Breaking bad news. 2: What evidence is available to guide clinicians?

Interprofessional collaboration between health professional learners when breaking bad news: a scoping review of teaching approaches

OBJECTIVE

The objective of this scoping review was to examine teaching approaches used to teach interprofessional health professional learners how to break bad news collaboratively.

INTRODUCTION

When breaking bad news, health professionals must be equipped to deliver it skillfully and collaboratively; however, the literature shows that this skill receives little attention in program curricula. Consequently, health professionals can feel inadequately prepared to deliver bad news, which may lead to increased burnout, distress, and compassion fatigue.

INCLUSION CRITERIA

Studies that describe teaching approaches used to teach learners how to break bad news collaboratively were considered for inclusion. Studies must have included 2 or more undergraduate and/or postgraduate learners working toward a professional health or social care qualification/degree at a university or college. Studies including lay, complementary and alternative, or non-health/social care learners were excluded. Due to the primary language of the research team, only English articles were included.

METHODS

The JBI 3-step process was followed for developing the search. Databases searched included MEDLINE (Ovid), CINAHL (EBSCOhost), Embase, Education Resource Complete (EBSCOhost), and Social Work Abstracts (EBSCOhost). The initial search was conducted on February 11, 2021, and was updated on May 17, 2022. Title and abstract screening and data extraction were completed by 2 independent reviewers. Disagreements were resolved through discussion or with a third reviewer. Results are presented in tabular or diagrammatic format, together with a narrative summary.

RESULTS

Thirteen studies were included in the scoping review, with a range of methodologies and designs (pre/post surveys, qualitative, feasibility, mixed methods, cross-sectional, quality improvement, and methodological triangulation). The majority of papers were from the United States (n=8; 61.5%). All but 1 study used simulation-enhanced interprofessional education as the preferred method to teach interprofessional cohorts of learners how to break bad news. The bulk of simulations were face-to-face (n=11; 84.6%). Three studies (23.1%) were reported as high fidelity, while the remainder did not disclose fidelity. All studies that used simulation to teach students how to break bad news utilized simulated participants/patients to portray patients and/or family in the simulations. The academic level of participants varied, with the majority noted as undergraduate (n=7; 53.8%); 3 studies (23.1%) indicated a mix of undergraduate and graduate participants, 2 (15.4%) were graduate only, and 1 (7.7%) was not disclosed. There was a range of health professional programs represented by participants, with medicine and nursing equally in the majority (n=10; 76.9%).

CONCLUSIONS

Simulation-enhanced interprofessional education was the most reported teaching approach to teach interprofessional cohorts of students how to break bad news collaboratively. Inconsistencies were noted in the language used to describe bad news, use of breaking bad news and interprofessional competency frameworks, and integration of interprofessional education and simulation best practices. Further research should focus on other interprofessional approaches to teaching how to break bad news; how best to incorporate interprofessional competencies into interprofessional breaking bad news education; whether interprofessional education is enhancing collaborative breaking bad news; and whether what is learned about breaking bad news is being retained over the long-term and incorporated into practice. Future simulation-specific research should explore whether and how the Healthcare Simulation Standards of Best Practice are being implemented and whether simulation is resulting in student satisfaction and enhanced learning.

Interprofessional collaboration between health professional learners when breaking bad news: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to examine pedagogies used to teach interprofessional health learners how to break bad news collaboratively.

INTRODUCTION

Breaking bad news is a skill health care professionals must be equipped to deliver well, yet literature shows that this skill receives little attention in program curricula. Consequently, health care professionals feel inadequately prepared to deliver bad news, leading to greater burnout, distress, and fatigue.

INCLUSION CRITERIA

Studies that describe pedagogies used to teach breaking bad news will be considered for inclusion. Studies must include two or more undergraduate and/or postgraduate learners working towards a professional health or social care qualification or degree at a university or college. Studies including lay, complementary and alternative, or non-health or social care professional learners will be excluded.

METHODS

The JBI three-step process will be followed for developing the search. Databases to be searched include MEDLINE, CINAHL, Embase, Education Resource Centre, and Social Work Abstracts. Title and abstract screening through to data extraction will be completed by two independent reviewers and any disagreements will be resolved through discussion, or with a third reviewer. Results will be presented in tabular or diagrammatic form, together with a narrative summary.

Experiences and views of receiving and delivering information about recovery in acquired neurological conditions: a systematic review of qualitative literature

OBJECTIVE

To review and synthesise qualitative literature relating to the views, perceptions and experiences of patients with acquired neurological conditions and their caregivers about the process of receiving information about recovery; as well as the views and experiences of healthcare professionals involved in delivering this information.

DESIGN

Systematic review of qualitative studies.

DATA SOURCES

MEDLINE, Embase, AMED, CINAHL, PsycINFO, Web of Science and the Cochrane library were searched from their inception to July 2019.

DATA EXTRACTION AND SYNTHESIS

Two reviewers extracted data from the included studies and assessed quality using an established tool. Thematic synthesis was used to synthesise the findings of included studies.

