The Use of Expectancy and Empathy When Communicating With Patients With Advanced Breast Cancer; an Observational Study of Clinician-Patient Consultations

Physician-dominated conversations: An analysis of illness understanding discussions among patients with advanced cancer

CONTEXT

Effective communication between patients and oncologists is crucial, particularly around illness understanding. When this communication is asymmetric or imbalanced, it can hinder shared decision-making and lead to suboptimal clinical outcomes.

OBJECTIVES

We sought to describe physician-patient speech imbalances ("asymmetry") in illness understanding portions of discussions between oncologists and advanced cancer patients and explore potential trends related to patient characteristics.

METHODS

Our study included 285 audio recordings of outpatient encounters between 40 oncologists and 139 patients with advanced cancer. We identified illness understanding communication via manual data annotation and analyzed clinician-patient speech ratios. For this project, a communication outcome of "asymmetry" was defined as taking place when one party spoke more than 60 % of all spoken characters related to illness understanding in the conversation. We used descriptive statistics to report frequency of asymmetric conversations by patient characteristics. We then examined whether certain patient characteristics were associated with presence of at least one asymmetric illness understanding discussion as a categorical variable.

RESULTS

At the conversation level, 77 % of all illness understanding discussions were asymmetric and clinician-dominated. At the patient level, 89 % experienced asymmetric illness understanding communication. We found that non-Hispanic white patients experienced a lower rate of asymmetry across their conversations compared to patients from other racial and ethnic backgrounds (73 % of conversations vs. 82 %).

CONCLUSIONS

Asymmetric, clinician-dominated communication was prevalent in illness understanding discussions.

PRACTICE IMPLICATIONS

Communication balances may be a relevant factor driving disparities in cancer care. Strategies are needed to address communication imbalances in serious illness conversations and enhance communication education.

Empathic Communication and Implicit Bias in the Context of Cancer Among a Medical Student Sample

Oncology clinicians often miss opportunities to communicate empathy to patients. The current study examined the relationship between implicit bias (based on cancer type and ethnicity) and medical students' empathic communication in encounters with standardized patients who presented as Hispanic (lung or colorectal) individuals diagnosed with cancer. Participants (101 medical students) completed the Implicit Association Test (IAT) to measure implicit bias based on cancer type (lung v. colorectal) and ethnicity (Hispanic v. non-Hispanic White). Empathic opportunities and responses (assessed by the Empathic Communication Coding System; ECCS) were evaluated in a mock consultation (Objective Structured Clinical Examination; OSCE) focused on smoking cessation in the context of cancer. Among the 241 empathic opportunities identified across the 101 encounters (M = 2.4), 158 (65.6%) received high empathy responses from the medical students. High empathy responses were most frequently used during challenge (73.2%) and emotion (77.3%) opportunities compared to progress (45.9%) opportunities. Higher levels of implicit bias against Hispanics predicted lower odds of an empathic response from the medical student (OR = 3.24, p = .04, 95% CI = 0.09-0.95). Further work is needed to understand the relationship between implicit bias and empathic communication and inform the development of interventions.

Optimizing placebo and minimizing nocebo effects through communication: e-learning and virtual reality training development

BACKGROUND

The effects of many treatments in healthcare are determined by factors other than the treatment itself. Patients' expectations and the relationship with their healthcare provider can significantly affect treatment outcomes and thereby play a major role in eliciting placebo and nocebo effects. We aim to develop and evaluate an innovative communication training, consisting of an e-learning and virtual reality (VR) training, for healthcare providers across all disciplines, to optimize placebo and minimize nocebo effects through healthcare provider-patient communication. The current paper describes the development, mid-term evaluation, optimization, and final evaluation of the communication training, conducted in The Netherlands.

METHODS

The development of both the e-learning and the VR training consisted of four phases: 1) content and technical development, 2) mid-term evaluation by healthcare providers and placebo/communication researchers, 3) optimization of the training, and 4) final evaluation by healthcare providers. To ensure the success, applicability, authenticity, and user-friendliness of the communication training, there was ongoing structural collaboration with healthcare providers as future end users, experts in the field of placebo/communication research, and educational experts in all phases.

RESULTS

Placebo/communication researchers and healthcare providers evaluated the e-learning positively (overall 7.9 on 0-10 scale) and the content was perceived as useful, accessible, and interesting. The VR training was assessed with an overall 6.9 (0-10 scale) and was evaluated as user-friendly and a safe method for practicing communication skills. Although there were some concerns regarding the authenticity of the VR training (i.e. to what extent the virtual patient reacts like a real patient), placebo and communication researchers, as well as healthcare providers, recognized the significant potential of the VR training for the future.

