Attitudes, beliefs and perceptions regarding truth disclosure of cancer-related information in the Middle East: a review

BRCA1/2 mutations and outcomes among Middle Eastern patients with early-onset breast cancer in Oman

BACKGROUND

High prevalence of early-onset breast cancer (EOBC) has been reported in Middle Eastern populations. For example, in Oman more than 50% of patients with breast cancer (BC) are under age 45 at diagnosis. Causes for this high incidence are unknown. Germline BRCA gene mutations have been associated with EOBC, however, prevalence of these mutations and how they relate to EOBC in Oman has not been assessed.

PATIENTS AND METHODS

Clinical data were collected for patients with BC treated at Royal Hospital, Oman between 2010 and 2022. Germline BRCA1/2 gene mutations were identified using sequencing and MLPA. Correlation and Kaplan-Meier survival analyses were performed to test relationships among clinico-pathological features, gene mutations, and outcomes.

RESULTS

Total of 1336 Middle Eastern patients with BC were included; 611 were aged <45 at diagnosis (45.7%). No significant correlation was found between BRCA1/2 mutation status and EOBC (P = .229), and the majority of EOBC cases had no family history of BC. EOBC tumors did, however, differ in clinicopathological features; EOBCs were significantly larger (P < .0001), of higher grade (P < .0001), and included more HER2-enriched, and triple negative subtypes (P = .018) compared with later onset cases. Accordingly, survival analyses revealed that EOBC had significantly worse disease-free survival (P = .002). BRCA gene variants showed a distinct range of mutations including, in BRCA2, 3 previously unreported mutations and 4 potential founder recurrent mutations.

CONCLUSION

Our findings showed that germline BRCA1/2 mutations were not over-represented in EOBC cases in Oman, and therefore are unlikely to be responsible for high EOBC rates.

Conspiracy of Silence in Head and Neck Cancer Diagnosis: A Scoping Review

Cancer disclosure represents a complex healthcare dynamic. Physicians or caregivers may be prompted to withhold diagnosis information from patients. This study aims to comprehensively map and synthesize available evidence about diagnosis nondisclosure regarding head and neck cancer (HNC) patients. Following the Joanna Briggs Institute guidelines, a scoping review was conducted across major databases without period restriction, yielding 9238 publications. After screening and selection, a descriptive synthesis was conducted. Sixteen studies were included, primarily conducted in academic settings (75%) from Europe and Asia, with a total population of 662 patients predominantly diagnosed with brain, oral, pharyngeal, or laryngeal tumors. Remarkably, 22.51% of patients were unaware of their diagnosis. Although physicians were the main source of diagnostic information (35%), they reported to often use vague terms to convey malignancy. Additionally, 13.29% of patients were aware of their diagnosis from sources other than doctors or caregivers. Caregivers (55%) supported diagnosis concealment, and physicians tended to respect family wishes. A high diagnosis-to-death interval, education, and age significantly influenced diagnosis disclosure. HNC patients expressed a desire for personalized open communication. Multiple factors influenced the decision on diagnosis disclosure. Current evidence on this topic varies significantly, and there is limited research on the consequences of nondisclosure. These findings reflect the underestimation of the patients' outlook in the diagnosis process and highlight the need for further research, aiming to establish open communication and patient autonomy during the oncological journey.

Discussion of the do-not-resuscitate (DNR) orders with the family caregivers of cancer patients: An example from a major cancer center in Saudi Arabia

OBJECTIVES

To explore the views of the family caregivers (FCGs) about the "do-not-resuscitate" (DNR) discussions and decision-making processes that occurred during hospitalization in a Saudi cancer center.

METHODS

In this cross-sectional survey, the FCGs of inpatients with advanced cancer completed a self-administered questionnaire soon after giving the patients a DNR status designation by their oncologists.

RESULTS

Eighty-two FCGs participated in the study, with a median age of 36.5 years and male preponderance (70.7%). The FCGs were mostly sons (41.5%), daughters (14%), or brothers (11%) of patients. Only 13.4% of mentally competent patients had the chance to listen to the DNR discussion. The discussion mainly occurred in the ward corridor (48.8%) or another room away from the patients' rooms (35.4%). In 36.6% of cases, the discussion took ≤5 minutes. Half of the FCGs stated that the oncologists' justifications for the DNR decision were unconvincing. The majority (84.2%) of the FCGs felt that the healthcare providers should share the DNR decision-making with patients (1.2%), families (69.5%), or both (13.4%). FCGs ≤ 30 years of age were more supportive of giving patients' families a chance to participate in the DNR decision-making process (p = 0.012).

SIGNIFICANCE OF RESULTS

There is considerable room for improving the current practice of DNR discussions and decision-making processes in the studied setting. A readily feasible rectifying measure is to ensure the adequacy of time and privacy when planning for DNR discussions. We expect our findings to draw the attention of stakeholders to a compelling need for reviewing the current policies and processes, aiming to improve the experience of cancer patients and their FCGs.

Breaking bad news in oncology practice: experience and challenges of oncology health professionals in Ethiopia - an exploratory qualitative study

OBJECTIVE

To explore the experience and challenges health professionals face during breaking bad news (BBN) to patients with cancer in the oncology centre of Black Lion Specialized Hospital (BLSH), Addis Ababa, Ethiopia 2019.

DESIGN

An exploratory qualitative phenominological study using in-depth interviews was carried out in the only radiotherapy integrated oncology centre in Ethiopia during March 2019. Purposeful maximum variation sampling was used to select participants. OpenCode (V.4.02) assisted thematic analysis approach was employed to analyse the data.

PARTICIPANTS

Eleven oncology health practitioners (oncologists, residents and nurses) working at the oncology centre were interviewed. Repeated interviews and analysis were done until theoretical saturation.

RESULTS

All participants were cognisant of the positive outcome of proper and effective practice of BBN. However, they were practicing it empirically, no standardised protocols or guidelines were in place. Four dimensions of challenges were mentioned: (1) setup centric: unconducive environment, lack of protocols or guidelines, inaccessible treatment, and psychotherapy or counselling services; (2) health care centric, such as inadequate expertise, inadequate time due to patient load,treatment backlog, and referral system; (3) patients/family centric: poor medical literacy level, poor compliance, and family interference; and (4) sociocultural: wrong perception of families on BBN and treatment modalities, and opposition from religious leaders.

CONCLUSION

BBN is challenging for professionals caring for patients in the oncology centre of BLSH. Hence, there is a critical need to improve practices. Change efforts may focus on the development of contextualised, content and context specific practice oriented training programmes and curriculum interventions. Raising awareness of the community and religious leaders regarding the nature and treatment of cancer may also be a helpful adjunct.

Muslim Jurisprudence on Withdrawing Treatment from Incurable Patients: A Directed Content Analysis of the Papers of the Islamic Fiqh Council of the Muslim World League

This study investigates the views of contemporary Muslim jurists about withdrawing treatment of the terminally ill. Its aim is threefold. Firstly, it analyses jurists' views concerning core themes within the process of withdrawing treatment. Secondly, it provides insight into fatwas about withdrawing treatment. Thirdly, it compares these views with current medical standards in Europe and the Atlantic world on withdrawing treatment. The data consisted of six papers by Muslim jurists presented at the conference of the Islamic Fiqh Council in 2015. We conducted a directed content analysis (DCA) through a predetermined framework and compiled an overview of all previous fatwas referred to in the papers, which are also analysed. The results show that the general consensus is that if health cannot be restored, treatment may be withdrawn at the request of the patient and/or his family or on the initiative of the doctor. The accompanying fatwa emphasizes the importance of life-prolonging treatment if this does not harm the patient. It becomes apparent in the fatwa that the doctor has the monopoly in decision-making, which is inconsistent with current medical standards in Europe. Managing disclosure in view of the importance of maintaining the hope of Muslim patients may challenge the doctor's obligation to share a diagnosis with them.