RESULTS

Searches yielded 9105 titles, with 145 retained for full-text screening. Twenty-eight studies (30 papers) from eight countries were included. Inductive analysis resulted in 11 descriptive themes, from which 5 analytical themes were generated: the right information at the right time; managing expectations; it's not what you say, it's how you say it; learning how to talk about recovery and manage emotions; the context of uncertainty.

CONCLUSIONS

Our findings highlight the inherent challenges in talking about recovery in an emotional context, where breaking bad news is a key feature. Future interventions should focus on preparing staff to meet patients' and families' information needs, as well as ensuring they have the skills to discuss potential recovery and break bad news compassionately and share the uncertain trajectory characteristic of acquired neurological conditions. An agreed team-based approach to talking about recovery is recommended to ensure consistency and improve the experiences of patients and their families.

Development and preliminary evaluation of a communication skills training programme for hospital physicians by a specialized palliative care service: the 'Teach to Talk' programme

BACKGROUND

There is widespread agreement about the importance of communication skills training (CST) for healthcare professionals caring for cancer patients. Communication can be effectively learned and improved through specific CST. Existing CSTs have some limitations with regard to transferring the learning to the workplace. The aim of the study is developing, piloting, and preliminarily assessing a CST programme for hospital physicians caring for advanced cancer patients to improve communication competences.

METHODS

This is a Phase 0-I study that follows the Medical Research Council framework; this paper describes the following sections: a literature review on CST, the development of the Teach to Talk training programme (TtT), the development of a procedure for assessing the quality of the implementation process and assessing the feasibility of the implementation process, and the pilot programme. The study was performed at a 900-bed public hospital. The programme was implemented by the Specialized Palliative Care Service. The programme was proposed to 19 physicians from 2 departments.

RESULTS

The different components of the training course were identified, and a set of quality indicators was developed. The TtT programme was implemented; all the physicians attended the lesson, videos, and role-playing sessions. Only 25% of the physicians participated in the bedside training. It was more challenging to involve Haematology physicians in the programme.

CONCLUSIONS

The programme was completed as established for one of the two departments in which it was piloted. Thus, in spite of the good feedback from the trainees, a re-piloting of a different training program will be developed, considering in particular the bed side component. The program should be tailored on specific communication attitude and believes, probably different between different specialties.

Delivering bad news

News in medicine has an obligation to be helpful, accurate, comprehensible for the intended audience and part of an on-going professional relationship that enables the best outcomes available. These obligations have special poignancy when the news is bad, the patient is a child and the news scene is a busy medical practice, clinic or hospital. This paper aims to outline specific ways of being helpful when delivering bad news, within the constraints of daily practice, to a wide variety of developmentally different children at different stages in the family life cycle. The paper specifies the purpose, tasks, obstacles and practicalities of giving adverse information about the health of children in our clinical work. Adverse news needs to be embedded within delivering news more generally in our work. This presupposes a trusting relationship, an accurate understanding of the news to be delivered and a capacity to communicate medical complexity to the intended audience. There are multiple audiences for our medical news, at different developmental stages, each of whom needs help to 'hear the news' in different ways. Each developmental period within a broader family life cycle is briefly addressed. The limited evidence-base is outlined with a view to what the clinician can do to foster maximal support, understanding and on-going cooperation. The interplay between realism and optimism is highlighted so that accuracy and helpfulness are wedded as meaningfully and sensitively as possible. The aim is to be helpful rather than pursue an ideal of the unfaltering, polished and flawlessly performing clinician.

Breaking bad news from the doctors' perspective in a paternalistic society: the case of Sudan

Breaking bad news is a global challenge for all types of health providers. Our study assessed the attitude and practice from the doctors' perspective in a patriarchal society. A descriptive cross-sectional hospital-based study was conducted, involving doctors from both medical and surgical departments. Almost half of the respondents believed that Sudanese patients do not like to know their diagnosis, and a slightly higher proportion had no previous training on how to break bad news. Some 20% indicated that they would conceal the diagnosis from a patient if his or her relatives so requested. Less than one-quarter of respondents followed a standard protocol. Although most of the doctors subscribed to the notion that patients have the right to know everything about their illnesses, not all of them held this attitude towards their local patient population.

Development of a Web-Based Formative Self-Assessment Tool for Physicians to Practice Breaking Bad News (BRADNET)

BACKGROUND

Although most physicians in medical settings have to deliver bad news, the skills of delivering bad news to patients have been given insufficient attention. Delivering bad news is a complex communication task that includes verbal and nonverbal skills, the ability to recognize and respond to patients' emotions and the importance of considering the patient's environment such as culture and social status. How bad news is delivered can have consequences that may affect patients, sometimes over the long term.

OBJECTIVE

This project aimed to develop a Web-based formative self-assessment tool for physicians to practice delivering bad news to minimize the deleterious effects of poor way of breaking bad news about a disease, whatever the disease.