CONCLUSIONS

We have developed an innovative and user-friendly communication training, consisting of an e-learning and VR training (2D and 3D), that can be used to teach healthcare providers how to optimize placebo effects and minimize nocebo effects through healthcare provider-patient communication. Future studies can work on improved authenticity, translate the training into other languages and cultures, expand with additional VR cases, and measure the expected effects on providers communication skills and subsequently patient outcomes.

Physician Empathy in Doctor-Patient Communication: A Systematic Review

Physician empathy is at the heart of doctor-patient communication and significantly influences patient outcomes. However, the research on how physicians express their empathy and how physician empathy affects patient outcomes and doctor-patient communication has not been well summarized in the latest literature. Thus, we conducted a systematic review to synthesize existing studies on physician empathy and its value to patient outcomes and doctor-patient communication. The systematic review consisted of studies published in English peer-reviewed journals between January 2017 and October 2021. Following the PRISMA procedure, a total of 3055 articles were retrieved, and 11 articles were retained. The thematic analysis revealed three emergent themes: physicians' empathic expressions; patient outcomes (patient functional status, patient safety, and patient satisfaction); and empathy enhancing doctor-patient communication. This study highlighted the different ways empathy may be expressed by physicians and its positive effects on patient outcomes and doctor- patient communication. This study also suggested the under-researched areas that can be expanded in the future.

Timing of prognostic discussions in people with advanced cancer: a systematic review

PURPOSE

Many people with cancer (patients) want to know their prognosis (a quantitative estimate of their life expectancy) but this is often not discussed or poorly communicated. The optimal timing of prognostic discussions with people with advanced cancer is highly personalised and complex. We aimed to find, organise, and summarise research regarding the timing of discussions of prognosis with people with advanced cancer.

METHODS

We conducted a systematic review of publications from databases, clinical practice guidelines, and grey literature from inception to 2023. We also searched the reference lists of systematic reviews, editorials, and clinical trial registries. Eligibility criteria included publications regarding adults with advanced cancer that reported a timepoint when a discussion of prognosis occurred or should occur.

RESULTS

We included 63 of 798 identified references; most of which were cross-sectional cohort studies with a range of 4-9105 participants. Doctors and patients agreed on several timepoints including at diagnosis of advanced cancer, when the patient asked, upon disease progression, when there were no further anti-cancer treatments, and when recommending palliative care. Most of these timepoints aligned with published guidelines and expert recommendations. Other recommended timepoints depended on the doctor's clinical judgement, such as when the patient 'needed to know' or when the patient 'seemed ready'.

CONCLUSIONS

Prognostic discussions with people with advanced cancer need to be individualised, and there are several key timepoints when doctors should attempt to initiate these conversations. These recommended timepoints can inform clinical trial design and communication training for doctors to help improve prognostic understanding.

The influence of "bad news" and "neutral/good news" on patients' perception of physician empathy during oncology consultations

OBJECTIVES

Being met with empathy increases information sharing, treatment coherence, and helps patients to recover faster. However, we do not know how the content of the conversation about disease progression, new treatments, or other issues concerning serious illness affects patients' perceptions of the physician's empathy, and thus, the quality of the conversation. This study aimed to test the hypothesis that patients will rate their physician lower following a "bad news" consultation using the consultation and relational empathy (CARE) measure.

METHODS

A total of 186 outpatients from the Department of Oncology were recruited for this study. After meeting with a patient, the physician filled out a form, placing the patient in either the "bad news" group, or the "neutral/good news" group along with information about the patient and the consultation. The patient was given the CARE measure after the visit.

RESULTS

The patients who had received bad news rated their physicians a significantly lower score on the CARE measure, even though the effect size was small, than those who had neutral/good news. On average, bad news consultations were 11 min longer.

CONCLUSIONS

Physicians need to be aware of the patients' need to be known and understood, in addition to having skills to attend to emotional cues and concerns, since the current study's finding could be a sign either of the content being projected onto the physician or that the physician is focused on the message rather than on the patient.

Harmful communication behaviors in cancer care: A systematic review of patients and family caregivers perspectives

OBJECTIVE

Issues regarding clinician communication remain an important source of complaints within healthcare. This systematic review aims to determine cancer patients' and their family caregivers' views on which clinicians' communication behaviors can harm (i.e. eliciting negative feelings/consequences for patients/family caregivers).

