Breaking bad news. 3: Encouraging the adoption of best practices

Interactional skills training in undergraduate medical education: ten principles for guiding future research

BACKGROUND

High-quality healthcare requires practitioners who have technical competence and communication skills. Medical practitioners need interpersonal skills for gathering and transferring information to their patients, in addition to general consultation skills. Appropriate information gathering increases the likelihood of an accurate diagnosis. Transferring information should be performed in a way that promotes patient understanding and increases the probability of adherence to physician recommendations. This applies to: (i) primary prevention such as smoking cessation; (ii) secondary prevention including preparation for potentially threatening interventions; and (iii) tertiary care, including breaking bad news regarding treatment and prognosis.

DISCUSSION

This debate paper delineates factors associated with undergraduate medical communication skills training where robust research is needed. Ten key principles are presented and discussed, which are intended to guide future research in this field and ensure high quality studies with methodological rigour are conducted. The literature on communication skills training for medical school undergraduates continues to grow. A considerable portion of this output is represented by commentaries, descriptive studies or poorly designed interventions. As with any field of healthcare, quality research interventions are required to ensure practice is grounded in high-level evidence.

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.

Do we get it right? Radiation oncology outpatients' perceptions of the patient centredness of life expectancy disclosure

OBJECTIVE

A patient-centred approach to discussing life expectancy with cancer patients is recommended in Western countries. However, this approach to eliciting and meeting patient preferences can be challenging for clinicians. The aims of this study were the following: (i) to examine cancer patients' preferences for life expectancy disclosure; and (ii) to explore agreement between cancer patients' preferences for, and perceived experiences of, life expectancy disclosure.

METHODS

Cancer patients undergoing radiotherapy treatment in metropolitan Australia completed a cross-sectional touchscreen computer survey including optional questions about their life expectancy disclosure preferences and experiences.

RESULTS

Of the 208 respondents, 178 (86%) indicated that they would prefer their clinician to ask them before discussing life expectancy, and 30 (14%) indicated that they would prefer others (i.e. clinicians, family) to decide whether they were given life expectancy information. Of the 175 respondents who were classified as having a self- determined or other-determined disclosure experience, 105 (60%) reported an experience of life expectancy disclosure that was in accordance with their preferences. Cohen's κ was -0.04 (95% CI, -0.17, 0.08), indicating very poor agreement between patients' preferences for and perceived experiences of life expectancy disclosure (p = 0.74).

CONCLUSIONS

In light of patient-centred prognosis disclosure guidelines, our findings of a majority preference for, and experience of, a self-determined approach to life expectancy disclosure amongst radiation oncology patients are encouraging. However, poor agreement between preferences and experiences highlights that additional effort from clinicians is required in order to achieve a truly patient-centred approach to life expectancy disclosure.

Breaking the news of traumatic brain injury and incapacities

PRIMARY OBJECTIVE

This paper presents research results regarding disclosure of traumatic brain injury (TBI) diagnosis and resulting deficits of a study aiming to investigate the experiences of individuals who had sustained a TBI, their families, the physicians and health professionals involved, from the critical care episodes and subsequent rehabilitation.

RESEARCH DESIGN

Semi-structured interviews were conducted with individuals who had sustained a TBI (n = 8) and their families (n = 8) as well as with the health professionals (or service providers) (n = 22) and physicians (n = 9) who provided them care.

MAIN OUTCOMES AND RESULTS

Results revealed that the quality of the disclosure is strongly influenced by the medical uncertainty surrounding the TBI and the difficulties of healthcare professionals in dealing with the family's emotions.

CONCLUSIONS

Delivering bad news is always difficult, but it is possible to make this harrowing experience easier and, in so doing, enhance patient and family resilience.

Palliative care in amyotrophic lateral sclerosis, Parkinson's disease, and multiple sclerosis

BACKGROUND

Amyotrophic lateral sclerosis, Parkinson's disease, atypical parkinsonian syndromes, and multiple sclerosis are progressive neurologic disorders that cumulatively afflict a large number of people. Effective end-of-life palliative care depends upon an understanding of the clinical aspects of each of these disorders.

OBJECTIVES

The authors review the unique and overlapping aspects of each of these disorders with an emphasis upon the clinical management of symptoms.