METHODS

BReaking bAD NEws Tool (BRADNET) items were developed by reviewing existing protocols and recommendations for delivering bad news. We also examined instruments for assessing patient-physician communications and conducted semistructured interviews with patients and physicians. From this step, we selected specific themes and then pooled these themes before consensus was achieved on a good practices communication framework list. Items were then created from this list. To ensure that physicians found BRADNET acceptable, understandable, and relevant to their patients' condition, the tool was refined by a working group of clinicians familiar with delivering bad news. The think-aloud approach was used to explore the impact of the items and messages and why and how these messages could change physicians' relations with patients or how to deliver bad news. Finally, formative self-assessment sessions were constructed according to a double perspective of progression: a chronological progression of the disclosure of the bad news and the growing difficulty of items (difficulty concerning the expected level of self-reflection).

RESULTS

The good practices communication framework list comprised 70 specific issues related to breaking bad news pooled into 8 main domains: opening, preparing for the delivery of bad news, communication techniques, consultation content, attention, physician emotional management, shared decision making, and the relationship between the physician and the medical team. After constructing the items from this list, the items were extensively refined to make them more useful to the target audience, and one item was added. BRADNET contains 71 items, each including a question, response options, and a corresponding message, which were divided into 8 domains and assessed with 12 self-assessment sessions. The BRADNET Web-based platform was developed according to the cognitive load theory and the cognitive theory of multimedia learning.

CONCLUSIONS

The objective of this Web-based assessment tool was to create a "space" for reflection. It contained items leading to self-reflection and messages that introduced recommended communication behaviors. Our approach was innovative as it provided an inexpensive distance-learning self-assessment tool that was manageable and less time-consuming for physicians with often overwhelming schedules.

Strategies and challenges for communicating the diagnosis of cancer in cross-cultural clinical settings-Perspectives from South African healthcare professionals

Communicating the diagnosis of cancer in cross-cultural clinical settings is a complex task. This qualitative research article describes the content and process of informing Zulu patients in South Africa of the diagnosis of cancer, using osteosarcoma as the index diagnosis. We used a descriptive research design with census sampling and focus group interviews. We used an iterative thematic data analysis process and Guba's model of trustworthiness to ensure scientific rigor. Our results reinforced the use of well-accepted strategies for communicating the diagnosis of cancer. In addition, new strategies emerged which may be useful in other cross-cultural settings. These strategies included using the stages of cancer to explain the disease and its progression and instilling hope using a multidisciplinary team care model. We identified several patients, professionals, and organizational factors that complicate cross-cultural communication. We conclude by recommending the development of protocols for communication in these cross-cultural clinical settings.

The use of protocol in breaking bad news: evidence and ethos

This article discusses health professionals use of protocol in the breaking of bad news, focusing particularly on the well-known SPIKES framework. The evidence of impact on the patient experience is examined and recommendations are made for further outcome-based research. Existing evidence suggests that the model as commonly interpreted may not fully meet the needs of patients or reflect the clinical experience of breaking bad news for some professionals and further guidance may be needed to support them in their practice. The ethos of the step-wise protocol is debated, questioning whether it helps or hinders individualised care and the formation of a genuine relationship between patient and professional. Finally, recommendations for practice are offered.

Experiences and reflections of patients with motor neuron disease on breaking the news in a two-tiered appointment: a qualitative study

BACKGROUND

Breaking bad news should be fine-tuned to the individual patient, contain intelligible information, include emotional support and offer a tailor-made treatment plan. To achieve this goal in motor neuron disease (MND), neurologists of the amyotrophic lateral sclerosis (ALS) centre Amsterdam deliver the message on 2 separate visits within 14 days.

AIM

To evaluate how patients with MND react to and view disclosure of the diagnosis, in this 2-tiered approach.

METHODS

Non-participating observations and in-depth interviews with patients were conducted in 1 tertiary ALS referral centre. Qualitative analysis consisted of inductive analysis of observation reports and verbatim typed out interviews.

RESULTS

10 2-tiered appointments were observed and 21 Dutch patients with MND interviewed. They experienced the straightforward message to be suffering from a fatal disease as devastating, yet unavoidable. The prospect of a short-term second appointment offered structure for the period immediately following the diagnosis. The time between appointments provided the opportunity for a first reorientation on their changed perspective on their life. The second appointment allowed for detailed discussions about various aspects of MND and a tailor-made treatment plan.

CONCLUSIONS

The 2-tiered approach fits well with the way in which Dutch patients with MND process the disclosure of their diagnosis, gather information and handle the changed perspective on their life. It may serve as a model for other life-limiting diseases.