METHODS

We searched for all types of peer-reviewed studies that determined adult (≥18 years) cancer patients' and/or family caregivers' perspectives on which clinicians' communication behaviors can harm in several databases (PubMed, Embase, Web of Science, Cochrane Library, Emcare, PsycINFO and Academic Search Premier), supplemented by expert-consultation. Studies were screened using the Artificial intelligence screening tool of ASReview and data was analyzed using Thematic Analysis. To assess the quality of the studies the Qualsyst critical appraisal tool was used.

RESULTS

A total of 47 studies were included. Four main themes of harmful communication behaviors were identified: (1) Lack of tailored information provision (e.g. giving too little or too much/specific information) (2) Lack of tailored decision making (ranging from; patient exclusion, to the patients' responsibility, and/or haste) (3) Lack of feeling seen and heard (seen as a disease, not as a human being; not listened to concerns and emotions) (4) Lack of feeling held and remembered (forgotten agreements; lack of care continuity).

CONCLUSIONS

Our results reveal an overview of patients' and family caregivers' perspectives on which clinicians' communication behaviors can harm. Harm could be prevented when information and decision involvement are tailored and patients' and family caregivers' needs to feel seen, heard, held and remembered are met.

Consumer experiences of shame in clinical encounters for breast cancer treatment. "Who do you think you are- Angelina Jolie?"

BACKGROUND

Shame is a powerful negative emotion that has the potential to affect health. Due to the intimate nature of breast cancer treatment and its impact on body image, it is hypothesised that shame may be experienced during treatment. The aim of this study was to explore shame experiences related to clinical encounters for breast cancer treatment.

METHODS

People with a lived experience of breast cancer were invited to anonymously share their stories of shame through an online survey. Using qualitative methodology, the stories were examined, and themes identified.

PARTICIPANTS

Participants were members of the consumer organisation Breast Cancer Network Australia.

RESULTS

Stories were contributed by 38 participants. Most (n = 28, 73.7 %) were >5 years post-diagnosis. Shame was experienced in a range of clinical settings (consulting rooms, wards, operating theatres, radiotherapy departments). They involved a different health professionals (oncologists, surgeons, nurses, radiation therapists, psychologists.) Five themes were identified: (1) Body shame (sub-themes: Naked/vulnerable and Weight), (2) Communication (subthemes: Lack of compassion/impersonal manner and Not listening), (3) Being blamed (subthemes: diagnosis and complications), (4) Feeling unworthy (subthemes: Burden to staff and Unworthy of care), (5) Judgement for treatment choices.

CONCLUSIONS

Shame can be experienced in a range of situations, from scrutiny of the naked body to comments from health professionals. The impact of these experiences is profound, and the feelings of shame are carried for many years. These findings can inform strategies to support consumers and educate health professionals with the aim of reducing harm related to cancer treatment.

Good versus bad news consultations in advanced breast cancer: the role of empathy in information recall - an observational study

OBJECTIVE

We explored, in advanced breast cancer, whether: (1) patients recall less information following bad versus good news consultations; (2) empathy has a greater effect on recalled information following bad versus good news consultations.

METHODS

Observational study using audio-recorded consultations. Participants' recall of provided information about treatment options, aims/positive effects and side-effects was assessed. Clinician-expressed empathy and consultation type were determined. Regression analyses assessed associations between consultation type and recall, exploring moderating influences of clinician-expressed empathy.

RESULTS

For 41 consultations (18 bad news, 23 good news), recall data were completed; total recall (47% vs 73%, p=0.03) and recall about treatment options (67% vs 85%, p=0.08, trend) were significantly worse following bad news compared with good news consultations. Recall about treatment aims/positive effects (53% vs 70%, p=0.30) and side-effects (28% vs 49%, p=0.20) was not significantly worse following bad news. Empathy moderated the relationship between consultation type and total recall (p<0.01), recall about treatment options (p=0.03) and about aims/positive effects (p<0.01) but not about side-effects (p=0.10). Only following good news consultations empathy influenced recall favourably.

CONCLUSIONS

This explorative study suggests that in advanced cancer, information recall is especially impaired following bad news consultations, for which empathy does not improve remembered information.

How is complementary medicine discussed in oncology? Observing real-life communication between clinicians and patients with advanced cancer

OBJECTIVE

This study aims to examine the structure of communication about complementary medicine (CM) between patients with cancer and clinicians during oncology consultations.

METHODS

Previously, consultations between 29 clinicians and 80 patients with advanced cancer were recorded in six hospitals in the Netherlands. The present study considers a secondary analysis. References to CM during the consultation were coded using a self-developed observational coding scheme.

