A Literature Review of Nurses Challenges and Barriers in Assisting Patients and Families Facing Breaking Bad News

Objectives

Breaking bad news (BBN) is a challenging task for healthcare professionals, including nurses. The manner in which bad news is delivered can have a significant impact on patients and their families, either positive or negative. Understanding the roles, methods, obstacles, and challenges that nurses face in the process of delivering bad news is crucial for improving the quality of the delivery process.

Material and Methods

This narrative review synthesises related studies. The search was conducted through PubMed, Scopus, ScienceDirect and Sage, with no restriction on publication year. The main keywords were 'nurse's challenge', 'nurse's barrier', 'bad news', 'breaking bad news', and 'communicating bad news.' A total of 12 articles were selected from 1075 articles.

Results

Nurses play a key role in BBN before, during and after the process. Their activities include preparing patients to receive bad news, supporting patients and families when doctors deliver bad news and clarifying information obtained by patients and families regarding the prognosis of their illness. Nurses should possess skills such as building interpersonal relationships, therapeutic communication and providing emotional care for patients and their families. The main challenges and barriers for nurses in implementing BBN are due to a lack of skills and unpreparedness for patient and family reactions. After BBN, the most reported roles of nurses were supporting patients and families and helping them understand the information received from doctors. It is essential for nurses to have the necessary skills and preparedness to effectively deliver bad news to patients and their families.

Conclusion

Nurses play a crucial role in delivering bad news to patients and their families. They should be equipped with the necessary skills to effectively communicate with patients and their families during this difficult time. Further training for nurses in therapeutic communication, emotional care for patients and their families, and building interpersonal relationships could help to improve the quality of the delivery process.

Prognostic disclosure and quality of life in palliative care: a systematic review

INTRODUCTION

Prognostic disclosure is an important component of communication in palliative care. Disclosing information on poor prognosis may affect quality of life (QoL) of palliative care patients. However, the effects of prognostic disclosure on QoL across different cultures and countries are unclear.

OBJECTIVE

To review the effects of prognostic disclosure on QoL of palliative care patients.

METHODS

A systematic review was conducted across seven databases (AMED, CINAHL plus, Cochrane Library, Medline (via the PubMed interface), Embase, Scopus and Web of Science). All primary studies, of any design, that explored the effects of prognostic disclosure on QoL of adult palliative care patients were eligible.

RESULTS

A total of 1926 records were screened for eligibility. Twenty-five articles were included (11 cross-sectional, 10 cohort, 3 mixed methods and 1 qualitative study). Studies were conducted in 11 countries. Five studies reported the sources of prognostic disclosure, while 20 studies did not. Emotional QoL was the most reported domain among the studies. The effects of prognostic disclosure on emotional aspects, overall QoL and other domains, including symptoms, physical functions, role functions, social functions and cognitive functions, were inconsistent.

CONCLUSIONS

The effects of prognostic disclosure on QoL across cultures and countries are inconsistent. Cultural differences are not sufficient to explain the effects. Future research is needed to explore the association between prognostic disclosure and QoL, and develop tools to support clinicians to share prognostic information in the most sensitive and supportive way.

Single cases from multiple perspectives: a qualitative study comparing the experiences of patients, patients' caregivers, surgeons, and nurses when bad news is delivered about cancer

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Background:

Qualitative literature on the experiences of those delivering and receiving bad news about cancer has revealed what these parties consider important during the process across many different patient cases. The current study aims to add to this understanding by employing a “linked case" study design to directly compare the perspectives of patients, their caregivers, and health care professionals (HCPs) involved in a series of single-patient cases of breaking bad news.

Method:

Semistructured interviews were conducted with 13 participants (5 patients, 4 caregivers, 2 surgeons, and 2 nurses) who formed 5 linked cases. Interviews were analyzed using interpretative phenomenological analysis and directly compared within each linked case.

