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Herzog EM, Pirmorady Sehouli A, Boer J, Pietzner K, Petru E, Heinzelmann V, Roser E, Dimitrova D, Oskay-Özcelik G, Camara O, Sehouli J. How to break bad news and how to learn this skill: results from an international North-Eastern German Society for Gynecological Oncology (NOGGO) survey among physicians and medical students with 1089 participants. Int J Gynecol Cancer 2023; 33:1934-1942. [PMID: 38052472 PMCID: PMC10804030 DOI: 10.1136/ijgc-2023-004693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/09/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Delivering bad news to patients is one of the most challenging tasks in medical practice. Despite its great relevance to patients, relatives, and medical staff, there is a paucity of data pertaining to training, experience, expectations, and preferences of physicians and medical students on breaking bad news. METHODS We conducted an international survey in Germany, Switzerland, and Austria using an online questionnaire among physicians and medical students. RESULTS A total of 786 physicians and 303 medical students completed the survey. Physicians stated that 32.7% deliver bad news several times a week and 45.2% several times a month. Difficulties controlling their emotions (35.1%) and remaining professional (43.4%) were the greatest challenges for physicians. Delivering bad news is associated with feelings of anxiety, both among experienced physicians (median of 3.8 out of 10.0) and medical students (median of 5.3). Conveying bad news is a burden to physicians and consequently has a substantial impact on their job satisfaction. All participants reported the need for more communication training concerning this subject. Only 49.5% of medical students and 67.3% of physicians mentioned having learned adequate communication skills. Our data demonstrate that communication training decreases the level of anxiety and increases the feeling of self-confidence towards breaking bad news. Preferred educational tools were seminars with simulation (students: 71.4%, physicians: 49.5%), observing more senior faculty (students: 57.4%, physicians: 55.1%), and supervision and feedback sessions (students: 36.3%, physicians: 45.7%). The largest barriers regarding education on communication were limited time (students: 77.0%, physicians: 74.9%) and missing awareness of supervisors (students: 60.6%, physicians: 41.1%). CONCLUSIONS Our study showed a great need for systematic training and education in breaking bad news among physicians and medical students. Hospitals, medical schools, and postgraduate training programs are strongly encouraged to fill this gap, and improve sustainable doctor-patient communication to overcome the psychological burden for physicians.
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Affiliation(s)
- Emilie M Herzog
- Department of Gynecology, Center for Oncological Surgery, Campus Virchow Klinikum, Charité University Hospital Berlin, Berlin, Germany
| | - Adak Pirmorady Sehouli
- Department of Psychosomatic Medicine, Charité University Hospital Berlin, Berlin, Germany
- European Art Guild for Medicine and Culture, Berlin, Germany
| | - Jolijn Boer
- North-Eastern German Society for Gynecological Oncology (NOGGO eV), Berlin, Germany
| | - Klaus Pietzner
- Department of Gynecology, Center for Oncological Surgery, Campus Virchow Klinikum, Charité University Hospital Berlin, Berlin, Germany
| | - Edgar Petru
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Viola Heinzelmann
- Department of Gynecology and Gynecological Oncology, University Hospital Basel, Basel, Switzerland
| | - Eva Roser
- Department of Gynecology, Center for Oncological Surgery, Campus Virchow Klinikum, Charité University Hospital Berlin, Berlin, Germany
| | - Desislava Dimitrova
- Department of Gynecology, Center for Oncological Surgery, Campus Virchow Klinikum, Charité University Hospital Berlin, Berlin, Germany
| | - Gülten Oskay-Özcelik
- North-Eastern German Society for Gynecological Oncology (NOGGO eV), Berlin, Germany
| | - Oumar Camara
- North-Eastern German Society for Gynecological Oncology (NOGGO eV), Berlin, Germany
- Department of Gynecological Oncology and Breast Centre, Helios Hospital Gotha, Gotha, Germany
| | - Jalid Sehouli
- Department of Gynecology, Center for Oncological Surgery, Campus Virchow Klinikum, Charité University Hospital Berlin, Berlin, Germany
- European Art Guild for Medicine and Culture, Berlin, Germany
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Tranberg M, Brodin EM. Physicians' Lived Experience of Breaking Bad News in Clinical Practice: Five Essentials of a Relational Process. QUALITATIVE HEALTH RESEARCH 2023; 33:1349-1359. [PMID: 37793062 PMCID: PMC10666517 DOI: 10.1177/10497323231197534] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
The purpose of this study was to develop deeper knowledge about physicians' lived experiences of breaking bad news by identifying their common meanings and interrelatedness along with their potential alignment with process-oriented and relational aspects. Based on the methodology of descriptive phenomenology, in-depth interviews were conducted with 22 physicians from a wide variety of specialties. The participants were invited to freely reflect upon their experiences of breaking bad news by describing situations that had worked well and less well. Results showed that breaking bad news was fundamentally experienced as a relational process constituted by the five essentials of Becoming the bad messenger, Expecting the unpredictable, Being on stage, Professionally managing hope, and Mindfulness of the emotional relationship. In line with recent research, this study confirms that clinical communication involves much more than just delivering the message. However, it also contributes to existing knowledge by focusing on the phenomenology of physicians' experiences, which enables deeper understanding of the medical profession and the relational process of breaking bad news. As such, our findings are important to enable broader learning in, for example, medical education and continuing courses for clinical staff.