RESULTS

At least one reference to CM was observed in 35 out of 80 consultations (44 %), with a total of 73 references. In most cases, CM was initially referred to by patients. Clinicians often did not elaborate on the subject of CM. Relevant aspects related to CM (e.g., safety, effectiveness) were infrequently discussed. Both patients and clinicians showed predominantly neutral to positive attitudes towards CM.

CONCLUSIONS

This study shows that patients are still the main initiators of discussions about CM and the topic is not consistently discussed in daily oncology practice.

PRACTICE IMPLICATIONS

If exploration of patients' interest in CM or its use became routine in oncology practice, it may relieve patients of the burden of introducing the topic, decrease potential risks of CM use and increase access to evidence-based CM for all patients with cancer.

Possible alleviation of symptoms and side effects through clinicians' nocebo information and empathy in an experimental video vignette study

To alleviate anti-cancer treatment burden in advanced breast cancer, patient-clinician communication strategies based on nocebo-effect mechanisms are promising. We assessed distinct/combined effects on psychological outcomes (e.g. anxiety; main outcome) and side-effect expectations of (1) nocebo information about the (non)pharmacological origin of side effects, and (2) clinician-expressed empathy through reassurance of continuing support. Furthermore, we explored whether information and empathy effects on side-effect expectations were mediated by decreased anxiety. In a two-by-two experimental video-vignette design, 160 cancer patients/survivors and healthy women watched one of four videos differing in level of nocebo information (±) and empathy (±). Regression and mediation analysis were used to determine effects of information/empathy and explore anxiety's mediating role. Anxiety was not influenced by empathy or information (Stai-state: p = 0.295; p = 0.390, VAS p = 0.399; p = 0.823). Information improved (specific) side-effect coping expectations (p < 0.01). Empathy improved side-effect intensity expectations (p < 0.01 = specific; p < 0.05 = non-specific/partial) and specific side-effect probability expectations (p < 0.01), and increased satisfaction, trust, and self-efficacy (p < 0.001). No mediating effects were found of anxiety on expectations. Mainly empathy, but also nocebo information improved psychological outcomes and-mainly specific-side-effect expectations. Exploring the power of these communication elements in clinical practice is essential to diminish the anti-cancer treatment burden in advanced breast cancer.

Breast cancer and communication: monocentric experience of a self-assessment questionnaire

Background: The communication of the diagnosis of breast cancer induces to the patient a strong psychological trauma. Radiologists are at the forefront of communicating, either for a biopsy or the probable diagnosis of malignancy. This is a complex task, which requires the knowledge and application of correct “communicative models”, among which the SPIKES protocol represents a fundamental reference.

Design and methods: 110 patients, with a history of breast cancer, filled out a questionnaire consisting of six questions: five aimed at defining communication compliance with the SPIKES protocol, the sixth, consisting of six feelings, aimed at the knowledge of the next emotional state.

Results: Regarding compliance with various “strategic points” of the SPIKES protocol, questionnaires show that 70% of patients reported no omissions, while the remaining 30% reported omissions relatively to perception (56%), emotions (23%), setting (13%), knowledge (6%) and invitation (2%). The results showed the existence of a correlation between the final emotional state and the correct application of the SPIKES protocol; in fact, patients who reacted with a positive final emotional state-reported greater adherence to the strategic points of the SPIKES protocol.

Conclusions: In healthcare, knowing the communicative compliance of a team in giving “bad news” is fundamental, especially in breast cancer. The SPIKES protocol is recognized by the Literature as a fundamental reference able to affect “positively” the emotional state of patients. The proposed questionnaire is a valid tool to identify the weak points of communication and related criticalities, to improve clinical practice.

Nocebo effect in health communication: how to minimize it?

ABSTRACT Purpose: to describe the strategies used to minimize the nocebo effect in health communication. Methods: an integrative review of the literature. The keywords “nocebo effect” and “health communication” and their combinations were used in English, Portuguese, and Spanish to search publications from 2011 to 2021 in MEDLINE, Latin American and Caribbean Health Sciences Literature (LILACS), Cochrane Library, EMBASE, and Web of Science/ISI. The following research question was used: “Which strategies have been used to minimize the nocebo effect in health communication?”. Literature Review: altogether, 77 articles were found, although only six met the inclusion criteria and comprised the review sample. Their year of publication ranged from 2015 to 2021. Positive framing, assertive communication, and contextual factors were the strategies used to minimize the nocebo effect. Conclusion: the strategies used to minimize the nocebo effect were contextual factors, motivational talk, positive framing, assertive communication, and empathetic communication. These communication techniques are seemingly effective, though still little known by health professionals. This knowledge is important as it helps develop communicative skills aiming at humanized patient care.