Results:

Analyses identified 2 main superordinate themes. The first labeled “accurately perceiving and responding to needs," included HCPs recognizing and responding to patients’ and caregivers’ individual emotional and informational needs. The second labeled “carers fulfilling necessary roles," identified the various roles HCPs and patients’ caregivers took to satisfactorily meet patients’ needs.

Conclusions:

The findings suggest the importance of HCPs accurately perceiving and responding to patients’ and caregivers’ various needs and caregivers ability and willingness to fulfilling support roles in a way that aligns with their own resources and patients’ needs. This highlights the value of HCPs developing and applying interpersonal skills within bad news encounters, working as a team, and exploring caregivers’ resources for patient support.

The experiences of patients and their family members when receiving bad news about cancer: A qualitative meta-synthesis

OBJECTIVE

This qualitative meta-synthesis explored the subjective experiences of patients and their family members when receiving bad news about cancer, with a focus on what was important to them during this process and making future recommendations.

METHODS

A search of five electronic databases yielded 587 different records that resulted in 88 articles assessed against the inclusion/exclusion criteria. With the supplement of four additional records, 29 articles were analysed using thematic synthesis. A quality appraisal checklist was used to provide further information about the included articles.

RESULTS

Patients and family members experienced receiving bad news as a process that involved three phases, labelled as follows: "preparation", "delivery", and "adjusting and coping". The "preparation" phase had four themes: the setting, developing a relationship, knowing the patient, and forewarning. Four themes were identified during the "delivery" phase: emotional reactions, empathy not sympathy, active participation, and understanding. "Adjusting and coping" comprised four themes: hope, holistic support, being a protector, and ongoing relationships.

CONCLUSIONS

Receiving bad news is a significant experience for patients and family members. They want bad news delivered in an appropriate setting, in a manner consistent with their personal preferences, and have their psychological needs attended to within the context of an established relationship. Healthcare professionals can be assisted to deliver bad news in the best way possible by additional training and their workplace institutions providing quiet, private rooms, and sufficient time. Future research is needed to better understand family members' experiences and needs.

Sharing news of a lung cancer diagnosis with adult family members and friends: a qualitative study to inform a supportive intervention

OBJECTIVE

Extensive research exists on breaking bad news by clinicians. This study examines perspectives of patients and those accompanying them at diagnosis-giving of subsequently sharing news of lung cancer with adult family/friends, and views of healthcare professionals, to inform development of a supportive intervention.

METHODS

Qualitative interviews with 20 patients, 17 accompanying persons; focus groups and interviews with 27 healthcare professionals from four Thoracic Oncology Units. Intervention development workshops with 24 healthcare professionals and six service users with experience of sharing a cancer diagnosis. Framework thematic analysis.

RESULTS

Patients and accompanying persons shared news of lung cancer whilst coming to terms with the diagnosis. They recalled general support from healthcare professionals but not support with sharing bad news. Six elements were identified providing a framework for a potential intervention: 1-people to be told, 2-information to be shared, 3-timing of sharing, 4-responsibility for sharing, 5-methods of telling others and 6-reactions of those told.

CONCLUSION

This study identifies the challenge of sharing bad news and a potential framework to guide delivery of a supportive intervention tailored to individual needs of patients.

PRACTICE IMPLICATIONS

The identified framework could extend the portfolio of guidance on communication in cancer and potentially in other life-limiting conditions.

Balancing a changed life situation: the lived experience from next of kin to persons with inoperable lung cancer

The purpose of this study was to identify and describe the experiences of quality of life/life situation among those who were next of kin to persons with inoperable lung cancer. Data were collected in qualitative interviews, where 11 next of kin articulated their lived experiences, and were interpreted through interpretive phenomenology. Four themes were identified: changed life situation, experiences of uncertainty due to awareness of the ill person's changed health status, interpersonal relationships, and false hopes due to health care professionals' treatment. These four themes gave a structure presenting the essence: balancing a changed life situation. The findings of the study point out the importance of promoting support for the next of kin, because they are significantly affected by the changed life situation. There is a need to identify their needs and to support them.