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Affiliation(s)
- Mattias Tranberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
| | - Eva M. Brodin
- Department of Educational Sciences, Lund University, Lund, Sweden
- Centre for Higher and Adult Education (CHAE), Stellenbosch University, Stellenbosch, South Africa
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Appiah EO, Menlah A, Xu J, Susana AA, Agyekum BS, Garti I, Kob P, Kumah J. Exploring the challenges and roles of nurses in delivering palliative care for cancer patients and co-morbidities in Ghana. BMC Palliat Care 2023; 22:121. [PMID: 37635254 PMCID: PMC10464455 DOI: 10.1186/s12904-023-01211-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 06/23/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Patients suffering from chronic and life-threatening diseases receive inadequate palliative care in low-income countries, eventually leading to poor quality of life for these patients. Little is known about the experience of delivering palliative care in a low-resource country such as Ghana in comparison to higher-income countries. This study, therefore, aimed to assess the roles and challenges of nurses providing palliative care services for patients with cancer and life-limiting conditions at tertiary Hospitals in Ghana. METHODS Thirty oncology nurses at a tertiary Hospital in Ghana participated. All nurses were providing end-of-life care to patients with cancer. A qualitative exploratory-descriptive design and a semi-structured interview guide developed by the researchers were used. Interviews lasted on average forty minutes to 1 h were audio-recorded, and transcribed verbatim. Content analysis was carried out to generate themes and sub-themes. FINDINGS Participants were between the ages of 25 and 40 years. A higher percentage of females (n = 17, 57%) participated in the study than males (n = 13, 43%). Two main themes were generated which were the delivery of palliative care and the provision of home care services. The current roles of nurses were centered around pain management, home care services, spiritual needs, and psychological care. Challenges that hindered the implementation of palliative care included distress over expected and unexpected patient mortality, difficulty delivering bad news to patients and families, and frustration with health system resource shortages that negatively impacted patient care. CONCLUSION Palliative care is one of the essential services provided for patients with life-limiting conditions, and nurses play an active role in the provision of this care. Further research is needed to determine the most effective ways to deliver this care, particularly in developing nations like Ghana.
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Affiliation(s)
| | - Awube Menlah
- Charles Darwin University, Darwin City, Australia
| | - Jiayun Xu
- Purdue University School of Nursing, 502 University Street, West Lafayette, IN 47907-2069 USA
| | | | - Boateng Susana Agyekum
- Nursing Department, School of Nursing and Midwifery, Valley View University, Accra, Ghana
| | | | - Pascal Kob
- Nursing Training College, Lawra, Upper West Region Ghana
| | - Joyce Kumah
- Ghana Christian University College, Accra, Ghana
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Wahyuni S, Gautama MSN, Simamora TY. A Literature Review of Nurses Challenges and Barriers in Assisting Patients and Families Facing Breaking Bad News. Indian J Palliat Care 2023; 29:243-249. [PMID: 37700890 PMCID: PMC10493690 DOI: 10.25259/ijpc_128_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/22/2023] [Indexed: 09/14/2023] Open
Abstract
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.