Efeito nocebo na comunicação em saúde: como minimizá-lo?

RESUMO Objetivo: descrever as estratégias para minimizar o efeito nocebo na comunicação em saúde. Métodos: trata-se de uma revisão integrativa da literatura. Os descritores utilizados foram: “Efeito nocebo” e “comunicação em saúde”, em inglês, português e espanhol e suas combinações, no período de 2011 a 2021, nas bases de dados da Medline, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Cochrane Library, Embase e Web of Science/ISI. A pergunta de investigação para esse estudo foi: Quais as estratégias utilizadas para minimizar o efeito nocebo na comunicação em saúde? Revisão da Literatura: foram encontrados 77 artigos. Apenas seis preencheram os critérios de inclusão e compuseram a amostra da revisão. Os anos de publicação dos artigos variaram entre 2015 e 2021. As estratégias definidas para minimizar o efeito nocebo foram: enquadramento positivo, comunicação assertiva e utilização de fatores contextuais. Conclusão: as estratégias encontradas para minimizar o efeito nocebo foram fatores contextuais, conversa motivacional, enquadramento positivo, comunicação assertiva e comunicação empática. Essas técnicas de comunicação parecem ser efetivas, mas ainda são pouco conhecidas pelos profissionais em saúde. Esse conhecimento se faz importante, pois auxilia no desenvolvimento de habilidades comunicativas que visam à humanização do cuidado ao paciente.

Mind your words: Oncologists' communication that potentially harms patients with advanced cancer: A survey on patient perspectives

BACKGROUND

Many complaints in medicine and in advanced illnesses are about communication. Little is known about which specific communications harm. This study explored the perspectives of patients with advanced cancer about potentially harmful communication behaviors by oncologists and helpful alternatives.

METHODS

An online survey design was used that was based on literature scoping and patient/clinician/researcher input. Patients with advanced cancer (n = 74) reflected on the potential harmfulness of 19 communication situations. They were asked whether they perceived the situation as one in which communication could be harmful (yes/no). If they answered "yes," they were asked whether they perceived the examples as harmful (yes/no) or helpful (yes/no) and to provide open comments. Results were analyzed quantitatively and qualitatively (content analysis).

RESULTS

Communication regarding information provision, prognosis discussion, decision-making, and empathy could be unnecessarily potentially harmful, and this occurred in various ways, such as making vague promises instead of concrete ones (92%), being too directive in decision-making (qualitative), and not listening to the patient (88%). Not all patients considered other situations potentially harmful (eg, introducing the option of refraining from anticancer therapy [49%] and giving too much [prognostic] information [60%]). Exploring each individual patients' needs/preferences seemed to be a precondition for helpful communication.

CONCLUSIONS

This article provides patient perspectives on oncologists' unnecessarily potentially harmful communication behaviors and offers practical tools to improve communication in advanced cancer care. Both preventable pitfalls and delicate challenges requiring an individualized approach, where exploration might help, are described. Although providing difficult and unwelcome news is a core task for clinicians, this study might help them to do so while preventing potentially unnecessary harm.

Towards an open and effective dialogue on complementary medicine in oncology: protocol of patient participatory study 'COMMON'

INTRODUCTION

Approximately half of patients with cancer use some form of complementary medicine alongside conventional cancer treatment. The topic of complementary medicine often remains undiscussed in consultations between patients with cancer and their healthcare providers. This results in increased risks for adverse or interaction effects and decreased access to the benefits of evidence-based complementary medicine for patients with cancer. This paper describes the design of patient participatory study titled 'COMMON' that aims to explore and enhance open and effective communication about complementary medicine in oncology. The study is carried out in collaboration with 12 (former) patients with breast cancer as coresearchers.

METHODS AND ANALYSIS

The study complies with the six steps of the intervention mapping framework. Three non-academic hospitals recruit participants (patients with cancer, oncology healthcare providers and managers) for interviews about the organisation, experiences and needs regarding complementary medicine. To assess communication about complementary medicine, recorded oncology consultations are analysed. For an overview of evidence-based complementary medicine available to patients with cancer, a review of reviews is conducted on the evidence on cancer patient-reported outcomes of complementary medicine frequently used by patients with cancer, supplemented with an online search and survey among organisations and persons providing complementary medicine to patients with cancer. Together, these steps generate input for the development of a toolbox that supports an open and effective discussion on complementary medicine in oncology. In a pilot study, acceptability and usability of the toolbox are assessed among patients with cancer and oncology healthcare providers. Dissemination of the toolbox is covered by the commitment of stakeholder parties.