The role of family and culture in the disclosure of bad news: A multicentre cross-sectional study in Pakistan

Objectives

Disclosure of bad news is distressing for patients and family members. Our aim was to assess patients' perceptions and preferences regarding bad news in the health setting.

Methods

Cross-sectional, multi-centered study supported by an external grant in 15 Government and Private Hospitals across Pakistan. A sample size of 1673 patients and family members was used. Ethics permission/consent was taken from each participating hospital and participant. Responses were compared across provinces, gender, age, education and income.

Results

>80% patients preferred their relatives to know the diagnosis first and they wanted the news to be disclosed to them by doctors. Significant association between education level, income and preference for wanting to know the diagnosis was found. Reasons for wanting to know the diagnosis included treatment, prognosis and prevention options whereas reasons for not wanting to know included fear of emotions and God's will.

Conclusion

The majority of Pakistani patients want to be informed and want the family to know first. Preferences for disclosure vary across, age, education and income level.

Innovation

First countrywide study on this topic. Identifies need for culturally sensitive guidelines that include the family's role in disclosure of bad news.

"Why Me?", a Question of Opportunity

In accepting the reality of illness we are better able to make rational decisions about our health.

Information disclosure to cancer patients in Mainland China: A meta-analysis

OBJECTIVE

This study aims to systematically examine Chinese cancer patients' and families' preferences for information disclosure to the patient, patient awareness, and predictors of patient awareness.

METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. Web of Science, Scopus, Proquest, Taylor & Francis Online, and China National Knowledge Infrastructure were searched in April 2022 and Chinese Biomedical Literature Database in July 2022 for quantitative studies. The Mixed Methods Appraisal Tool was used for quality assessment.

RESULTS

A total of 22 studies were included, and the average quality score was 0.65/1. Meta-analyses showed that 89.6% and 81.8% of cancer patients wanted to know their diagnosis and prognosis, respectively. Meanwhile, 50.0% and 32.4% of families prefer diagnosis disclosure and prognosis disclosure to the patient, respectively. Significantly more patients than families favored disclosure to the patient. In reality, only 59.3% of cancer patients know their diagnosis, and 19.9% know their prognosis. For predictors, while patients' gender, cancer type (breast cancer or not), treatment method (operation or other), or complications (yes or no) do not influence diagnosis awareness, being younger, being married, having higher educational attainment, having early-stage rather than late-stage cancer, and being in a higher-grade hospital all predict better chances of knowing a diagnosis. No study explored predictors of patients' prognosis awareness. The findings did not vary according to publication time or sample size.

CONCLUSIONS

Chinese cancer patients are eager to know their diagnosis and prognosis, but families are hesitant about disclosure to the patient, and patients' awareness is low. While cultural, legal, and medical backgrounds lay the foundation for information disclosure in Mainland China, case-by-case practical factors also make a difference.

Evolving landscape of research on cancer-related cognitive impairment: A bibliometric analysis

Objective

This study describes the state of the art in the field of cancer-related cognitive impairment (CRCI) to facilitate research opportunities in future CRCI research.

Methods

Five databases were searched: PubMed, Web of Science, Cochrane Library, Cumulative Index to Nursing and Allied Health (CINAHL), and PsycINFO, from inception to August 20, 2022. Python, VOSviewer, and CiteSpace software were used for data preprocessing and analysis.

Results

The published articles were predominantly from the United States, followed by China and Canada. Breast cancer and brain tumors were the dominant cancer types. The study population consisted mainly of adult cancer survivors. Prospective and multicenter studies were the most frequently used study designs. Keyword co-occurrence and mutation analysis indicated major themes: drug therapy was the most common treatment cluster, and adverse effects were another major cluster. The etiology of CRCI was a research hotspot and included the exploration of chemotherapy-associated and psychosocial factors by using measurement tools, such as neuropsychological tests and treatment outcomes.

Conclusions

This study's findings highlight CRCI as a major research area, on the basis of the significantly increasing number of annual publications. Keyword co-occurrence analysis provided a quantitative visualization of the current research status for CRCI, but this method cannot provide in-depth qualitative insights explaining the potential emerging trends in this field.

PENS approach for breaking bad news in the oncology outpatient setting: a real-world report

PURPOSE

Breaking bad news (BBN) is a vital part of oncology practice. We conducted this study to assess an abbreviated PENS protocol [Patient preference, Explanation, Next appointment, and Support] for BBN in oncology outpatient (OP) settings.

METHODS

This observational study was conducted in a university teaching hospital, including cancer patients who were unaware of their condition and willing to discuss their disease status. The duration of BBN was the primary outcome. After the BBN session, patients filled a validated questionnaire; response scores of ≤ 13 were classified as content with BBN.

RESULTS

Fifty patients (mean age 53.7 years, range 28-76) were included in the study. The average duration of BBN was 6.1 (range 2-11) min. Assessed by the response score sum, 43 (86%) patients were satisfied with BBN. Only three (6%) of the discontented patients felt that the BBN duration was too short. Most (94%) of patients reported that they understood the information imparted during the BBN session. After the session, 36 (72%) patients admitted to either feeling the same or reassured compared to before the session. The oncologists also were comfortable with PENS.

CONCLUSIONS

The PENS approach is a practical method for BBN, especially when the oncologists have higher OP workloads. More extensive trials are required to validate the protocol in other settings.

TRIAL REGISTRATION

Clinical Trial Registry of India (CTRI/2021/07/034707).

Communication and information sharing with pediatric patients including refugees with advanced cancer, their caregivers, and health care professionals in Jordan: a qualitative study

Introduction

Effective communication in pediatric palliative cancer care is an important aspect of practice to enhance patient- and family-centered care, and to optimize decision-making. However, little is known about communication preferences practices from the perspectives of children, caregivers and their health care professionals (HCPs) in the Middle Eastern region. Furthermore, involving children in research is crucial but limited. This study aimed to describe the communication and information-sharing preferences and practices of children with advanced cancer, their caregivers, and health care professionals in Jordan.

Methods

A qualitative cross-sectional study was conducted using semi-structured face to face interviews with three groups of stakeholders (children, caregivers and HCPs). Purposive sampling recruited a diverse sample from inpatient and outpatient settings at a tertiary cancer center in Jordan. Procedures were in line with the Consolidated criteria for reporting qualitative research (COREQ) reporting guidelines. Verbatim transcripts were thematically analyzed.

Findings

Fifty-two stakeholders participated: 43 Jordanian and 9 refugees (25 children, 15 caregivers and 12 HCPs). Four major themes emerged: 1) Hiding information between the three stakeholders which includes parents who hide the information from their sick children and ask the HCPs to do so to protect the child from distressful emotions and children who hide their suffering from their parents to protect them from being sad; 2) Communication and sharing of clinical versus non-clinical information; 3) Preferred communication styles such as use of a companionate approach by acknowledging patients and caregivers' suffering, building a trustful relationship, proactive information sharing, considering child age and medical status, parents as facilitators in communication, and patients' and caregivers' health literacy; 4) Communication and information sharing with refugees where they had dialect issues, which hindered effective communication. Some refugees had unrealistically high expectations regarding their child's care and prognosis, which posed challenges to communication with staff.

Discussion

The novel findings of this study should inform better child-centered practices and better engage them in their care decisions. This study has demonstrated children's ability to engage in primary research and to express preferences, and parents' ability to share views on this sensitive topic.