Living with gynecologic cancer: experience of women and their partners

PURPOSE

To describe the experiences of Turkish women with gynecologic cancer and their partners.

DESIGN AND METHODS

Qualitative research using a descriptive phenomenological approach.

SETTING

Gynecologic oncology outpatient clinic of the Gulhane Military Medical Academy in Ankara, Turkey. Nineteen women with gynecologic cancer aged 43-70 years and 12 partners aged 46-73 years were recruited. Data were obtained through open-ended and in-depth, audio-taped interviews which lasted approximately 35-45 minutes each.

FINDINGS

Seven themes emerged from the participants' description of their experience: (a) experiences during the diagnosis period; (b) experiences during the treatment period; (c) the effect of cancer on family life; (d) changes in daily life; (e) coping methods and support sources; (f) the meaning of illness; and (g) experiencing the illness as a woman.

CONCLUSIONS

Receiving the diagnosis of gynecologic cancer was remembered as a very dramatic experience. The women and partners reported many physical and psychosocial difficulties relating to the treatment period. Healthcare professionals must understand and recognize cancer patients' and their partners' experiences to provide appropriate holistic care.

CLINICAL RELEVANCE

Nurses can only provide effective and comprehensive nursing care to gynecologic cancer patients and their families if they fully understand the physical, emotional, social, and spiritual experiences in their lives.

Disclosure of Incurable Illness to Spouses: Do They Want to Know? A Swedish Population-Based Follow-Up Study

Purpose

Awareness of the cancer patient's terminal state decreases the risk of psychological morbidity of the bereaved. We wanted to determine whether male spouses of cancer patients who died from their disease had received information that the illness was incurable and to determine their preferences of disclosure.

Participants and Methods

The study included 907 widowers whose wives had died of cancer. In an anonymous questionnaire, we asked whether the widower had received information that his wife's illness was incurable and about his attitudes towards receiving this information.

Results

Six hundred ninety-one widowers (76%) participated. Eighty percent of the widowers reported that they were told that the wife's cancer was incurable, and 21% reported that they had been informed within 1 week before the patient's death. Although 14% of the widowers did not think the next of kin should be told immediately when the patient's cancer is beyond cure, 39% of the men did not want the patient to be immediately informed. Furthermore, 71% of the men who were never informed about the incurable illness believed that the next of kin should receive that information immediately.

Conclusion

Although a large majority of men prefer an immediate disclosure about the incurable stage of their wife's illness, 41% of the husbands received this information during the last week of the patient's life or not at all. These findings indicate that there is room for improvement in the level of communication between health providers and the husbands of women with incurable cancer.

Can the caregiver replace his/her elderly cancer patient in the physician-patient line of communication?

GOALS OF WORKS: Only few studies have focussed on the information needs of senior cancer patients. The aim of this study was to evaluate to what extent caregivers perceive their elderly cancer patients' informational needs.

MATERIALS AND METHODS

Between June 2004 and February 2005, at the National Cancer Institute of Aviano (northern Italy), we asked 112 elderly cancer patients naïve for treatments (age >65 years) and their 112 accompanying family members to fill in a self-administered questionnaire exploring the patient's information needs and his/her information-seeking behaviour.

MAIN RESULTS

Elderly patients (60 males and 52 females, mean age 72 years) were mostly affected by genital-urinary (27%) or breast/gynaecological (25%) cancer. Caregivers were usually females (71%), daughters/sons (45%) and/or partners (41%). The interobserver agreement for the information request regarding cancer diagnosis and disease management, for the selected information sources consulted to acquire knowledge and for the reasons for seeking further information between the elderly patients and their caregivers were unsatisfactory to poor.

CONCLUSIONS

Our results show that caregivers misunderstand the informational needs of their patients. Therefore, elderly patient information preferences cannot be predicted accurately by talking to relatives. The recommendation to oncologists is to be more responsive to the needs of both elderly cancer patients and their family members.