ETHICS AND DISSEMINATION

The Medical Ethics Committee Arnhem-Nijmegen declared the study was exempted from formal approval under the Dutch Medical Research Involving Human Subjects Act. The results will be disseminated through open-access, peer-reviewed publications, stakeholder-reporting and presentations at relevant conferences.

Addressing challenges in information-provision: a qualitative study among oncologists and women with advanced breast cancer

BACKGROUND

There is a need for more insight into how to address challenges of information-provision for women with advanced breast cancer. We aimed to explore oncologists' and patients' views on (i) the challenges of information-provision, and (ii) possible strategies to address these challenges, meanwhile (iii) exploring the possible facilitating role of positive expectations and empathy.

METHODS

Semi-structured interviews were held with oncologists (n = 10) and women with advanced breast cancer (n = 14). Principles of Thematic Analysis were followed, with two researchers analyzing transcribed data, supported by Atlas.ti software.

RESULTS

Taken together the data from oncologists and patients, we found that when communicating with patients with advanced cancer, oncologists face challenges, including handling patients' unrealistic disease (status) beliefs, and choosing approaches for discussing available treatment options and their side effects. Possible strategies to address these challenges include balancing information with acceptance of denial, and using medical expertise to guide treatment discussions. A sensitive issue is whether to discuss the option of no anti-cancer treatment. Meanwhile, approaches and preferences for discussions of side effects vary. Positive expectations and empathy can facilitate information-provision by creating space and helping patients to open up more.

CONCLUSIONS

Integrating oncologists' and patients' views, oncologists can provide realistic information while also, temporarily, accepting denial, and can use their medical expertise to address challenges around unrealistic beliefs and discussion of treatment options. Finding ways to tailor discussions of no anti-cancer treatment and side-effect information are needed. Positive expectations and empathy might facilitate - tailored - information-provision, leading ultimately to patient-centered care lying at the heart of medicine.

How are emotional distress and reassurance expressed in medical consultations for people with long-term conditions who were unable to receive curative treatment? A pilot observational study with huntington's disease and prostate cancer

Objective

It is unclear whether how people with long-term conditions express distress, and how clinicians respond, influences perceptions of consultation outcomes. The pilot study examined emotional distress and reassurance in consultations with people whose long-term conditions (at the time of consultations) were treated using active surveillance or symptom management (as no curative treatment was suitable).

Methods

An observational pilot study was conducted involving consultations between people with long-term conditions and their respective clinician. Consultations between three clinicians (two Huntington’s Disease; one Prostate Cancer) and 22 people with long-term conditions (11 Huntington’s Disease; 11 Prostate Cancer) were audio-recorded. Participants also completed an expanded Consultation and Relational Empathy (CARE) Measure. Two researchers coded sessions using Verona Coding Definitions of Emotional Sequences (VR-CoDES/VR-CoDES-P). Code frequencies were calculated, t tests performed between conditions, and Pearson’s correlations performed for associations between CARE responses and clinician utterances.

Results

People with long-term conditions expressed emotional distress on average 4.45 times per session, averaging 1.09 Concern and 3.36 Cue utterances. Clinicians responded with more explicit (2.59) and space-providing (3.36), than non-explicit (1.86) and space-reducing (1.09), responses per session. Clinicians expressed spontaneous reassurance on average 5.18 times per session, averaging 3.77 Cognitive and 1.5 Affective reassurance utterances. Huntington’s Disease consultations featured significantly more 'Cues', 'Concerns' and 'Overall' 'Emotional Distress', and 'Cognitive' and 'Overall' ‘Reassurance'.

Conclusion

Emotional distress was expressed more using hints than explicit concern utterances. Clinicians predominantly explicitly explored distress rather than providing information/advice and provided advice using spontaneous cognitive reassurance. People with Huntington’s Disease expressed more concerns and received more reassurance, indicating different needs between conditions. Future research is required to explore emotional distress and reassurance in a larger sample of participants and long-term condition types, and how the practical implications of these findings may be used to enhance outcomes of consultations.

Trial registration

N/A.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00833-z.

Health literacy, information provision and satisfaction in advanced cancer consultations: two observational studies using level of education as a proxy

OBJECTIVES

Patients with low health literacy (LHL) might feel less informed and satisfied with provided information than patients with high health literacy (HHL). In the setting of advanced cancer, we explored whether LHL patients, compared with HHL patients are: (1) often less informed, and (2) less satisfied with clinicians' communication (a) in general and (b) following information provision specifically.

