5 (Incorrect) Reasons Oncologists Avoid Bad-News Talks

Nick Mulcahy

July 06, 2012

July 6, 2012 — Five commonly accepted reasons that oncologists avoid discussing poor prognosis with cancer patients are all "incorrect," according to an essay published online July 2 in the Journal of Clinical Oncology.

There is one reason for avoiding such talks that "holds truth": Doctors "do not like to have these discussions" because "they are hard on us," write Jennifer Mack, MD, from the Dana-Farber Cancer Institute and Children's Hospital Boston in Massachusetts, and Thomas J. Smith, MD, from the Johns Hopkins Medical Institutions, Baltimore, Maryland.

The essayists remind their fellow clinicians that "our patients want us to have these conversations, difficult as they are for all involved."

Drs. Mack and Smith list 5 reasons that oncologists unnecessarily shy away from bad news talks:

  • Patients get depressed

  • The truth kills hope

  • Hospice or palliative care reduces survival

  • This talk is not culturally appropriate

  • Prognosis is unknowable

They then cite evidence that dispels each reason, more or less.

The field of oncology has recently gotten better at talking to patients about poor prognosis, said an expert asked to comment on the essay.

"There has been a lot of work trying to address difficult communications tasks recently," said Jim Wallace, MD, from the University of Chicago in Illinois. There has been a "trend" in "finding ways to help oncologists improve their skills," he told Medscape Medical News.

Dr. Wallace was the lead author of a 2006 study that surveyed oncologists about breaking bad news to patients, as reported by Medscape Medical News. He and his colleagues found that negative emotions were much more common than positive ones among oncologists. Specifically, 47% of respondents described negative emotions such as sadness and anxiety, whereas only 14% reported positive feelings such as optimism, hope, helpfulness, and relief.

Dr. Wallace has strong opinions about training oncologists in such communication.

This training should become mandatory.

"For oncologists who are directly involved in patient care, this training should become mandatory," he said. "Oncology should begin to explore means of evaluating this competency prior to full-time patient care."

The avoidance of bad news talk has some serious consequences, the essayists note. "Patients lose good time with their families and for reflection and spend more time in the hospital and intensive care unit," Drs. Mack and Smith write. The avoidance can be neglectful, they suggest. For example, half of all patients with lung cancer get to 2 months before death without being offered hospice.

Bad news talks are potentially cost effective. "We think this is one way we can improve care, give people more realistic choices, and reduce the rising cost of care," write Drs. Mack and Smith.

They reviewed various books and studies on the subject of discussing bad news with cancer patients, and found a host of "underlying misconceptions" among healthcare professionals. In their essay, they present the evidence they accumulated to counter these "incorrect" ideas about the effects of discussing poor prognosis.

Refuting the Reasons

Patients get depressed. The essayists say the opposite is true. "Giving patients honest information may allow them and their caregivers to cope with illness better." The evidence includes the Coping With Cancer study, in which patients who reported having end-of-life discussions had no higher rates of depression or worry and had lower rates of ventilation and resuscitation and more and earlier hospice enrollment (JAMA. 2008;300:1665-1673).

The truth kills hope. Drs. Mack and Smith say that hope can be maintained by patients even after truthful discussions about there being no chance for a cure. They cite studies of cancer patients with advanced disease in which patients were highly hopeful about their lives both before and after the disclosure of the likely prognosis. In other words, hope was a concept about life, regardless of its length, they found.

Hospice or palliative care reduces survival. The essayists note that multiple studies suggest that survival is equal or better with hospice or palliative care. For example, in a study of 4500 Medicare beneficiaries, hospice use was associated with increased survival in patients with either congestive heart failure or 1 of 5 cancers (J Pain Symptom Manage. 2007;33:238-246).

This talk is not culturally appropriate. The Drs. Mack and Smith admit that it is "true that patients of different ethnic and cultural backgrounds often have different preferences for information." But they argue that no clinician should assume a person of a particular background does not want to talk about death because some of his or her compatriots feel that way. "Physicians who want to know their patients' preferences for prognostic information should ask," they say.

Prognosis is unknowable. The essayists admit this is true — prognosis is a mystery to some degree. But they argue that "although we never know precisely how long a patient has to live, uncertainty should not be used as an excuse." They maintain that a "reasonable prognosis or range of possible outcomes" can help patients come "closer to the truth."

J Clin Oncol. Published online July 2, 2012. Abstract

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