ALS patients and caregivers communication preferences and information seeking behaviour

To evaluate information preferences and information seeking behaviour in ALS patients and caregivers. Sixty ALS patients and caregivers couples were interviewed using a structured questionnaire about the content of diagnosis communication and their information seeking behaviour. The patients (35 men and 25 women) had a mean age of 63.4 years (SD 9.5). The caregivers (21 men and 39 women) had a mean age of 53.3 years (SD 14.9). The overall satisfaction with bad news communication and the impression that the physician had understood their feelings were higher amongst patients. Both parties indicated that the most important aspects to be informed were current researches, disease-modifying therapies and ALS outcome. Approximately 55% of patients and 83.3% of caregivers searched for information from sources outside the healthcare system. The most frequently checked source was internet, although its reliability was rated low. The caring neurologist should better attune the content of communication to patients' and caregivers' preferences, trying to understand what they want to know and encouraging them to make precise questions. Health professionals should be aware that ALS patients and caregivers often use internet to obtain information and should help them to better sort-out and interpret the news they found.

Collaborative communication in pediatric palliative care: a foundation for problem-solving and decision-making

In an ideal world, all of us - patients, parents, family members, nurses, physicians, social workers, therapists, pastoral care workers, and others - would always work together in a collaborative manner to provide the best care possible. This article bases the framework for this ideal upon studies of communication between patients, families, and clinicians, as well as more general works on communication, collaboration, decision-making, mediation, and ethics, and is comprised of four parts: what is meant by collaborative communication; key concepts that influence how we frame the situations that children with life-threatening conditions confront and how these frameworks shape the care we provide; general topics that are important to the task of collaborative communication, specifically how we use heuristics when we set about to solve complicated problems; and three common tasks of collaborative communication, offering practical advice for patient care.

Truth-telling in discussing prognosis in advanced life-limiting illnesses: a systematic review

Many health professionals (HPs) express discomfort at having to broach the topic of prognosis, including limited life expectancy, and may withhold information or not disclose prognosis. A systematic review was conducted of 46 studies relating to truth-telling in discussing prognosis with patients with progressive, advanced life-limiting illnesses and their caregivers. Relevant studies meeting the inclusion criteria were identified by searching computerized databases (MEDLINE, EMBASE, CINAHL, PsychINFO and Cochrane Register of Controlled Trials) up to November 2004, with handsearching of studies, as well as inclusion of studies satisfying selection criteria reported in 2005 by the authors. The reference lists of identified studies were hand-searched for further relevant studies. Inclusion criteria were studies of any design evaluating communication of prognostic information that included adult patients with an advanced, life-limiting illness; their caregivers; and qualified HPs. Results showed that although the majority of HPs believed that patients and caregivers should be told the truth about the prognosis, in practice, many either avoid discussing the topic or withhold information. Reasons include perceived lack of training, stress, no time to attend to the patient's emotional needs, fear of a negative impact on the patient, uncertainty about prognostication, requests from family members to withhold information and a feeling of inadequacy or hopelessness regarding the unavailability of further curative treatment. Studies suggest that patients can discuss the topic without it having a negative impact on them. Differences and similarities in findings from different cultures are explored.

Existential Loneliness in a Palliative Home Care Setting

BACKGROUND

The diagnosis of an incurable disease implies an existential crisis. This study focused on the emotions, perceptions, and experiences of existential isolation in palliative patients with cancer and their families.

MATERIALS AND METHODS

A total of 40 respondents (20 patients and 20 family members) were interviewed in depth. All were Swedes who defined themselves as nonreligious. The patients were enrolled in an advanced hospital-based home care team. The interviews were taped, transcribed, and analyzed with a qualitative, hermeneutic method.

RESULTS

The data revealed experiences of existential loneliness with the impending death as a primary source. Experiences of being alone in "a world of one's own" were common. The changes in everyday life and the increasingly restricted social interaction because of the illness meant that the patient partly lost the protection against isolation that the spirit of community normally provides. Other situations that had a triggered the existential isolation were, for example, when a patient in need of support was left alone, when he or she was treated disrespectfully or in a way that made him or her feel invisible, or when people avoided contact because of uneasiness or fear. Changes in one's own body and mood gave rise to feelings of loneliness and unfamiliarity toward oneself. When a staff member touched the patient's body in a nonempathic way, this could induce feelings of being treated like an animal.