Delivering bad news: an approach according to jewish scriptures

Despite a preoccupation in the medical literature with developing an effective approach for breaking bad news, the sources are based on personal opinion alone and only in some instances on qualitative research. Recognizing the gravity of this topic coupled with respect for the wisdom of the written and oral Jewish scriptures, this work is an attempt to delve into the diverse ancient writings to draw conclusions regarding a recommended methodology to guide and inform this task. It is interesting to learn that most elements related to this topic have previously been raised in various forms in the scriptures. The issues range from where, when, and how the bearer of bad news should undertake this duty, to details such as the environment, the format, the speed, and depth of the details to be disclosed. The essence of this paper is to enrich the reader using both positive and negative examples found in the Jewish heritage. Adopting these principles will hopefully provide an effective method for performing this unpleasant obligation, with the goal of limiting harmful consequences as much as possible.

Interprofessional communication skills training for serious illness: evaluation of a small-group, simulated patient intervention

BACKGROUND

Communication with patients and families is an essential component of high-quality care in serious illness. Small-group skills training can result in new communication behaviors, but past studies have used facilitators with extensive experience, raising concerns this is not scalable.

OBJECTIVE

The objective was to investigate the effect of an experiential communication skills building workshop (Codetalk), led by newly trained facilitators, on internal medicine trainees' and nurse practitioner students' ability to communicate bad news and express empathy.

DESIGN

Trainees participated in Codetalk; skill improvement was evaluated through pre- and post- standardized patient (SP) encounters.

SETTING AND SUBJECTS

The subjects were internal medicine residents and nurse practitioner students at two universities.

INTERVENTION AND MEASUREMENTS

The study was carried out in anywhere from five to eight half-day sessions over a month. The first and last sessions included audiotaped trainee SP encounters coded for effective communication behaviors. The primary outcome was change in communication scores from pre-intervention to post-intervention. We also measured trainee characteristics to identify predictors of performance and change in performance over time.

RESULTS

We enrolled 145 trainees who completed pre- and post-intervention SP interviews-with participation rates of 52% for physicians and 14% for nurse practitioners. Trainees' scores improved in 8 of 11 coded behaviors (p<0.05). The only significant predictors of performance were having participated in the intervention (p<0.001) and study site (p<0.003). The only predictor of improvement in performance over time was participating in the intervention (p<0.001).

CONCLUSIONS

A communication skills intervention using newly trained facilitators was associated with improvement in trainees' skills in giving bad news and expressing empathy. Improvement in communication skills did not vary by trainee characteristics.

How do we talk to the children? Child life consultation to support the children of seriously ill adult inpatients

BACKGROUND

Families with young children often struggle to talk about and cope with a parent's life-threatening illness and potential death. Adult interdisciplinary palliative medicine teams often feel unprepared to facilitate the open communication with these children that has been shown to reduce anxiety, depression, and other behavioral problems. In pediatric settings, child life specialists routinely provide this support to hospitalized children as well as their siblings and parents. Although these services are the standard of care in pediatrics, no research reports their use in the care of children of adults with serious illness.

OBJECTIVE

Our aim is to describe a pilot child life consultation service for the children of seriously ill adult inpatients.

DESIGN

We summarize the support needs of these children, their families, and the medical staff caring for them and report our experience with developing a child life consultation service to meet these needs.

SETTING/SUBJECTS

Our service assists seriously ill adult inpatients and their families in a university medical center.

RESULTS

Informal feedback from families and staff was uniformly positive. During consultations, family and child coping mechanisms were assessed and supported. Interventions were chosen to enhance the children's processing and self-expression and to facilitate family communication.

CONCLUSION

All hospitals should consider providing broad-based in-service training enabling their staff to improve the support they offer to the children of seriously ill parents. Medical centers with access to child life services should consider developing a child life consultation service to further enhance this support. More research is needed to evaluate both the short- and long-term clinical impact of these interventions.

Diagnosing women with HPV: the impact of diagnosis disclosure methods

OBJECTIVE

Little data exists on women's HPV diagnosis encounters. This research focuses on impacts of the communicative medium used to inform women of their HPV status. We conducted a qualitative study to identify the mediums used to communicate HPV diagnoses and the impact of each medium on the diagnosis experience.

METHOD

Twenty-five women with HPV completed semi-structured interviews, which we recorded and transcribed. We relied on grounded theory techniques in both data collection and analysis.

RESULTS

There are three primary mediums health care providers use to inform women of their HPV diagnosis: phone calls, mailed letters/email, and face-to-face interactions. Implications regarding each medium are identified and discussed.

CONCLUSION

There are drawbacks associated with the use of each medium that healthcare practitioners should be aware of and seek to avoid.

PRACTICE IMPLICATIONS

Healthcare providers can utilize descriptions of diagnosis encounters and the recommendations accompanying them to understand and modify ways they choose to inform individuals of an HPV diagnosis.

Notification and support for people exposed to the risk of Creutzfeldt-Jakob disease (CJD) (or other prion diseases) through medical treatment (iatrogenically)

BACKGROUND

Creutzfeldt-Jakob disease (CJD) and variant CJD (vCJD) are rare and always-fatal diseases transmissible via certain medical procedures. If a person is exposed to the disease risk through medical treatment, they may need to be notified of this to prevent them passing the risk to others in healthcare settings and to enable additional infection control measures to be put in place for certain procedures. As CJD is incurable, and unable to be screened for or effectively treated, communicating this risk information after an exposure incident may have significant implications for the person at risk, their families/ carers and healthcare professionals. The best ways to notify people of their exposure to the risk of CJD or vCJD, and to support them subsequently, are currently unknown.