Patients' right to know: A scoping review

AIMS AND OBJECTIVES

To analyse research-based evidence about patients' right to know from their own perspective to promote ethically high-quality nursing and to identify future research areas.

BACKGROUND

Patients' right to know is a fundamental right. Although of topical research interest, the current state of scientific evidence on patients' right to know has not been reviewed.

DESIGN

A scoping review according to the methodological framework by Arksey & O'Malley and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

METHODS

In June 2022, a literature search was conducted in the Ovid Medline, CINAHL and Cochrane Library databases. The inclusion criteria were peer-reviewed, empirical studies on the right to know with samples comprising adult patients. Data were analysed with inductive content analysis, and methodological quality was assessed with Mixed Methods Appraisal Tool.

RESULTS

Out of 2658 identified reports, 12 were selected for analysis. Based on the results, the research on patients' right to know can be classified into two main content categories: (1) expectations of the right and (2) realisation of the right. In the quality assessment, most of the reports did not meet all the quality criteria, the most common deficits being related to instrumentation and risk of bias.

CONCLUSIONS

Research-based evidence on patients' right to know provided a general insight into expectations and realisation of the right to know and not to know. The results indicate a need for continued efforts for novel approaches with high-quality methodological choices in future studies.

RELEVANCE TO CLINICAL PRACTICE

Nurses make constantly ethical decisions: The findings of this study can be useful for their decision-making and understanding of the patient's perspective on knowledge issues, and therefore, support ethically high-quality patient education.

PATIENT OR PUBLIC CONTRIBUTION

No direct patient or public contribution to the review.

Patients' preference approach to overcome the moral implications of family-centred decisions in Saudi medical settings

BACKGROUND

In Saudi clinical settings, cultural influences can give a patient's family authority to override the patient's autonomous right to make informed health-related decisions. Cultural values should not prevent patients from exercising their genuine preferences when making medical decisions in their own best interests.

DISCUSSION

This article discusses the moral implications of family-centred medical decisions for autonomous patients who are competent and capable of making decisions. The author argues that socio-cultural values do not justify the decision to override patient autonomy when patients express a preference for making their own choices.

CONCLUSION

The author recommends the use of a model of shared decision-making that accounts for both individual and relational conceptions of autonomy, approaching patients' preferences in all medical encounters with the aim of minimising the potential for socio-cultural values to undermine patient autonomy. Although this approach is a safeguard against both family and medical paternalism, allowance is made for clinicians to act in weakly paternalistic ways when patients at high risk of exacerbating existing medical conditions are likely to benefit from delaying or limiting the disclosure of potentially distressing but non-fatal diagnoses and prognoses. Thus, the author argues that even in a culture that supports family involvement in management decisions, physicians should respect patient autonomy by asking patients for their preferences in the disclosure of their medical diagnoses, prognoses and management options and verifying patients' preferences about the roles they wish their families to play (if any) in health-related decisions.

Oncologist approaches to communicating uncertain disease status in pediatric cancer: a qualitative study

Background

Most patients with cancer and their caregivers desire honest, clear prognostic communication, yet oncologists often disclose prognosis inconsistently. Prognostic communication becomes even more challenging when disease progression is unclear or equivocal. Presently, oncologist approaches for discussing uncertain disease findings are poorly understood.

Methods

In this prospective, longitudinal study, we audio-recorded serial disease reevaluation conversations between children with high-risk cancer, their families, and their primary oncologists over 24 months and conducted content analysis at recorded timepoints when oncologists categorized disease progression as equivocal.

Results

Of the 265 medical discussions recorded across the illness course for 33 patient-parent dyads, a total of 40 recorded discussions took place at equivocal timepoints, comprising > 500 min of medical dialogue. Prognosis talk encompassed < 3% of dialogue and was absent in nearly half of equivocal discussions (17/40, 42.5%). Curability statements were identified in only two conversations. Inductive content analysis of dialogue revealed four distinct patterns for communicating equivocal disease status: (1) up-front reassurance, (2) softening the message, (3) describing possible disease progression without interpretation, (4) expressing uncertainty without discussing the bigger picture.

Conclusion

Oncologists rarely discuss prognosis with children with high-risk cancer and their families at timepoints when disease progression is not definitive. Formal guidance is needed to better support oncologists in navigating uncertainty while sharing honest, person- and family-centered information about prognosis.

Supplementary information

The online version contains supplementary material available at 10.1186/s12885-022-10190-6.

Factors influencing terminal cancer patients' autonomous DNR decision: a longitudinal statutory document and clinical database study

Objective

Much of our knowledge of patient autonomy of DNR (do-not-resuscitate) is derived from the cross-sectional questionnaire surveys. Using signatures on statutory documents and medical records, we analyzed longitudinal data to understand the fact of terminal cancer patients’ autonomous DNR decision-making in Taiwan.

Methods

Using the medical information system database of one public medical center in Taiwan, we identified hospitalized cancer patients who died between Jan. 2017 and Dec. 2018, collected their demographic and clinical course data and records of their statutory DNR document types, letter of intent (DNR-LOI) signed by the patient personally and the consent form signed by their close relatives.

Results

We identified 1,338 signed DNR documents, 754 (56.35%) being DNR-LOI. Many patients had the first DNR order within their last week of life (40.81%). Signing the DNR-LOI was positively associated with being under the care of a family medicine physician prior to death at last hospitalization and having hospice palliative care and negatively associated with patient age ≥ 65 years, no formal education, having ≥ 3 children, having the first DNR order to death ≤ 29 days, and the last admission in an intensive care unit.

Conclusions

A substantial proportion of terminal cancer patients did not sign DNR documents by themselves. It indicates they may not know their actual terminal conditions and lose the last chance to grasp time to express their life values and wishes. Medical staff involving cancer patient care may need further education on the legal and ethical issues revolving around patient autonomy and training on communicating end-of-life options with the patients. We suggest proactively discussing DNR decision issues with terminal cancer patients no later than when their estimated survival is close to 1 month.

Justification for requiring disclosure of diagnoses and prognoses to dying patients in saudi medical settings: a Maqasid Al-Shariah-based Islamic bioethics approach

Background

In Saudi clinical settings, benevolent family care that reflects strongly held sociocultural values is commonly used to justify overriding respect for patient autonomy. Because the welfare of individuals is commonly regarded as inseparable from the welfare of their family as a whole, these values are widely believed to obligate the family to protect the welfare of its members by, for example, giving the family authority over what healthcare practitioners disclose to patients about their diagnoses and prognoses and preventing them from making informed decisions about their healthcare.

Discussion

Family dominance over the healthcare decisions of competent patients is ethically problematic when the family prevent healthcare practitioners from disclosing diagnoses and prognoses to patients who have the capacity to consent and make decisions in their own best interests. Thus, the author holds that sociocultural values ought to be respected only when they do not prevent competent patients from knowing their diagnoses and prognoses or prevent them from making their own decisions.

Conclusion

Healthcare practitioners should not allow patients’ families to control what can or cannot be disclosed to competent patients. This is particularly important when patients are approaching death so that they may address their material and spiritual wishes—among other needs—as they prepare for death. Justification for this position is drawn from the Maqasid Al-Shariah-based Islamic bioethics approach, from which it is possible to argue that the harm of withholding diagnoses and prognoses from patients who are imminently dying outweighs the potential benefits.