Relatives in end-of-life care--part 1: a systematic review of the literature the five last years, January 1999-February 2004

AIM

To review systematically research conducted during the past five years focusing on the relatives' situation and needs in end-of-life care.

BACKGROUND AND AIM

That relatives make a large contribution in the care of the dying is well-known. In this situation, relatives often have to solve many new practical problems in the care as well as dealing with the sorrow of both themselves and the dying person. In recent years, palliative care has been developed in many countries and many new studies have been carried out.

METHODS

A systematic search of the literature was performed in the CINAHL and Medline databases. Of the 94 papers analysed, there were 59 qualitative and 35 quantitative studies with differing designs. The studies were carried out in 11 countries and were published in 34 different journals.

RESULTS

The results were categorized in two main themes with several subthemes: (1) being a close relative--the situation: (i) exposed position--new responsibility, (ii) balance between burden and capacity and (iii) positive values; (2) being a close relative--needs: (i) good patient care, (ii) being present, (iii) knowing and communicating and (iv) support from and trusting relationship with the professional. The relative's feelings of security and trust in the professional were found to be of great importance.

CONCLUSION

More than twice as many studies had a descriptive/explorative design, which is of importance in the assessment of evidence. However, different studies complement one another and in summary, it can be said that analytic evidence is unequivocal: good patient care, communication, information and the attitude of the professional are of decisive importance regarding relatives' situation. These results are also in accord with earlier review studies.

RELEVANCE TO CLINICAL PRACTICE

Staff members have a great deal of responsibility for assuring that the patient feels as good as possible, facilitating relatives' involvement based on the family's wishes and limiting the stress and difficulties experienced by the family. The results showed that the relative's satisfaction could depend on the attitude of the professional as well as on good communication, good listening and good information. This can also be viewed as a prerequisite for the professional to get to know the family and to provide 'care in the light'.

Care at the end of life in critically ill patients: the European perspective

PURPOSE OF REVIEW

Care surrounding end-of-life has become a major topic in the intensive care medicine literature. Cultural and regional variations are associated with transatlantic debates about decisions to forego life-sustaining therapies and lead to recent international statements. The aim of this review is to provide insight into the decisions to forego life sustaining therapies and end-of-life care in Europe.

RECENT FINDINGS

Although decisions to forego life-sustaining therapies are increasingly made in European countries, frequency and characteristics of end-of-life care are still heterogeneous. Moreover, even though many determinants of these variations have been identified, epidemiologic and interventional studies still provide additional information. In agreement with public opinions, recent European laws have emphasized the patient's autonomy. In real life, advance care planning is rarely used. Decisions are often made by caregivers (physicians and nurses) or families, these latter being less involved than in North America. Not only ethic divergences between physicians but also cultural variations account for this disparity.

SUMMARY

To optimize end-of-life care in the intensive care unit, there is an urgent need for the development of palliative and multidisciplinary care in Europe. Furthermore, it highlights the need for culturally competent care, adapted to needs and values of every single patient and family. In addition, a lack of communication with families and within the medical team, an uninformed public about end-of-life issues, and insufficient training of intensive care unit staff are crucial barriers to end-of-life care development. Special awareness of professionals and innovative research are needed to promote a high-standard of end-of-life care in the intensive care unit.

The needs of terminally ill cancer patients versus those of caregivers for information regarding prognosis and end-of-life issues

BACKGROUND

The difficulty of negotiating the concerns of family members while also respecting the needs of the patient adds complexity to the task of discussing prognosis and end-of-life (EOL) issues with terminally ill cancer patients. The informational needs of caregivers may be different from those of the patients themselves with regard to these topics. However, to the authors' knowledge, this issue has received relatively little research attention.

