 10 (62.5%) considered appropriate the way in which the news was given. The justifications were: sincerity of the professional, delicacy to give the news, giving hope to the family, use of appropriate words and demonstration of caring about the newborn. Six participants (37.5%) considered inadequate the way of breaking bad news. The reasons were: unpreparedness and lack of knowledge about the child's case, use of difficult language, haste or anxiety and discouragement of family hope. Most of the news was given by a professional alone, often by a medical resident.

CONCLUSIONS

The communication of bad news was considered adequate by the parents, although this perception was not unanimous. This study, therefore, indicates that it is necessary to improve the communication of bad news in this NICU. Training professionals can assist in this process.

Predictors of genetic beliefs toward cancer risk perceptions among adults in the United States: Implications for prevention or early detection

The objective of this study is to assess predictors of genetic beliefs toward cancer risk perceptions among adults, aged 18 years and over, in the United States (US). Data were obtained from the National Cancer Institute's (NCI) Health Information National Trends Survey 2014 (HINTS) 4 Cycle 4. Bivariate and multivariable logistic regression analyses were conducted to assess factors associated with an individual's beliefs about genetic and cancer risk perceptions. The results showed that African Americans, Non-White Hispanics, Non-Hispanic Asians, individuals with a high school education or less, and annual household incomes less than $20,000 and do not believe that health behaviors play some role in determining whether a person will develop cancer was significantly less likely to report that genetics plays at least some role in whether a person will develop cancer. Findings of this study provide an opportunity for genetic counselors to address beliefs about genetics and cancer risk perceptions among minority populations and promote health equity.