Palliative Care Utilisation Among Non-Western Migrants in Denmark: A Qualitative Study Of the Experiences of Patients, Family Caregivers and Healthcare Professionals

This study explores care experiences while utilising palliative care services of non-western migrant families from the perspectives of patients, family caregivers, and healthcare professionals in Denmark. Twenty-three semi-structured individual and group interviews were conducted among eight patients with a life-threatening disease, 11 family caregivers, and ten healthcare professionals. Thematic analysis revealed three themes: 1) Communication between families and healthcare professionals; 2) Building and lack of trusting relations, and feeling safe, and 3) Access to information and navigating in the healthcare system. Moreover, ''language and culture'' emerged as transaction themes that are not mutually exclusive, however, interconnect across the mentioned three themes. Non-western migrant families can be supported by healthcare professionals' cultural competency training, negotiating on providing services concerning information, patient preferences, family involvement, and palliative care setting. This study findings urge inter-sectoral collaboration to ensure needs-oriented and linguistically and culturally appropriate palliative care services for non-western migrant families in Denmark.

Public information needs and attitudes regarding cancer and cancer patients in Oman: a cross-sectional survey

BACKGROUND

Exploring public information needs and attitudes towards cancer patients might be the first step in developing an intervention that encourages public engagement in early detection and cancer prevention programmes.

AIM

To explore Omani public information needs and attitudes towards cancer in Oman.

METHODS

A cross-sectional survey design was used.

FINDINGS

Of the 569 participants, 369 (64.9%) were female; the mean age was 30.9 (SD=9.5) years. Of the participants, 94.4% wanted to be informed if they were found to have cancer in the future. The mean total attitudes score was 40.2 (SD=4.7) out of a maximum 48. Further, being employed, preferring to be informed about cancer diagnosis and having positive attitudes towards cancer and cancer patients predicted higher information needs.

CONCLUSIONS

The current paternalistic approach seems to be no longer appropriate for cancer patients in Oman, and more active patient involvement in decision-making is needed.

The role of socioeconomic status in the relationship between social support and burden among cancer caregivers

While much research has focused on the direct impact of socioeconomic status on cancer patients, what is not clear is the impact of socioeconomic status on social support and the burden of care for caregivers. In this study, a cross-sectional method, using a convenience sampling approach, was adopted to collect the data of 191 caregivers of cancer patients who were referred to the oncology clinic and cancer institute of hospitals affiliated with Tehran University of Medical Sciences, Iran. The participants completed a questionnaire on basic demographics, the short version of the Burden Scale for Family Caregivers, and Zimet Multidimensional Perceived Social Support. A maximum likelihood exploratory factor analysis with oblique rotation to assess the factor structure of the constructs and the measurement model was conducted. The two-factor model consisting of 22 items explained 65.116% of the variance. There was a significant negative relationship between social support and burden (b = -0.771, P < 0.001) and also between economic status and burden (b = -0.308, P < 0.01). Moreover, there was a significant positive association between the interaction of social support and economic status and burden (b = 0.138, P < 0.05). More specifically, the negative relationship between social support and burden was statistically stronger for participants with weak economic status (b = -0.663, P < 0.001) than those with good economic status (b = -0.356, P < 0.01). Social support and an individual's economic status are essential determinants of caregiver burden. Further studies are recommended to better inform the precise support needed by caregivers to enhance their quality of life, and ultimately, that of the patients under their care.

Truth Disclosure at the End of Life: A Qualitative Study of Internal Medicine Residents in the United Arab Emirates

BACKGROUND

Respect for patient autonomy has become the guiding biomedical ethical tenet in the West; yet, moral values are contextual and culturally relevant. In the collectivist society of the Middle East, families and physicians have historically believed that concealing truth about a terminal illness is more ethical and compassionate. Recent studies reveal a trend toward truth disclosure.

OBJECTIVE

To gain insight into resident experiences with, and barriers to, truth disclosure in terminally ill patients in the United Arab Emirates (UAE).

METHODS

Focus group interviews were conducted with first through fourth year internal medicine residents and recent graduates at two large academic medical centers in the UAE. Qualitative thematic content analysis was used to identify themes related to communication and truth telling in end-of-life care.

RESULTS

Residents revealed that non-disclosure of medical information in serious illness is a common practice in UAE hospitals. Barriers to truth telling include family objection, deficits in medical training, and inconsistently implemented institutional guidelines.

CONCLUSION

Educational and policy interventions are needed to improve physician-patient communication, decrease patient-family-physician tension, and alleviate trainee moral distress.

Nurses’ Experiences of Transitional Care in Multiple Chronic Conditions

Transitional care is a designed plan to ensure the continuity of care received by patients as they transfer between different locations or levels of care. The aim of this paper is to explore nurses’ experiences of transitional care in multiple chronic conditions. A qualitative method with a conventional content analysis approach was utilized. The study was conducted at university hospitals in 2 big cities (Isfahan and Tehran) of Iran. This study is performed from November 2018 to December 2019 using deep, semi-structured, and face-to-face interviews which are focused on nurses’ experiences of transitional care. Data collection continued until saturation was reached. Finally, 15 nurses take part in this study. Data collection and data analysis were conducted concurrently. Data were analyzed using Graneheim and Lundman’s techniques. Two main themes providing a descriptive summary of the major elements of transitional care identified: “threat to patient safety” and “Care breakdown”. Findings showed an exclusive image of unsafe transitional care which was done unplanned without appropriate delegating care to family and threat patient safety. There is still a gap in the transition from hospital to home. Nursing managers can address this issue by creating a culture of teamwork, training competent nurses by continuum education, and more supervision of nursing care. Policymakers can ensure continuity of care by developing policies and programs about transitional care.

Informal caregivers of older Muslims diagnosed with cancer: A portrait of depression, social support, and faith

OBJECTIVE

Islamic population constitute more than 20% of the world population and is growing rapidly. Nevertheless, data concerning informal caregiving to older Muslim patients diagnosed with cancer are scarce. Improving the well-being of caregivers is a vital step to optimal care for the patients themselves throughout the Muslim community and the world. This study focuses on a sample of Palestinian caregivers of older Muslim patients diagnosed with cancer living in East Jerusalem, the West Bank, and Gaza. The study aims to describe the socio-demographic characteristics of the caregivers and to understand their social support, and identify predictors of caregivers' depression.

METHODS

A cross-sectional study of a convenience sample of 99 dyads of Palestinian patients (age ≥65) and their informal caregivers. Depression and social support were measured using the five items of the Geriatric Depression Scale and the Cancer Perceived Agents of Social Support questionnaire.

RESULTS

Caregivers were most frequently adult children (52%) or spouses (32%), with male patients cared for by spouses (47.5%) or sons (32%), and female patients by daughters (50%). Clinical levels of depression were reported by 76% of the caregivers and 85% of patients. The significant predictors of caregiver depression were female gender, lower education, lower perceived social support from spouse and family, and higher perceived support from faith.

SIGNIFICANCE OF RESULTS

Healthcare providers serving the study population should determine the position and role of the caregiver within the social and family structure surrounding the patients' families. This understanding may facilitate overcoming barriers to effective and meaningful social support.

Attitudes of Physicians in Jordan Towards Non-Disclosure of Health Information

Objectives

This report aims to investigate the attitudes of physicians in Jordan towards non-disclosure of health information among physicians, with a focus on those who are 'always truthful' and those who are not.

Methods

The report is based on the second subset of data from a cross-sectional study-conducted between January and August 2016-of the truth disclosure practices among and attitudes of physicians in Jordan. The sample consisted of 240 physicians selected from four major hospitals by stratified random sampling and invited to complete a self-administered questionnaire regarding truth disclosure attitudes. The attitudes of physicians who were 'always truthful' were compared with those who were not.