METHODS

Data from two observational studies using recorded consultations were combined. Clinicians' provided information and patients' health literacy level-defined by educational levels-and satisfaction were measured. Χ2 tests and regression (moderation) analyses assessed the relation between health literacy and information provision, and between information provision and satisfaction, meanwhile exploring moderating influences of health literacy.

RESULTS

Of 61 included patients, 25 (41%) had LHL. LHL and HHL patients were equally seldom informed about the disease's incurability (36% vs 42%, p=0.66). LHL patients were more often informed about the option of not pursuing anticancer therapy than HHL patients (28% vs 8%, p=0.04). LHL patients were more satisfied with clinicians' communication than HHL patients (M=9.3 vs M=8.5, p=0.03), especially when the option of no anticancer treatment was discussed (p=0.04). Discussing the disease's incurability did not influence satisfaction levels (p=0.58) for LHL and HHL patients.

CONCLUSIONS

LHL patients were not less informed, yet more satisfied than HHL patients. Both groups were equally seldom informed about the disease's incurability. No anticancer therapy was mostly discussed with LHL patients who were more satisfied following this information. Clinicians should be encouraged to inform all patients about the disease status and (non)treatment options, while not overlooking empathic support.

The power of clinician-expressed empathy to increase information recall in advanced breast cancer care: an observational study in clinical care, exploring the mediating role of anxiety

OBJECTIVE

Experimental studies have found that clinician-expressed empathy improves patients' information recall in (advanced) cancer consultations. It remains unclear, however, whether these results are generalizable to clinical care and, if so, what the underlying mechanism is. We aimed to i) determine the relationship between clinician-expressed empathy and patients' information recall in clinical advanced breast cancer consultations; and ii) test whether the relationship between clinician-expressed empathy and recall is mediated by a decrease in patients' anxiety.

METHODS

Forty-one consultations between oncologists and female patients with advanced breast cancer were audio recorded. Patients' post-consultation information recall and pre- and post-consultation anxiety (0-100) were assessed. Recall was scored according to a self-created questionnaire. Clinician-expressed empathy (0-100) was assessed by observers. Structural Equation Modelling was used for all analyses.

RESULTS

Participants remembered 61% of the information discussed. Clinician-expressed empathy significantly increased patients' total information recall (p = .041) and recall of treatment aims/positive effects (p = .028). The mediating role of anxiety could not be established.

CONCLUSION

Although the underlying mechanism remains unclear, clinicians have a powerful tool to improve seriously ill breast cancer patients' recall of information: empathy.

PRACTICE IMPLICATIONS

These insights should encourage clinicians to express empathy; practical communication training might prove helpful.

Discussing Prognosis with Empathy to Cancer Patients

PURPOSE OF REVIEW

Our goal was to provide healthcare professionals (HCPs) with evidence-based data about what can be done to handle prognostic discussions with empathy.

RECENT FINDINGS

First, disclosing prognosis involves a good reason to do so and making sure that the patient will be able to process the discussion. Second, communication tips are given for the three dimensions of empathy: "establishing rapport with the patient," which should not be overlooked; the emotional dimension, which involves an accurate understanding of the patient and communication skills; and the "active/positive" dimension which is about giving hope, explaining things clearly and helping patients take control with shared decision-making and a planned future. Although communication tips are helpful, empathy training should be based more on the development of HCPs' emotional skills, in order to help them regulate their emotions and thus be more comfortable with those of patients and families. Furthermore, research into empathy toward minorities and relatives is needed.

Instrumental and affective communication with patients with limited health literacy in the palliative phase of cancer or COPD

Background

Patients have a ‘need to know’ (instrumental need) and a ‘need to feel known’ (affective need). During consultations with patients with limited health literacy (LHL) in the palliative phase of their disease, both the instrumental and the affective communication skills of healthcare providers are important. The study aims to explore instrumental and affective communication between care providers and LHL patients in the palliative phase of COPD or cancer.

Methods

In 2018, consultations between LHL patients in the palliative phase of cancer or COPD and their healthcare providers were video-recorded in four hospitals in the Netherlands. As there was no observation algorithm available for this setting, several items were created to parameterize healthcare providers’ instrumental communication (seven items: understanding, patient priorities, medical status, treatment options, treatment consequences, prognosis, and information about emotional distress) and affective communication (six items: hope, support, reassurance, empathy, appreciation, and emotional coping). The degree of each item was recorded for each consultation, with relevant segments of the observation selected and transcribed to support the items.