METHODS

The authors conducted focus groups and individual interviews with 19 patients with far advanced cancer and 24 caregivers from 3 palliative care (PC) services in Sydney and 22 PC health professionals (HPs) from around Australia. The focus groups and individual interviews were audiotaped and fully transcribed. Additional focus groups or individual interviews were conducted until no additional topics were raised. The participants' narratives were analyzed using qualitative methodology.

RESULTS

The participants had varying views regarding whether patients and caregivers should be told different information concerning prognosis and EOL issues. Three themes were identified from the transcripts regarding meeting the informational needs of both the patients and caregivers: 1) the importance of consistency and openness, 2) the specific information needed to care for the patient, and 3) the value of having separate discussions with the patient and caregiver. A desire to restrict the patient's access to information by the caregiver or vice versa was reported by the HPs to be one of the most challenging issues when discussing prognosis and EOL issues. Three themes were identified with regard to this issue: 1) autonomy versus protection, 2) negotiating family dynamics, and 3) difficulty using interpreters.

CONCLUSIONS

The results of the current study emphasized the importance of considering the distinct informational needs of caregivers, as well as those of the patient, when discussing prognosis and EOL issues.

Family-physician interactions in the intensive care unit

Surrogate designation has the potential to represent the patient's wishes and promote successful family involvement in decision making when options exist as to the patient's medical management. In recent years, intensive care unit physicians and nurses have promoted family-centered care on the basis that adequate and effective communication with family members is the key to substitute decision making, thereby protecting patient autonomy. The two-step model for the family-physician relationship in the intensive care unit including early and effective provision of information to the family followed by family input into decision making is described as well as specific needs of the family members of dying patients. A research agenda is outlined for further investigating the family-physician relationship in the intensive care unit. This agenda includes a) improvement of communication skills for health care workers; b) research in the area of information and communication; c) interventions in non-intensive care unit areas to promote programs for teaching communication skills to all members of the medical profession; d) research on potential conflict between medical best interest and the ethics of autonomy; and e) publicity to enhance society's interest in advance care planning and surrogate designation amplified by debate in the media and other sounding boards. These studies should focus both on families and on intensive care unit workers. Assessments of postintervention outcomes in family members would provide insights into how well family-centered care matches family expectations and protects families from distress, not only during the intensive care unit stay but also during the ensuing weeks and months.

Justification for information and knowledge: Perceptions of family members in palliative home care in Sweden

Objective: Several studies have concluded that family members in palliative home care want information about the patient's disease. The aim of this study was to describe family members' perceptions of their motivation for receiving information about the patient's disease.

Method:Semistructured tape-recorded interviews were performed with 20 family members of patients with incurable progressive cancer who were admitted to hospital-based home care in Sweden. Data were analyzed using a qualitative phenomenographic method.

Results:Family members justified their informational needs by emphasizing that they needed to understand and confirm what would happen when the disease progressed, to be mentally prepared for the future, to organize their daily life, to be a source of information to others, and that receiving information was a natural right.

Significance of results:This study has revealed some explanations as to why family members want information. In clinical practice, it is important that palliative care team members are aware of family members' level of knowledge and their need for information, as this mental preparation is important.

Communication with family members of patients dying in the intensive care unit

In intensive care units the patient is usually unconscious and/or incompetent so that the relationship shifts to the family. Interactions between caregivers and families usually follow one of three models. In the first model, a family representative receives information from the caregivers but does not participate in decisions or physical care. In the second model, the ICU caregivers attempt to provide care consistent with the patient's wishes and values as described by the family. In the third model, the family members communicate their own wishes, provide physical care to the patient, and participate in medical decision-making. After a description of the studies that measured the quality of information provided to ICU families and by discussing the extent to which respecting the principle of patient autonomy is feasible in the ICU, we will review the literature on studies that identified specific needs of families of dying patients and specific challenges faced by intensivists as they seek to inform the families of dying patients. The need for family-centered care and for a better communication within the patient-family-caregiver trio is also highlighted.