Results

A total of 164 physicians (response rate: 68%) completed the questionnaire. Of these, 17 (10%) were 'always truthful', while the remaining 144 (90%) were not. Physicians who were 'always truthful' were more likely to indicate that non-disclosure is 'unethical' (77% versus 39%; P = 0.009). Moreover, physicians who were 'always truthful' were more likely to disagree that non-disclosure is beneficial for the physical and psychological health of patients (82% versus 55%; P = 0.03). Most of the surveyed physicians agreed that all patients have the right to know their diagnosis, most patients prefer to know their diagnosis and the introduction of legislation to enforce disclosure would positively affect medical practice in Jordan.

Conclusion

The differential attitudes of physicians who were 'always truthful' and those who were 'not always truthful' suggests a rationale behind independent non-disclosure; namely, that non-disclosure is ethically justifiable and beneficial for the physical and psychological health of patients.

Breaking Bad News in Cancer Care: Ethiopian Patients Want More Information Than What Family and the Public Want Them to Have

PURPOSE

This study explores the preferences of patients with cancer, family caregivers, and the general public regarding breaking bad news in an Ethiopian oncology setting.

METHODS

The study was conducted at Tikur Anbessa (Black Lion) Specialized Hospital. The sample consists of patients with a confirmed cancer diagnosis, their family caregivers, and representatives from the general public with 150 subjects per cohort. The study used a comparative cross-sectional design and multivariable data analysis.

RESULTS

The patients would like to be informed, which contradicts the preferences of family caregivers. This creates an ethical dilemma for staff in terms of how much they involve their patients in clinical decision making. The patients also indicate that information should not be withheld from them. By contrast, the general public prefers information about poor life expectancy to be communicated to family only, which may reflect a widespread public perception of cancer as a deadly disease.

CONCLUSION

The findings indicate the complexity of communication-related preferences concerning breaking bad news in oncology care in Ethiopia. It requires oncologists to probe patient attitudes before information disclosure to find a balance between involving patients in communication at the same time as keeping a constructive alliance with family caregivers.

The Role of Beliefs and Psychological Factors in Caring of Patients With Cancer: The Lived Experiences of Informal Caregivers

Cancer affects not only the patient but also family members as informal caregivers. In order for family caregivers to achieve balance and improve their caregiving roles, it is essential to identify the beliefs and psychological aspects affecting them. The present study was carried out qualitatively with a descriptive phenomenological design in 2020. The main participants in this study were selected from one of the major referral centers for cancer patients in West Azerbaijan Province, located in northwestern, Iran. Twenty-two family caregivers were selected through a purposive sampling method. Data analysis showed that the 3 main themes of "emotional and religious preconceptions," "feeling committed to caring for beloveds," and "resilience" played a prominent role in family caregivers. These factors led to caregivers' commitment to and responsibility for care. Holistic care necessitates consideration of all aspects of human life. The results of this study led to an understanding of the complex tendencies and feelings of family caregivers. Based on the results, it was found that care is influenced by beliefs, religious preconceptions, sociocultural, and psychological factors. Identifying these variables helps medical staff share planning, interventions, and counseling with family caregivers and address issues that affect them.

Relationship between perceived social support and psychological hardiness with family communication patterns and quality of life of oncology patients

AIM

The purpose of this study was to determine the relationship between PSS, PH, FCP and QoL of oncology patients.

METHODS

In this descriptive-correlational study, 340 oncology patients were selected with convenience sampling method from the hospitals in Tehran 2018-2019. Data were collected using, "PSS," "PH," "FCP" and "European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, EORTC QLQ-C30." Data were analysed using descriptive and inferential statistics using SPSS21 and Amos.

RESULTS

The direct effect and the total effect of PSS and FCP on QoL were significant (p < .001), but their indirect effect was not significant (p > .05) and the effect of PH on QoL was not significant (p = .96). The Root Mean Squares of Error Approximations (RMSEA), Non-Normed Fit Index (NNFI), Comparative Fit Index (CFI) and Goodness of Fit Index (GFI) were estimated 0.07, 0.97, 0.98 and 0.91, respectively.

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.

The physician-nurse collaboration in truth disclosure: from nurses' perspective

BACKGROUND

Collaboration between physicians and nurses is critical. However, a limited number of studies have provided insights into the status of physician-nurse collaboration in truth disclosure.

METHODS

A cross-sectional survey was conducted using an electronic questionnaire among Chinese nurses who attended a provincial conference. The Nurse-Physician Collaboration Scale was administered to nurses to assess the collaboration in truth disclosure from their perspective. A multiple-choice question was asked to assess the perceived difficulties in truth disclosure. Descriptive statistics, univariate, and multiple stepwise regression analyses were performed to evaluate physician-nurse collaboration in truth disclosure.

RESULTS

A total of 287 nurses completed the survey, and 279 of them reported that they had carried out truth disclosures among patients. The average score for physician-nurse collaboration in truth disclosure was 3.98 ± 0.72. The majority of nurses (73.1-81%) responded positively to different dimensions of collaboration in truth disclosure. The results of multiple stepwise regression analysis showed that seniority (B = - 0.111, 95% confidence interval [CI] = - 0.167-- 0.055, p < 0.001) and frequency of truth disclosure (B = 0.162, 95%CI = 0.076-0.249, p < 0.001) were the only two factors associated with collaboration in truth disclosure between physicians and nurses. The most common barrier perceived by nurses was fear of patients' negative emotions or their suicide attempts after truth telling.

CONCLUSIONS

Most nurses responded positively to physician-nurse collaboration in truth disclosure. Various difficulties existed in the practice of truth-telling collaboration. Further studies are required to test the potential interventions to promote cooperation between nurses and physicians in truth disclosure.

White lies in pediatric care: a qualitative study from nurses' perspective

Communication and sharing information with ill children are challenging. To protect a child from the bitter reality, sometimes use of well-intended untruths, or white lies is necessary. This research aimed at studying the experiences of nurses about the use of white lies in in pediatric clinical setting.

In this qualitative, content-analysis study, 24 on-duty pediatric nurses were interviewed in 2019. Data were collected through purposeful sampling using semi-structured interviews, and the collected data were analyzed according to Granheim and Landman’s method using MAXQDA-10 software.

Eighteen female and six male nurses with the mean age of 42 ± 3/7 years and mean work experience of 16 ± 4/1 years were selected to participate in this study. Data analysis showed that use of white lies depends on both situation and several other factors classified into five general categories: nature of data, childhood characteristics, family norms, treatment team’s capabilities and organization policies.

Treatment team members need to improve their communication skills to convey therapeutic information to the ill child’s family appropriately. To do so, special guidelines should be prepared for healthcare staff in pediatric clinical setting.

Differences in practice and preferences associated with truth-telling to cancer patients

BACKGROUND

Doctors should disclose the diagnosis to patients according to the principle of autonomy. However, not disclosing the diagnosis and prognosis to cancer patients remains common in mainland China.

OBJECTIVE

The study explored the experiences and attitudes of patients with cancer, family members, and the medical staff in truth-telling.

RESEARCH DESIGN

A quantitative survey with three closed-ended questionnaires was conducted.

PARTICIPANTS

In all, 137 patients with cancer, 134 family members caring for cancer cases, and 54 medical staff were surveyed. Descriptive statistics were used to summarize all characteristics, and the chi-square test was performed to analyze group differences in attitudes toward cancer disclosure.

ETHICAL CONSIDERATIONS

This study was approved by the Committee on Ethics of Biomedicine Research, at the Second Military Medical University (HJEC-2018-YF-001). Informed consent was obtained from all participants prior to study commencement.