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Affiliation(s)
- Surya Wahyuni
- Master of Nursing Program, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Made Satya Nugraha Gautama
- Master of Nursing Program, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Tiur Yulianta Simamora
- Master of Nursing Program, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
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Anestis E, Eccles FJR, Fletcher I, Simpson J. Neurologists' lived experiences of communicating the diagnosis of a motor neurodegenerative condition: an interpretative phenomenological analysis. BMC Neurol 2023; 23:178. [PMID: 37138217 PMCID: PMC10155430 DOI: 10.1186/s12883-023-03233-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/29/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND Receiving the diagnosis of a motor neurodegenerative condition (MNDC) can be a life-changing experience. Although several studies of individuals' experiences have indicated dissatisfaction with aspects of how an MNDC diagnosis was communicated, few studies have addressed doctors' experiences of breaking bad news for these conditions, especially from a qualitative perspective. This study explored UK neurologists' lived experience of delivering an MNDC diagnosis. METHODS Interpretative phenomenological analysis was used as the overarching method. Eight consultant neurologists working with patients with MNDCs took part in individual, semi-structured interviews. RESULTS Two themes were constructed from the data: 'Meeting patients' emotional and information needs at diagnosis: a balancing act between disease, patient and organization-related factors', and 'Empathy makes the job harder: the emotional impact and uncovered vulnerabilities associated with breaking bad news'. Breaking the news of an MNDC diagnosis was challenging for participants, both in terms of achieving a patient-centred approach and in terms of dealing with their own emotions during the process. CONCLUSIONS Based on the study's findings an attempt to explain sub-optimal diagnostic experiences documented in patient studies was made and how organizational changes can support neurologists with this demanding clinical task was discussed.
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Affiliation(s)
- Eleftherios Anestis
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK.
| | - Fiona J R Eccles
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Ian Fletcher
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Jane Simpson
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
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Ayora A, Nogueras C, Jiménez-Panés S, Cortiñas-Rovira S. Teaching (remotely) to communicate (remotely) with relatives of patients during lockdown due to the COVID-19 pandemic. PEC INNOVATION 2023; 2:100151. [PMID: 37016635 PMCID: PMC10052879 DOI: 10.1016/j.pecinn.2023.100151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 03/06/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023]
Abstract
Aim In 2020, due to the pandemic, the lack of specific knowledge on breaking bad news over the phone became apparent. This study aims at assessing the differences, or lack thereof, in satisfaction reported by participants in the different formats of a course in telephone communication for breaking bad news to families of patients, developed based on the previous experience of a team dedicated to this task during the peak of the pandemic. Methods Four courses were delivered, two in a fully streamed format and two in a blended format, part pre-recorded, part streamed. There were 41 attendants, mostly doctors, but also nurses, social workers, occupational therapists, and administrative staff who deal with families. Subsequently, a survey was conducted to assess the degree of satisfaction of the participants. Results Both formats scored very positively, with small advantages for the fully streamed format, mainly due to the difference in interaction activities. Conclusions The main conclusion is the need for these courses, which are demanded by the professionals themselves, without forgetting the benefit obtained from interprofessional education that enriches interaction and learning. Innovation The inclusion of administrative staff allows for a global vision of care for family members, which improves it.
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Affiliation(s)
- Ara Ayora
- Scientific Communication Research Group (GRECC), Department of Communication, Universitat Pompeu Fabra, Barcelona, Spain
| | - Carme Nogueras
- Geriatric Department at Hospital Universitari Germans Trias i Pujol in Barcelona, Spain
| | | | - Sergi Cortiñas-Rovira
- Scientific Communication Research Group (GRECC), Department of Communication, Universitat Pompeu Fabra and UPF-BSM Barcelona School of Management, Barcelona, Spain
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Kotłowska A, Przeniosło J, Sobczak K, Plenikowski J, Trzciński M, Lenkiewicz O, Lenkiewicz J. Influence of Personal Experiences of Medical Students on Their Assessment of Delivering Bad News. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12040. [PMID: 36231342 PMCID: PMC9565137 DOI: 10.3390/ijerph191912040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND We aimed to identify which attitudes and emotions accompany latter-year medical students as they experience situations where bad news is communicated. METHODS A cross-sectional study was conducted using the computer-assisted web interview (CAWI) methodology in a group of 321 fifth- and sixth-year medical students from 14 medical universities in Poland. Correlations were analyzed using Pearson's χ2 test. For the categorical variables, subject profiles were analyzed using K-means clustering. RESULTS Students' self-assessments of their competence in delivering bad news (DBN) differed depending on the type of experience they had with it. More than half of the students had observed a situation of DBN (63.6%) and as many as 26.5% of the participants had received bad news themselves. These two groups were less likely to declare a lack of DBN-related skills (43.4% and 33.4%, respectively) than others. In this study, 9% of the students had personally delivered bad news. Only 13.4% of these students rated their DBN skills as insufficient. They were also the least likely to express concern regarding high levels of stress (29.6%) and anxiety (48%). CONCLUSIONS The ability to personally deliver bad medical news to a patient was the most effective form of gaining experience in DBN. Being a bearer of bad news may help students develop their own strategies for coping with difficult emotions and develop their professional competences, leading to improved medical care and patient comfort.