OBJECTIVES

To evaluate the effects of interventions to notify and support consumers (patients and their family members or carers) in situations where exposure to the risk of CJD or vCJD has occurred as a result of medical treatment (iatrogenically), on consumer, healthcare provider and healthcare system outcomes.

SEARCH STRATEGY

We searched the Cochrane Consumers and Communication Review Group Specialised Register (10 February, 2009), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2009), MEDLINE (OVID SP), EMBASE (OVID SP), PsycINFO (OVID SP), CINAHL (EBSCO Host), Current Contents (OVID SP) and Dissertation Abstracts (Proquest) from start date to February 2009. We searched MEDLINE In-process and Other Non-indexed Citations (OVID SP) and Sociological Abstracts (CSA) in November 2009. We searched reference lists, websites, and contacted consumer groups and experts for details of relevant research.

SELECTION CRITERIA

Randomised and quasi-randomised controlled studies, controlled before-and-after studies and interrupted time series analyses assessing the effects of any intervention to communicate with (notify or support) people exposed to the risk of CJD or vCJD through medical treatment were included. We sought outcomes relevant to consumers, health providers and health services, including both benefits and harms.

DATA COLLECTION AND ANALYSIS

Cochrane reviewTwo authors independently assessed studies for inclusion against selection criteria, and would have applied standard Cochrane review methodology were any studies identified.Thematic synthesisWe also conducted a thematic synthesis by systematically identifying and screening those studies that met the same population, intervention and outcome criteria as the Cochrane review, but that were identified from the broader literature providing evidence on policy implementation and consumer experiences. We systematically extracted and synthesised the data from these studies to produce a thematic synthesis, presented in appendices to this Cochrane review, which assembles evidence on the views, experiences and acceptability of notification and support strategies for people at risk.

MAIN RESULTS

Results of the Cochrane reviewNo studies meeting the study design criteria were identified for inclusion in this Cochrane review.Results of thematic synthesisIn total, 49 studies and pieces of literature meeting the same population, intervention and outcome criteria as the Cochrane review, but identified from the broader literature providing evidence on policy implementation and consumer experiences, were included and formed the basis of a thematic synthesis, and which is presented in appendices to this Cochrane review. The thematic synthesis indicates that ideally communication may be considered as a longitudinal multicomponent programme, ensuring that notification and support are coordinated; that communication is tailored and responsive to need; and that activities to support individual risk communication, such as widespread education and monitoring of access to health care for those at risk, are in place. The thematic synthesis also indicates that poor communication practices may have negative impacts or cause harm, such as discrimination in accessing health care.

AUTHORS' CONCLUSIONS

There is insufficient rigorous evidence to determine the effects of interventions to notify people at CJD or vCJD risk and to support them subsequently, or to identify the best approach to communication in these situations. The thematic synthesis can be used to inform policy and practice decisions for communicating with people at risk in the absence of rigorous evaluative studies.

Sugar-coaters and straight talkers: communicating about developmental delays in primary care

OBJECTIVES

The goals were to investigate parents' and early intervention (EI) specialists' beliefs and experiences regarding discussing child development in primary care and to identify communication barriers and opportunities.

METHODS

Focus groups were held with (1) mothers of young children with typical development, (2) mothers of young children who received EI services, and (3) EI specialists. Seven groups (N = 46 participants) were conducted in the greater Cleveland, Ohio, area. Meetings were audio-recorded, transcribed, coded, and analyzed, to identify themes.

RESULTS

Most mothers reported a preference for a nonalarmist style of communication when developmental delays are suspected. In contrast, some mothers preferred a more direct style, including the use of labels to help them understand their child's development. The importance of preparation to accept information about developmental delays emerged as a theme in all groups. Elements contributing to preparedness included information about expected developmental skills, suggestions for promoting skills, and a specific time frame for follow-up evaluation. Mothers of children with disabilities perceived that early reassurance of normalcy by providers in response to their concerns led to self-doubt and increased difficulty accepting the diagnosis.

CONCLUSIONS

Mothers and EI specialists have clear ideas about factors that promote or impede communication regarding child development. This information can inform primary care providers' approaches to monitoring and screening the development of young children and to communicating with parents regarding suspected developmental delays.