FINDINGS

A total of 59.8% of patients were informed about their diagnosis within 1 week, and 19.7% inferred theirs. The medical staff preferred to prioritize family members in informing about patient diagnosis while 77.4% of patients preferred to be told the whole truth at the time of initial diagnosis. More patients than family members and medical staff wanted the patients to be informed about the diagnosis (p < 0.001). A significant difference was found between the patients and family members regarding who should tell the patients.

DISCUSSION

The willingness of patients in knowing the truth was underestimated by their family members as well as the medical staff. Guessing the truth indirectly may exert negative effects on the patients, and not telling the truth is inappropriate in patients who want to be informed.

CONCLUSION

Disclosure of a cancer diagnosis is a complex process involving medical practice, as well as a range of cultural, ethical, and legal factors. The medical staff should first assess each patient's willingness in truth-telling and inform about disease diagnosis with respect. Emotional support and comfort from family members are encouraged. Anyone in the patient's care team, especially nurses, could be integrated in the process of truth-telling.

POLE and POLD1 germline exonuclease domain pathogenic variants, a rare event in colorectal cancer from the Middle East

Background

Colorectal cancer (CRC) is a major contributor to morbidity and mortality related to cancer. Only ~5% of all CRCs occur as a result of pathogenic variants in well‐defined CRC predisposing genes. The frequency and effect of exonuclease domain pathogenic variants of POLE and POLD1 genes in Middle Eastern CRCs is still unknown.

Methods

Targeted capture sequencing and Sanger sequencing technologies were employed to investigate the germline exonuclease domain pathogenic variants of POLE and POLD1 in Middle Eastern CRCs. Immunohistochemical analysis of POLE and POLD1 was performed to look for associations between protein expression and clinico‐pathological characteristics.

Results

Five damaging or possibly damaging variants (0.44%) were detected in 1,135 CRC cases, four in POLE gene (0.35%, 4/1,135) and one (0.1%, 1/1,135) in POLD1 gene. Furthermore, low POLE protein expression was identified in 38.9% (417/1071) cases and a significant association with lymph node involvement (p = .0184) and grade 3 tumors (p = .0139) was observed. Whereas, low POLD1 expression was observed in 51.9% (555/1069) of cases and was significantly associated with adenocarcinoma histology (p = .0164), larger tumor size (T3 and T4 tumors; p = .0012), and stage III tumors (p = .0341).

Conclusion

POLE and POLD1 exonuclease domain pathogenic variants frequency in CRC cases was very low and these exonuclease domain pathogenic variants might be rare causative events of CRC in the Middle East. POLE and POLD1 can be included in multi‐gene panels to screen CRC patients.

Do You Transfer Your Skills? From Sports to Health Management in Cancer Patients

Skill transfer is a process where personal cognitive and behavioral abilities are applied to contexts that are different from the one in which they were originally learned. Literature demonstrates that skill transferability is possible: for example, people can apply skills learned in sports to other life-domains (such as school, work, or health management) with the aim to improve individual characteristics and reach personal goals. To do this, several factors, such as positive communication, adequate context, a person-centered perspective, and specific strategies, are necessary. On the basis of this, the aim of this contribution is explore the relationship between sports and health management skills to enhance the coach/athlete as well as the patient/physician relationships. Useful strategies for skill transfer from sports to cancer management are shown.

Germline POLE and POLD1 proofreading domain mutations in endometrial carcinoma from Middle Eastern region

Background

Endometrial carcinoma (EC) accounts for 5.8% of all cancers in Saudi females. Although most ECs are sporadic, 2–5% tend to be familial, being associated with Lynch syndrome and Cowden syndrome. In this study, we attempted to uncover the frequency, spectrum and phenotype of germline mutations in the proofreading domain of POLE and POLD1 genes in a large cohort of ECs from Middle Eastern region.

Methods

We performed Capture sequencing and Sanger sequencing to screen for proofreading domains of POLE and POLD1 genes in 432 EC cases, followed by evaluation of protein expression using immunohistochemistry. Variant interpretation was performed using PolyPhen-2, MutationAssessor, SIFT, CADD and Mutation Taster.

Results

In our cohort, four mutations (0.93%) were identified in 432 EC cases, two each in POLE and POLD1 proofreading domains. Furthermore, low expression of POLE and POLD1 was noted in 41.1% (170/1414) and 59.9% (251/419) of cases, respectively. Both the cases harboring POLE mutation showed high nuclear expression of POLE protein, whereas, of the two POLD1 mutant cases, one case showed high expression and another case showed low expression of POLD1 protein.

Conclusions

Our study shows that germline mutations in POLE and POLD1 proofreading region are a rare cause of EC in Middle Eastern population. However, it is still feasible to screen multiple cancer related genes in EC patients from Middle Eastern region using multigene panels including POLE and POLD1.

Nurses' experiences and attitudes toward diagnosis disclosure for cancer patients in China: A qualitative study

OBJECTIVE

To qualitatively investigate and explore oncology nurses' perceptions of cancer diagnosis disclosure (CDD) for cancer patients.

METHODS

Purposive sampling led to the inclusion of 25 nurses with diverse characteristics from four inpatient oncology nursing wards in two tertiary hospitals. Semistructured, one-on-one, in-depth interviews were conducted. Colaizzi's analysis method was performed with NVivo software to develop categories and themes.

RESULTS

Four themes were identified: (a) impact of CDD, including advantages and disadvantages for patients and nurse distress; (b) barriers to CDD, including requests from family members, patients themselves, and communication skills; (c) strategies for CDD, including communication with family members, physician-nurse collaboration, and patient education; and (d) nurses' roles in CDD, including active participants and promoters and advocates.

CONCLUSIONS

More channels of information and education on cancer, cancer diagnosis, life, and death will be needed in the future. Nurses should actively participate in cancer diagnosis delivery, and more collaboration between nurses and physicians must occur.

Perceptions of Cancer Status Disclosure in Lebanon

In Lebanon, cancer used to be regarded as a taboo and referred to as "the disease" and was rarely disclosed to patients. However, patients are now increasingly interested in knowing their cancer status but with varying degrees of information requested. The aim of this qualitative descriptive study was to explore the perceptions of cancer patients, their families, oncologists, and healthy individuals concerning the disclosure of cancer prognosis. In-depth interviews were conducted with 21 family members, 20 middle-aged cancer patients, 11 elderly cancer patients, 22 healthy individuals, and 6 oncologists at the American University of Beirut Medical Center. The interviews focused on the following: general perception of cancer in Lebanese society, type, and extent of information that should be disclosed, factors affecting patient autonomy, and elements contributing to the decisions taken by oncologists and patients. The oncologist's compassion and communication with patients affected their emotional status greatly, and some gaps in communication skills of oncologists were in need of standardized training courses to improve the process of cancer status disclosure. Also, patients had an increased preference towards the disclosure of cancer prognosis, and a desire to know the truth and this need increased as the patient progressed to a terminal state. Future work should be directed at addressing the needs of cancer patients through every disease stage. More research and further deliberation are needed to confirm the findings of this study since the Lebanese Code of Medical Practice does not protect the right of full disclosure.

Palliative care for older South Asian migrants: A systematic review

Objective

South Asian migrants have a higher burden of life-threatening diseases and chronic diseases compared to other ethnic groups. Yet, knowledge gaps remain around their palliative care needs in the host countries. The aim of the review was to present results from a systematic literature review of available international evidence on experiences with and perspectives on palliative care among older South Asian migrants, relatives, and healthcare providers.

Methods

A systematic review in accordance with PRISMA guidelines was conducted in February 2018, searching PubMed, CINAHL, PsychINFO, and EMBASE databases. PROSPERO #CRD42018093464. Studies included empirical research, providing international evidence on experiences and perspectives on palliative care of South Asian migrants and were published between 2000 and 2018. Thematic synthesis was used to analyze data.