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Affiliation(s)
- Agata Kotłowska
- Faculty of Medicine, Student Scientific Circle of Medical Communication at the Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Julia Przeniosło
- Faculty of Medicine, Student Scientific Circle of Medical Communication at the Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Krzysztof Sobczak
- Department of Sociology of Medicine and Social Pathology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Jan Plenikowski
- Faculty of Medicine, Student Scientific Circle of Medical Communication at the Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Marcin Trzciński
- Faculty of Medicine, Student Scientific Circle of Medical Communication at the Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Oliwia Lenkiewicz
- Faculty of Medicine, Student Scientific Circle of Medical Communication at the Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Julia Lenkiewicz
- Faculty of Medicine, Student Scientific Circle of Medical Communication at the Medical University of Gdansk, 80-210 Gdansk, Poland
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Delivering Bad News: Self-Assessment and Educational Preferences of Medical Students. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19052622. [PMID: 35270311 PMCID: PMC8910051 DOI: 10.3390/ijerph19052622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 02/18/2022] [Accepted: 02/22/2022] [Indexed: 01/25/2023]
Abstract
Background: Numerous reports indicate the educational deficiencies of medical students in delivering bad-news-related skills. Evaluation of the performance of training programs in this area should be one of the key components of the educational process. The purpose of this study was to analyze medical students’ preferences and educational needs regarding DBN (delivering bad news). The effect of clinical experience on the self-assessment of skills was analyzed. Methods: The quantitative survey was conducted using the CAWI technique. The study involved 321 fifth- and sixth-year medical students from 14 medical universities in Poland. Pearson’s χ2 test was used for statistical analysis. The profile of respondents for categorical variables was determined by KMeans analysis. Results: As many as 75.1% of students revealed that they did not feel sufficiently prepared for DBN. Only 18.7% reported having adequate competence in this area. More than half of the inquired students (63.6%) witnessed a situation during their clinical practice in which a physician provided a patient with information about an unfavorable diagnosis. These students were less likely to declare that they could not deliver BN (43.4%) than students who had no such experience (58.2%). As many as 86.3% of the respondents reported the need for more time in DBN skills training. Students mostly preferred active teaching methods. Conclusions: Understanding students’ learning needs and preferences can help medical schools optimize their education programs to develop DBN-related competencies.
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Ngwenya N, Crang C, Farquhar M, Rintoul RC, Mahadeva R, Calvert LD, Murray SA, Barclay S. Communicating uncertainty: contrasting the communication experiences of patients with advanced COPD and incurable lung cancer. Fam Pract 2021; 38:637-643. [PMID: 33871548 PMCID: PMC8604275 DOI: 10.1093/fampra/cmab024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Due to the uncertain disease trajectory and variable rate of progression in chronic obstructive pulmonary disease (COPD), health care professionals (HCPs) are challenged in explaining what the future may hold for patients compared to those with lung cancer (LC). Support and communication of timely information can significantly improve health outcomes. OBJECTIVE This study sought to identify factors that impact communication and support and recommend ways to improve patients' understanding of living with life-threatening illness. METHODS Semi-structured interviews with patients with LC (n = 22) and advanced COPD (n = 18), their informal carers (21 LC and 18 COPD) and HCPs (n = 51). Patients were recruited from primary and secondary care in the East of England, UK, during 2010-12. RESULTS Directness and clarity characterized communication in LC, whereas uncertainty and limited explanations predominated in COPD. Discussions on how the disease might impact on decisions and preferences to be made in the future were less common in COPD. Information for LC patients was mainly from hospital clinicians and any information for COPD patients mainly from primary care clinicians. CONCLUSIONS The experience of COPD patients could be improved by professionals soon after diagnosis explaining to them the typical pattern of decline in COPD, highlighting the inherent uncertainties about when exacerbations and death may occur. This conversation should lead to planning for the different challenges that the patient and informal carer recognize as most important to them. This contrasts with the 'breaking bad news' conversation that oncologists are highly trained to deliver.
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Affiliation(s)
- Nothando Ngwenya
- Social Science and Research Ethics Department, Africa Health Research Institute, KwaZulu-Natal, South Africa.,Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Clare Crang
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Morag Farquhar
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Robert C Rintoul
- Department of Oncology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.,Department of Oncology, University of Cambridge, UK
| | - Ravi Mahadeva
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Lori D Calvert
- North West Anglia Hospitals NHS Foundation Trust, Cambridgeshire, UK
| | - Scott A Murray
- Primary Palliative Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Stephen Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Affiliation(s)
- Wen-Hsun Chang
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Wen-Ling Lee
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Nursing, Oriental Institute of Technology, New Taipei City, Taiwan, ROC
- Department of Medicine, Cheng-Hsin General Hospital, Taipei, Taiwan, ROC
| | - Peng-Hui Wang
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan, ROC
- Female Cancer Foundation, Taipei, Taiwan, ROC
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