Results

Consultations between 17 care providers and 39 patients were video-recorded and analyzed. Care providers primarily used instrumental communication, most often by giving information about treatment options and assessing patients’ care priorities. Care providers assessed patients’ understanding of their disease less often. The patients’ prognosis was not mentioned in half the consultations. Within the affective domain, the care providers did provide support for their patients; providing hope, reassurance, empathy, and appreciation and discussing emotional coping were observed less often.

Conclusions

Care providers used mostly instrumental communication, especially treatment information, in consultations with LHL patients in the palliative phase of cancer or COPD. Most care providers did not check if the patient understood the information, which is rather crucial, especially given patients’ limited level of health literacy. Healthcare providers did provide support for patients, but other expressions of affective communication by care providers were less common. To adapt the communication to LHL patients in palliative care, care providers could be less wordy and reduce the amount of information, use ‘teach-back’ techniques and pay more attention to affective communication.

Evaluation of an End-of-Life Essentials Online Education Module on Chronic Complex Illness End-of-Life Care

Chronic complex illness/multimorbidity is a leading cause of death worldwide. Many people with chronic complex illnesses die in hospital, with the overall quality of end-of-life care requiring substantial improvement, necessitating an increase in the knowledge of the health professionals caring for them. End-of-Life-Essentials (EOLE) offers online education modules for health professionals working in acute hospitals, including one on chronic complex illness. A quantitative pre-post-evaluation analysis was undertaken on data from learners (n = 1489), who completed a questionnaire related to knowledge gained from module completion between December 2018 and November 2019. A qualitative post-evaluation analysis was also conducted using data on learner responses to a question posed between May and November 2019. Results showed a significant positive impact on learners' knowledge, skill, attitude, and confidence in providing end-of-life care to patients living with chronic complex illness. The majority (82.9%, n = 900) intended to change their practice after module completion. A total of n = 559 qualitative comments were analysed thematically, with three major themes emerging: Patient centred care and care planning, Discussion of prognosis, and Valued communication skills. This evaluation has demonstrated that healthcare professionals could benefit from this education to improve quality of care of the dying.

Patients' and Clinicians' Perceptions of Clinician-Expressed Empathy in Advanced Cancer Consultations and Associations with Patient Outcomes

Background: Empathy is a cornerstone of effective communication. However, clinicians' and patients' perceptions of clinician-expressed empathy might differ. The independent perceptions of patients and clinicians on clinician-expressed empathy in advanced cancer consultations and the associations of these perceptions with patient outcomes are unknown. Objective: We assessed (1) patients' and clinicians' independent perceptions of clinician-(self-)expressed empathy in advanced cancer consultations and (2) the associations between these perceptions and affective patient outcomes. Methods: This observational study included data from 41 consultations in the advanced breast cancer setting. Postconsultation, patients' and clinicians' perceptions of clinician-expressed empathy were assessed, as well as patients' (1) pre-post anxiety, (2) post-anxiety, (3) emotional well-being, and (4) satisfaction. Multilevel regression analyses were run to draw conclusions. Results: Patients perceived higher levels of empathy than clinicians, without a significant relationship between the two (mean [M] = 85.47, standard deviation [SD] = 14.00 vs. M = 61.88, SD = 15.30, 0-100 scale; β = 0.14, p < 0.138, 95% confidence interval [CI] = -0.04 to 0.32). Higher patient-perceived empathy was associated with decreased anxiety [(1) β = -0.67, p = 0.039, 95% CI = -1.30 to -0.03; (2) β = -0.15, p = 0.042, 95% CI = -0.30 to -0.01], higher satisfaction (β = 0.05, p < 0.001, 95% CI = 0.03 to 0.08), and lower emotional distress (β = -0.32, p < 0.001, 95% CI = -0.48 to -0.16). There were no associations with clinicians' perceptions [(1) β = -0.34, p = 0.307, 95% CI = -1.00 to 0.31; (2) β = -0.02, p = 0.824, 95% CI = -0.17 to 0.14; (3) β < 0.01, p = 0.918, 95% CI = -0.03 to 0.02; (4) β = 0.08, p = 0.335, 95% CI = -0.08 to 0.25]. Conclusions: Patients' and clinicians' empathy perceptions differed. In improving patient outcomes, the focus should be on patients' perceptions of clinician-expressed empathy. Future research could focus on ways to elicit patients' perceptions of empathy with the higher aim of improving patient outcomes.