Are we there yet? The state of the evidence base for guidelines on breaking bad news to cancer patients

The way clinicians break bad news to cancer patients has been retrospectively associated with poor psychosocial outcomes for patients. Education and practice in breaking bad news may be ineffective for improving patients' well-being unless it is informed by a sound evidence base. In the health field, research efforts are expected to advance evidence over time to inform evidence-based practice. Key characteristics of an advancing evidence base are a predominance of new data, and rigorous intervention studies which prospectively demonstrate improved outcomes. This review aimed to examine the progress of the evidence base in breaking bad news to cancer patients. Manual and computer-based searches (Medline and PsycINFO) were performed to identify publications on the topic of breaking bad news to cancer patients published between January 1995 and March 2009. Relevant publications were coded in terms of whether they provided new data, examined psychosocial outcomes for patients or tested intervention strategies and whether intervention studies met criteria for design rigour. Of the 245 relevant publications, 55.5% provided new data and 16.7% were intervention studies. Much of the intervention effort was directed towards improving provider skills rather than patient outcomes (9.8% of studies). Less than 2% of publications were rigorous intervention studies which addressed psychosocial outcomes for patients. Rigorous intervention studies which evaluate strategies for improving psychosocial outcomes in relation to breaking bad news to cancer patients are needed. Current practice and training regarding breaking bad news cannot be regarded as evidence-based until further research is completed.

Evidence-Based Recommendations for Information and Care Planning in Cancer Care

The practice of oncology is characterized by challenging communication tasks that make it difficult to ensure optimal physician-patient information sharing and care planning. Discussions of diagnosis, prognosis, and patient goals are essential processes that inform decisions. However, data suggest that there are deficiencies in this area. We conducted a systematic review to identify the evidence supporting high-quality clinical practices for information and care planning in the context of cancer care as part of the RAND Cancer Quality–Assessing Symptoms, Side Effects, and Indicators of Supportive Treatment Project. Domains of information and care planning that are important for high-quality cancer care include integration of palliation into cancer care, advance care planning, sentinel events as markers for the need to readdress a patient's goals of care, and continuity of care planning. The standards presented here for information and care planning in cancer care should be incorporated into care pathways and should become the expectation rather than the exception.

Sexually acquired infections: do lay experiences of partner notification challenge practice?

AIM

This paper is a report of a study to explore experiences of partner notification for syphilis from the perspectives of gay, bisexual and other men who have sex with men.

BACKGROUND

Partner notification is the 'cornerstone' of the prevention and control of sexually acquired infections. As a health strategy, it has been in use for over six decades and is employed across all continents. Its success relies almost entirely on the voluntary response of index patients in disclosing details of their sexual partners and sexual practices and the voluntary response of sexual partners who have been traced. However, internationally, few studies have explicitly explored lay experiences of partner notification.

METHOD

A purposive sample of 40 gay, bisexual and other men who have sex with men was recruited from two genitourinary clinics in the Greater Dublin area of Ireland and a variety of gay social venues. Semi-structured interviews were carried out between December 2002 and February 2004.

FINDINGS

Men's perspectives on partner notification featured three interweaving stages: on tracing sexual partners, on informing partners and on attending clinics. Participants were in favour of partner notification, but did not find it easy to comply with the demands it made on their relationships. Compliance was difficult not only because of the problem of physically tracing casual and anonymous partners, but also because of the challenge of actually notifying partners. The main incentive for contacts to attend clinics was concern for their own health and that of others. Barriers to attending were fear of being exposed to the stigma of being gay and/or having a sexually acquired infection.

CONCLUSION

There is a need to develop evidence-based methods, which are grounded in the lay experience, to support index patients in 'breaking bad news' and for continued efforts to de-stigmatize sexually acquired infections and homosexuality in the view of the general public.

Pushing up daisies: implicit and explicit language in oncologist-patient communication about death

GOALS OF WORK

Although there are guidelines regarding how conversations with patients about prognosis in life-limiting illness should occur, there are little data about what doctors actually say. This study was designed to qualitatively analyze the language that oncologists and cancer patients use when talking about death.

SUBJECTS AND METHODS

We recruited 29 adults who had incurable forms of cancer, were scheduled for a first-time visit with one of six oncologists affiliated with a teaching hospital in Australia, and consented to having their visit audiotaped and transcribed. Using content analytic techniques, we coded various features of language usage.

MAIN RESULTS

Of the 29 visits, 23 (79.3%) included prognostic utterances about treatment-related and disease-related outcomes. In 12 (52.2%) of these 23 visits, explicit language about death ("terminal," variations of "death") was used. It was most commonly used by the oncologist after the physical examination, but it was sometimes used by patients or their kin, usually before the examination and involving emotional questioning about the patient's future. In all 23 (100%) visits, implicit language (euphemistic or indirect talk) was used in discussing death and focused on an anticipated life span (mentioned in 87.0% of visits), estimated time frame (69.6%), or projected survival (47.8%).

CONCLUSIONS

Instead of using the word "death," most participants used some alternative phrase, including implicit language. Although oncologists are more likely than patients and their kin to use explicit language in discussing death, the oncologists tend to couple it with implicit language, possibly to mitigate the message effects.

A systematic review on communicating with patients about evidence

OBJECTIVE

To conduct a systematic search for (1) the effectiveness of evidence-based communication tools to increase patient understanding of evidence, (2) effective formats for representing probabilistic information and (3) effective strategies for eliciting patient preferences about evidence. A case scenario is used to illustrate some of the difficulties of putting these results into practice.