DESIGN

The authors review current management and the supporting literature.

CONCLUSIONS

Clinicians have many effective therapeutic options to choose from when managing the symptoms produced by these disorders.

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.

Communicating life-threatening diagnoses to patients in the emergency department

Disclosing a new, life-threatening diagnosis to a patient is difficult for the physician, the patient, and the family. The disclosure provokes a wide range of reactions from both the patient and family, to which the emergency physician must respond. This interaction is further complicated by the limited time the emergency physician can spend with the patient, the strained resources of a busy emergency department (ED), and, oftentimes, the inability to make a definitive diagnosis based on the ED workup and evaluation. We present a case seen recently in the ED in which a new, life-threatening illness requires disclosure. We offer guidelines for the emergency physician that emphasize patient- and family-centered disclosure of the worrisome diagnostic findings. Additionally, we discuss the essential roles of other allied health professionals in addressing the patient's nonmedical concerns (eg, health insurance, social issues) and in creating a smooth transition for the patient from the ED to further inpatient or outpatient care.

Experiences at the time of diagnosis of parents who have a child with a bone dysplasia resulting in short stature

Many studies have shown that, for families who are given the diagnosis of a disability, satisfaction with disclosure is an important element. Information given and the attitudes of the disclosing health professionals during this critical period have a significant effect on the coping and adaptation of the family. While most studies dealt with conditions involving intellectual disability or cancer, this study was conducted to explore parents' experience of being told that their child had a condition, such as a bone dysplasia, that would result in significant short stature. Semistructured interviews were conducted with 11 families who had children diagnosed with a bone dysplasia, specifically, achondroplasia (n = 9) and pseudoachondroplasia (n = 2). Families were recruited through the Bone Dysplasia Clinic at the Royal Children's Hospital, Victoria, Australia and via contact with the Short Statured People's Association of Victoria. Parents were asked about how they were told of their child's diagnosis, how they would have preferred to have been told, and what would have made the experience less distressing for them. Transcripts of the interviews were analyzed, and major themes were identified relating to the parents' experiences. Our data suggest that the manner in which the diagnosis is conveyed to the parents plays a significant role in their adjustment and acceptance. Provision of written information relating to the condition, possible medical complications, positive outlook for their child's future, and how to find social services and supports were some of the most significant issues for the parents. The multidisciplinary approach of the Bone Dysplasia Clinic was important to parents in the continued management of the families.

Communication in the cancer 'bad news' consultation: patient perceptions and psychological adjustment

The purpose of this study was to explore relationships between breast cancer survivors' experiences during the diagnostic consultation and their subsequent long-term psychological adjustment. Sixty women (M age=53 years) who had been diagnosed with local or regional breast cancer (Stage 0-IIIA) an average of 28 months prior were interviewed by telephone. Measures included: Cancer Diagnostic Interview Scale, Anxiety subscale of the Hospital Anxiety and Depression Scale, Posttraumatic Stress Disorder Checklist - Civilian Version, Center for Epidemiologic Studies Depression Scale, and ad hoc items regarding memory for, and satisfaction with, the diagnostic consultation. After controlling for demographic and clinical variables, the three CDIS subscales accounted for 12% of the variance in women's PCL-C scores (F change=3.46, p<0.05). The CDIS-Caring subscale was a significant predictor in the 'best-fit' regression model for each of the three indices of long-term distress (all B's>-0.23, p<0.05). In contrast, the CDIS-Competence subscale was not a significant predictor in any of the 'best-fit' models. Additionally, women's satisfaction with physician behavior during the diagnostic consultation was unrelated to all adjustment measures (r's<0.10, p's>0.50). Findings suggest that women's perceptions of physicians' interpersonal skills during the diagnostic consultation are associated with later psychological adjustment.

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.

Breaking bad news--development of a hospital-based training workshop

The skills required to break bad news have been written about extensively and are taught in medical schools. Recent initiatives have concentrated on improving the skills of doctors and nurses in senior positions, who act as role models for their junior colleagues. A multiprofessional learning situation can be a threatening environment, in which colleagues may worry about exposing some of the weaknesses in their knowledge and skills regarding communication with patients. We describe the initiation, running, and evaluation of successful training workshops on breaking bad news in a large British district hospital.

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.