Results

A total of 30 articles were included: qualitative (24), quantitative (5), and mixed methods (1). Three main themes were discovered: 1) palliative care practice within the family, 2) trust as a precondition of palliative care, and 3) the importance of knowledge and cultural competency. All the themes, to a greater or lesser extent, are related to access to and use of palliative care services by South Asian migrant families.

Significance of results

Involvement of family members in palliative care decision making could improve the satisfaction of South Asian migrant families toward the service. For example, Advanced Care Planning involving family members could be a possible way to engage family members in palliative care decision making. Supportive interventions, e.g. providing knowledge, aimed at patients and their family members might improve knowledge and increase awareness among South Asian migrant families of palliative care. Knowledge gained from this review could be implemented with other ethnic minority groups.

“Al-Khabith”—The malignant cunning disease: Sociocultural complexity and social representations of cancer in the occupied Palestinian territory

This qualitative research aims to understand the sociocultural complexity and social representations of cancer in the occupied Palestinian territory. The researcher conducted 16 in-depth semi-structured individual interviews with Palestinians from the occupied Palestinian territory, using thematic analysis as a methodology and social representation theory as the theatrical framework. The findings revealed three main themes. The first theme is social representations of cancer and cancer treatments divided into four subthemes: (1.1) manifestations of dilemmatic indeterminacy and vagueness. The second subtheme (1.2) refers to social representations of cancer in close proximity with death. The third subtheme (1.3) is constituted by metaphorical social representations of cancer, and the fourth (1.4) refers to social re-presentations of cancer. The second theme is the paradoxical social representations of cancer patients as divided into three subthemes: (2.1) pity-based societal responses, (2.2) manifestations of stigma, and (2.3) cancer rumors, a form of collective sense-making. The third theme, religious discourses and social representations of cancer, is divided into three subthemes: (3.1) cancer as predestined by the will of God, (3.2) cancer as a punishment or a trial, and (3.3) a spiritual journey of healing. The implications of this research suggest that social representations research can take a lead in promoting social and health change. The biomedical paradigm alone is failing in Palestine to encounter the sociocultural complexity connected to representations of cancer and its impact on future-health behaviors. Thus, stakeholders and policy-makers in Palestine need to build a mutual interaction between scientific encounters and lay thinking encounters. This requires building community-based health interventions and a sustainable health promotion programs to ensure higher penetration to the social outreach (families, hospital setting, clinics, and schools). To combat ill-health beliefs, stakeholders can benefit from utilization of community participation through creating space for dialogue and debate about cancer and its representations, which accordingly moving towards social and health change.

Conspiracy of Silence in Palliative Care: A Concept Analysis

BACKGROUND AND AIM

With chronic diseases on the rise, there is a growing demand for palliative care. The global landscape of the integration of palliative care into health-care systems is incipient, which leads to a lack of social awareness of this reality and consequently, to communication failures, particularly a conspiracy of silence. The aim of this study was to analyze the concept of conspiracy of silence in palliative care.

MATERIALS AND METHODS

Walker and Avant method of concept analysis was used. Review and synthesis of literature supported the analysis process. Forty-seven articles were analyzed.

RESULTS

Results showed that the conspiracy of silence in palliative care is a communication failure, typical of limited life expectancy prognosis, and involves patients, their families, and health-care teams. Lack of autonomy, overburden, family malfunctioning and coping, and health-care dehumanization are consequences of the conspiracy of silence in palliative care.

CONCLUSIONS

The present study had found that scales to measure this concept as well as interventions that consider important factors in the communication process in palliative care identified in this analysis are needed.

Death attitudes and truth disclosure: A survey of family caregivers of elders with terminal cancer in China

Background:

Although family caregivers play an important role in end-of-life care decisions, few studies have examined the communication between family caregivers and patients at the end of life.

Objective:

The objective was to describe family caregivers’ attitudes toward death, hospice, and truth disclosure.

Research design:

A quantitative method was used, and a closed-ended survey of 140 family caregivers was conducted in China. The subjects included 140 primary family caregivers of elders with terminal cancer enrolled at a hospice center from April to August 2017.

Participants:

140 primary family caregivers of elders with terminal cancer participated the study.

Research Context:

A high proportion of cancer patients continue to receive inadequate information about their illness. Family caregivers’ inhibitions about disclosing information to cancer patients have not yet been the objects of research in China.

Ethical considerations:

This study was reported to and approved by the Regional Ethics Committee in Shenzhen, China.

Findings:

A questionnaire survey collected information on family caregivers’ background information, emotional state, personal needs, death attitudes, and truth-disclosure opinions. The results revealed that family caregivers’ death attitudes and truth-disclosure opinions played an important role in the process of caring for elders with terminal cancer.

Discussion:

By adopting a quantitative method, the author revealed not only the general patterns of family caregivers’ attitudes toward cancer diagnosis disclosure but also the reasons for their actions and the practices of family disclosure.

Conclusion:

The findings suggested that ineffective communication concerning end-of-life issues resulted from family caregivers’ lack of discussion and difficulty in hearing the news. Future studies should examine strategies for optimal communication between family caregivers and patients, especially with regard to breaking the bad news. Professional training in breaking bad news is important and is associated with self-reported truth-disclosure practices among family caregivers.

The impact of informing diagnosis on quality of life in patients with cancer: A protocol of systematic review and meta-analysis

BACKGROUND

Cancer is the second leading cause of death globally. More millions new cancer cases are diagnosed, and millions persons died due to cancer each year. There are different attitudes on disclosure of diagnosis to the patients with cancer. The current systematic reviews are qualitative, and indicate that there is limited evidence on the association between awareness of diagnosis and quality of life in patients with cancer. In this study, we aim to evaluate the effect of awareness of diagnosis on quality of life in patients with cancer by conducting a systematic review and meta-analysis.

METHODS

We will perform a comprehensive electronic search in the databases below: MEDLINE (via PubMed), EMBASE, Cochrane Central Register of Controlled Trials, PsycINFO, WEB OF SCIENCE, Chinese Biomedical Literature database, WANFANG database, and China National Knowledge Infrastructure. The cohort studies focusing on the association between awareness of diagnosis and quality of life in patients with cancer will be included. The risk of bias for the included studies will be appraised using the Newcastle-Ottawa Scale tool for cohort study. We will pool the effect estimates from the included studies to quantitatively present the strength of the association of interest.

RESULTS

This study will present pooled effect estimates regarding the impact of informing diagnosis on quality of life in patients with cancer.

CONCLUSION

This is the first quantitative systematic review which tends to provide modest evidence on the association between informing diagnosis and quality of life in patients with cacner.

PROSPERO REGISTRATION NUMBER

CRD42017060073.

Evaluating the World Health Organization’s International Classification of Functioning, Disability and Health Framework as a Participation Model for Cancer Survivors in Turkey

Improvements in diagnosis and treatment options for cancer now allow cancer survivors to live longer, and as a result, services are necessary to help individuals live an active and meaningful life in the community. The purpose of this study was to evaluate the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) framework as a participation model for cancer survivors in Turkey. Results from simultaneous regression analyses indicated educational attainment, fatigue, perceived stress, role functioning, social functioning, core self-evaluations, independent self-construal, social support, and autonomy support were significantly associated with participation. Specific interventions including health education, psychological workshops, support groups, and assistive technology may improve cancer survivors’ motivation and desire to actively engage in community activities. Higher levels of participation were also found when cancer survivors were involved in the treatment decision-making process, and felt cared for and understood by their treatment providers.