DATA SOURCES

Systematic search of The Cochrane Library, Medline, Psychinfo, Embase and Cancerlit.

REVIEW METHODS

Systematic reviews of randomized controlled trials (RCTs) and high quality RCTs were included. Studies were excluded if they did not address the question, were focused on behavioural outcomes without attempting to increase understanding, were concerned with counselling as a therapeutic intervention, or were specific to communication regarding clinical trial participation.

RESULTS

We found 10 systematic reviews of RCTs and 30 additional RCTs addressing our questions. Communication tools in most formats (verbal, written, video, provider-delivered, computer-based) will increase patients' understanding but are more likely to do so if structured, tailored and/or interactive. Probabilistic information is best represented as event rates (natural frequencies) in relevant groups of people, rather than words, probabilities or summarized as effect measures such as relative risk reduction. Illustrations such as cartoons, or graphs (vertical bar charts) appear to aid understanding. Values clarification exercises may be better than standard utility techniques for eliciting preferences in individual decision making. Looking for effective evidence-based communication tools for prostatic specific antigen testing highlighted the challenges for clinicians and consumers in accessing tools that are evidence-based in design as well as content.

CONCLUSION

There is an increasing body of evidence supporting the design of effective evidence-based communication tools but variable access to such tools in practice.

Breaking bad news: qualitative evaluation of an interprofessional learning opportunity

This paper analyses the effects of bringing together a small group of nursing and medical students to learn the skills needed to break bad news to patients. It outlines the qualitative and quantitative methods used, to provide the reader with a comprehensive account of the teaching, learning and research strategies drawn on during the study. The paper examines the evaluation phase, as this aspect is of greatest import if such initiatives are to flourish. The facet of the study analysed in detail concerns the students' responses to the open-ended qualitative questionnaires. In coding the data, three researchers independently highlighted a series of themes associated with the benefits and hazards of nursing and medical students learning and working together. Finally, the paper closes by arguing that trust and mutual respect are vital ingredients if collaborative working is to become part of the medical and nursing curriculum.

Patterns and barriers in information disclosure between health care professionals and relatives with cancer patients in Greek society

The issue of whether, how and how much to tell cancer patients concerning diagnosis is still approached in various ways across different countries and cultures. The health care team-patient relationship is a triangle consisting of the health care professionals, the patient and the family. Each part supports the other two and is affected by the changes that happen in the triangle. The objective of the study was to investigate the communication context through which health care professionals and families with cancer patients interact. In Greece, physicians have the tendency to tell the truth more often today than in the past, although the majority still disclose the truth to the next of kin. Nurses in Greece are considered to be the most suitable health care professionals for the patients to share their thoughts and feelings with. Nevertheless, the decision on information disclosure lies with the treating physician. In Greek society the patient's family plays an important role in the provision of care and information disclosure. They often decide on the patient's behalf.

Towards better communication in cancer care: a framework for developing evidence-based interventions

Increasing recognition of the complexity and difficulty of communication in patient care has led to a burgeoning but chaotic literature that tends to be incomplete on any one topic. A co-ordinated, planned approach is required to facilitate the rapid development and implementation of evidence-based interventions in this area. We propose a seven-stage model of communication research that is designed to provide clear directions to improve communication in cancer care. The stages are: (1) identification of communication difficulties; (2) documentation of patient and clinician views; (3) identification of practices associated with better outcomes; (4) the development of evidence-based guidelines and interventions; (5) testing the effectiveness of the intervention in changing current practice and improving patient outcomes; (6) dissemination of the effective interventions; and (7) broad adoption of the intervention. Examples are provided for each stage of research to elucidate the type of study proposed.

Identifying signals of suffering by linking verbal and facial cues

Here, the authors describe microanalytically the two main behavioral states in suffering (enduring and emotional suffering) so that in subsequent research, appropriate comforting responses to ease and relieve suffering can be identified for each behavioral state. Their objectives were to describe the facial expressions of enduring and emotional suffering, and to link them with verbal narrative and thus develop a microanalytic description of each behavioral state. Using Ekman's modified EMFACS, they videotaped interviews with 19 participants and coded co-occurring verbal text and expressions. They also documented differences between each behavioral state and the transitions from enduring to emotional suffering. Enduring and emotional suffering are distinct and identifiable behaviors. These formerly implicit behavioral cues can be used in clinical assessment and research.

Health professionals' perceptions of breaking bad news

The growth of the "patient-centred" approach to health care has highlighted the importance of quality communication practices. One area that remains problematic, however, is the process of breaking bad new to patients and/or relatives. Hence, there have been calls for more research and training in this domain. Reports the findings of a study that used the critical incident technique to explore the breaking bad news encounter from the perspective of the health care practitioner. In total 33 senior medical and nursing staff reported on situations in which they described specific, vividly recalled, experiences of both "effective" and "ineffective" bad news delivery. These reported incidents were content analysed and a range of key dimensions was identified for both effective and ineffective experiences. Interpersonal communication skills emerged as particularly salient factors and these are discussed in detail, together with implications for future research and training.

The good news about giving bad news to patients

BACKGROUND

There are few data available on how physicians inform patients about bad news. We surveyed internists about how they convey this information.

METHODS

We surveyed internists about their activities in giving bad news to patients. One set of questions was about activities for the emotional support of the patient (11 items), and the other was about activities for creating a supportive environment for delivering bad news (9 items). The impact of demographic factors on the performance of emotionally supportive items, environmentally supportive items, and on the number of minutes reportedly spent delivering news was analyzed by analysis of variance and multiple regression analysis.

RESULTS

More than half of the internists reported that they always or frequently performed 10 of the 11 emotionally supportive items and 6 of the 9 environmentally supportive items while giving bad news to patients. The average time reportedly spent in giving bad news was 27 minutes. Although training in giving bad news had a significant impact on the number of emotionally supportive items reported (P <.05), only 25% of respondents had any previous training in this area. Being older, a woman, unmarried, and having a history of major illness were also associated with reporting a greater number of emotionally supportive activities.

CONCLUSIONS

Internists report that they inform patients of bad news appropriately. Some deficiencies exist, specifically in discussing prognosis and referral of patients to support groups. Physician educational efforts should include discussion of prognosis with patients as well as the availability of support groups.

Should a diagnosis of Alzheimer's disease be disclosed?

There is evidence that some health practitioners may be reluctant to disclose a diagnosis of Alzheimer's disease (AD) to patients. However, this reluctance towards disclosure may not be in accordance with patient expectation. This study examined the attitudes of 100 undergraduate psychology students towards disclosure practices in relation to AD, before and after exposure to AD education. After AD education, 93% of participants indicated a desire to be informed of a diagnosis of AD, and 95% of participants were in favour of telling a close relative a diagnosis of AD. Results are discussed in terms of the relationship between age and attitudes towards AD diagnosis. It is concluded that the high rate of support for disclosure of AD diagnoses to patients among younger adults may reflect a change in the information preferences of patients brought about by a shift away from a patriarchal medical model, toward a more autonomous model of health.

Terminal care and bereavement

Care of patients at the end of life requires a high level of clinical vigilance, compassion and skill. The involvement of the patient's primary neurologist in end-of-life care and into bereavement can be an invaluable comfort to the patient and family. An understanding of the techniques for assessing and anticipating patient and family needs and knowledge of the resources available is essential if the neurologist is to provide guidance in their care.

[Disclosure of a diagnosis of cancer: paradoxes and misunderstandings]

INTRODUCTION

Announcing to a patient that he has cancer is a key moment both in the relationship between this patient and his doctor and in the setting up of quality communications. However, the quality of this communication is often impaired by the presence of paradoxes and misunderstandings.

CURRENT KNOWLEDGE AND KEY POINTS

The particularities of cancer, the defense mechanisms of the different contributors and cancer representations can increase the sources of misunderstandings, which will leave an indelible mark on the patient at the beginning of the disease.

FUTURE AND PROJECTS

What's at stake in that type of announcement in terms of compliance should not be neglected. Practitioners becoming aware of those phenomena and communication rules should improve the modes of announcement.

SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer

We describe a protocol for disclosing unfavorable information-"breaking bad news"-to cancer patients about their illness. Straightforward and practical, the protocol meets the requirements defined by published research on this topic. The protocol (SPIKES) consists of six steps. The goal is to enable the clinician to fulfill the four most important objectives of the interview disclosing bad news: gathering information from the patient, transmitting the medical information, providing support to the patient, and eliciting the patient's collaboration in developing a strategy or treatment plan for the future. Oncologists, oncology trainees, and medical students who have been taught the protocol have reported increased confidence in their ability to disclose unfavorable medical information to patients. Directions for continuing assessment of the protocol are suggested.

How should doctors communicate the diagnosis of cancer to patients?

The majority of doctors in North America, Australia and much of Europe now inform patients about a cancer diagnosis. However, many doctors report that they have difficulty disclosing a cancer diagnosis. Poor doctor-patient communication skills may lead to psychological distress including increased anxiety and depression and poorer psychological adjustment to cancer. Presenting 'bad' news in an unhurried, honest, balanced and empathic fashion has been shown to produce greater satisfaction with communication of the news. Consensus guidelines have been developed to assist doctors to disclose a cancer diagnosis. Important aspects include exploring the patient's expectations, warning him/her that the news is bad, giving the news at the patient's own pace, allowing time for the patient to react and eliciting the patient's concerns. Doctor-patient communication can be improved by including training courses in communication skills for medical students and clinicians and providing audiotapes of bad news consultations to enhance patient recall of information and increase patient satisfaction with communication. Additional research is needed to investigate effects of strategies to implement guidelines for delivering a cancer diagnosis.