Going Forward Lightening the Shadow of Cancer: Experiences of Family Caregivers Toward Empowerment

This qualitative study was conducted to explore the empowerment experiences of family caregivers of patients with cancer. Empowerment consisted of 3 main categories: (1) seeking tranquility with the help of religious beliefs, (2) developing a positive attitude, and (3) restoring control over the situation. Results may help nurses for planning spiritual and supportive care.

Truth Disclosure Practices of Physicians in Jordan

Disclosure of health information is a sensitive matter, particularly in the context of serious illness. In conservative societies-those which predominate in the developing world-direct truth disclosure undoubtedly presents an ethical conundrum to the modern physician. The aim of this study is to explore the truth disclosure practices of physicians in Jordan, a developing country. In this descriptive, cross-sectional study, 240 physicians were initially selected by stratified random sampling. The sample was drawn from four major hospitals in Amman, Jordan. A closed-ended questionnaire was distributed and completed by self-report. A total of 164 physicians completed the questionnaire. Thirty-seven physicians (23 per cent) usually withheld the diagnosis of "serious illness" from patients, while 127 physicians (77 per cent) usually divulged the information directly. Among the latter, 108 physicians (86 per cent) made exceptions to their disclosure policy. Specialists were more likely to withhold health information (p = 0.04998). Non-disclosure was primarily motivated by request from the patient's family (seventy-one participants, 54 per cent). In twenty cases (15 per cent), non-disclosure was undertaken independently. In conclusion, most respondents opt to disclose the truth; however, the vast majority of these respondents make exceptions. Instances of non-disclosure are primarily motivated by sociocultural constructs.

Truth Telling in the Setting of Cultural Differences and Incurable Pediatric Illness: A Review

IMPORTANCE

Navigating requests from parents or family caregivers not to disclose poor prognosis to seriously ill children can be challenging, especially when the requests seem culturally mediated. Pediatric clinicians must balance obligations to respect individual patient autonomy, professional truth telling, and tolerance of multicultural values.

OBSERVATIONS

To provide suggestions for respectful and ethically appropriate responses to nondisclosure requests, we used a hypothetical case example of a Middle Eastern adolescent patient with incurable cancer and conducted an ethical analysis incorporating (1) evidence from both Western and Middle Eastern medical literature and (2) theories of cultural relativism and justice. While Western medical literature tends to prioritize patient autonomy and corresponding truth telling, the weight of evidence from the Middle East suggests high variability between and within individual countries, patient-physician relationships, and families regarding truth-telling practices and preferences. A common reason for nondisclosure in both populations is protecting the child from distressing information. Cultural relativism fosters tolerance of diverse beliefs and behaviors by forbidding judgment on foreign societal codes of conduct. It does not justify assumptions that all individuals within a single culture share the same values, nor does it demand that clinicians sacrifice their own codes of conduct out of cultural respect. We suggest some phrases that may help clinicians explore motivations behind nondisclosure requests and gently confront conflict in order to serve the patient's best interest.

CONCLUSIONS AND RELEVANCE

It is sometimes ethically permissible to defer to family values regarding nondisclosure, but such deferral is not unique to cultural differences. Early setting of expectations and boundaries, as well as ongoing exploration of family and health care professional concerns, may mitigate conflict.

Why do oncologists hide the truth? Disclosure of cancer diagnoses to patients in China: A multisource assessment using mixed methods

OBJECTIVE

In the United States and most European countries, cancer diagnoses are disclosed to patients. In China, however, the trend toward full disclosure has progressed slowly. The present study aimed to explore attitudes toward truth-telling practice among physicians, patients, patients' family members, and the general population, and reasons for nondisclosure.

METHODS

We administered a short survey to 212 physicians, 143 patients with cancer, 413 family members of patients with cancer, and 1415 members of the general population. A MANOVA was performed to examine group differences in attitudes toward cancer disclosure. In addition, we interviewed 20 oncologists. Interview data were analyzed using NVivo10. After the interview, we administered another short survey to 143 patients with cancer.

RESULTS

Quantitative data indicated that physicians were the least, and patients the most, in favor of disclosure. Qualitative data among physicians and follow-up surveys among cancer patients revealed 5 reasons for the concealment of cancer diagnoses by physicians, including lack of awareness of patients' right to knowledge, cultural influences, insufficient medical resources and training, families' financial concerns, and the need to protect doctors from violence.

CONCLUSION

There is a discrepancy between the needs of patients and those in medical practice. These results deepen our understanding regarding the reasons for oncologists' attitudes toward nondisclosure.

Family physicians' opinions on and difficulties with breaking bad news

Highlights

Breaking bad news is still deemed a difficult task by family physicians.Family physicians feel they need training in breaking bad news.The family physicians' attitude to this issue is different from what they would wish if they themselves had a life-threatening disease.

Background

Family practice is the specialty with the highest number of doctors and covers all of Portugal. Therefore, the attitude of these doctors may have a high impact on patients.

Objective

To explore the opinion and difficulties of Portuguese family doctors on dealing with communication with patients with life threatening diseases.

Methods

A questionnaire was sent to about 10% of family doctors of Northern Portugal. The questionnaire included questions about the disclosure of information, if they feel they need training courses and what they would want if they had a life-threatening disease.

Results

A questionnaire was given to 196 doctors and 159 (81%) participated in this study. The median age was 43 years (26-64) and 108 (68%) were females. One hundred thirty-five (85%) consider that breaking bad news is a difficult task. One hundred twenty-four (78%) feel they need training in breaking bad news. For many doctors, the disclosure of diagnoses and prognoses has a detrimental psychological effect and affects patients' hope, but gives patients' control of the situation. Given a situation where the doctors themselves had a life-threatening disease, the vast majority would want to know the diagnosis and the prognosis and to participate in treatment decisions.

Conclusions

Breaking bad news is still a difficult task. Their attitude to this duty is different from what they would wish if they themselves had a life-threatening disease. One important conclusion is the need of specific training in communication for family physicians that should begin in the training phase of their specialty.

Global Cancer in Women: Cancer Control Priorities

This review is an abbreviated version of a report prepared for the American Cancer Society Global Health department and EMD Serono, Inc., a subsidiary of Merck KGaA, Darmstadt, Germany, which was released at the Union for International Cancer Control World Cancer Congress in Paris in November 2016. The original report can be found at https://www.cancer.org/health-care-professionals/our-global-health-work/global-cancer-burden/global-burden-of-cancer-in-women.html. Staff in the Intramural Research Department of the American Cancer Society designed and conducted the study, including analysis, interpretation, and presentation of the review. The funding sources had no involvement in the study design, data analysis and interpretation, or preparation of the reviewThe global burden of cancer in women has recently received much attention, but there are few comprehensive reviews of the burden and policy approaches to reduce it. This article, second in series of two, summarizes the most important cancer control priorities with specific examples of proven interventions, with a particular focus on primary prevention in low- and middle-income countries (LMIC). There are a number of effective cancer control measures available to countries of all resource levels. Many of these measures are extremely cost-effective, especially in the case of tobacco control and vaccination. Countries must prioritize efforts to reduce known cancer risk factors and make prevention accessible to all. Effective treatments and palliative care are also needed for those who develop cancer. Given scarce resources, this may seem infeasible in many LMICs, but past experience with other diseases like HIV, tuberculosis, and malaria have shown that it is possible to make affordable care accessible to all. Expansion of population-based cancer registries and research in LMICs are needed for setting cancer control priorities and for determining the most effective interventions. For LMICs, all of these activities require support and commitment from the global community. Cancer Epidemiol Biomarkers Prev; 26(4); 458-70. ©2017 AACRSee related article by Torre et al. in this CEBP Focus section, "Global Cancer in Women."