Delivering bad news to patients with cancer requires oncologists to continuously consider many different factors, including their individual relationship with the patient, the patient's family, the institutional and systemic environment, and the cultural milieu.
So comment a group of French researchers who report a meta-analysis of 40 studies published between 1992 and 2014 that focused on the experiences and points of view about breaking bad news to patients among 600 oncologists from 12 countries. The review was published online June 29 in the Journal of Clinical Oncology.
"Extending the development of the ability to personalize and adapt therapeutic treatment to this realm of communications would be a major step forward from the stereotyped way that oncologists are currently trained in communication skills," write Guilhem Bousquet, MD, PhD, from Université Paris Diderot, Sorbonne, Paris, France, and colleagues.
Oncologists in the United States agree.
"There are lots of complexities with relaying bad news," Teresa Gilewski, MD, from Memorial Sloan Kettering Cancer Center, New York, told Medscape Medical News.
"The relationship between the physician and the patient and the family members and other healthcare providers is a very complex one, and in order to try to optimize the relationships among all those individuals, you have to pay close attention to everything that is going on between them. This article highlights the complexities we face when we have to give bad news," Dr Gilewski said.
Eduardo Bruera, MD, from the Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer, Houston, also noted the complexity of delivering unwelcome news to patients with cancer.
"This study emphasizes the complex and demanding nature of breaking bad news. This is a medical procedure not less difficult than prescribing chemotherapy or inserting a PEG [percutaneous endoscopic gastrostomy] tube," Dr Bruera told Medscape Medical News.
He and his group did previous research, reported by Medscape Medical News, showing that delivering bad news itself can negatively affect patients' perception of the oncologist.
"We found that it can have this negative impact, even when delivered impeccably well," he told Medscape Medical News.
Details of Meta-analysis
Dr Bousquet and colleagues write that two broad themes emerged from their meta-analysis:
the patient-oncologist encounter during the breaking of bad news, comprising essential aspects of the communication between the two parties; and
external factors shaping the patient-oncologist encounter, composed of the systemic and cultural factors that influence the disclosure process.
With regard to the patient-oncologist encounter, oncologists often reported that they first tried to assess the patient's knowledge about the course of the illness, and they stressed how important it was for the patient to ask direct questions. They tended to interpret the absence of questions as unwillingness to know.
Oncologists stressed that the breaking of bad news is a balancing act between informing patients and sustaining their hope. They also emphasized that the breaking of bad news does not take place in a single moment in time but is an ongoing process.
They avoided explicit discussion of patients' deaths, rarely gave percentages about survival, provided general time frames rather than precise timing of survival. They tended to believe that patients did not desire precise information and that if they wanted it, they would ask for it.
"Sustaining hope is particularly challenging for terminally ill patients, who are going to die, and collusion in maintaining unrealistic expectations during the stages of terminal illness was noted," the authors write.
Breaking bad news was emotionally difficult and unpleasant for oncologists. They described both physiologic reactions, such as heightened autonomic arousal, and emotional reactions, such as anxiety, anger, exhaustion, guilt, a feeling of failure, and frustration.
As a result, some oncologists tended to use rigid or "dysfunctional cognitive and behavioural approaches," the authors write.
Additionally, their analysis demonstrated the importance of considering the characteristics of the patient's family or caregivers to determine the best way to include them during the disclosure of the bad news.
"Family presence is an important variable, and the readiness of close relatives to receive bad news is an element that must be included in the oncologist's balancing act. This is especially true when communicating the need for transition to palliative treatment," note the authors.
The family can be a help when it comes to addressing important issues around a patient's care but can also be a hindrance, especially where there is family resistance to the idea of palliative care.
"Separate discussions with the patient and the family have been suggested, but oncologists underline the importance of first obtaining the patient's permission to talk with family members," the authors write.
Other things that can make delivering bad news in the oncology setting difficult include lack of time, limited access to private rooms, constant ringing of telephones, a lack of internal communication among healthcare professionals, and oncologists' perceptions of insufficient training in breaking bad news.
Poverty, plus the availability and costs of treatments, can also influence the disclosure of bad news, mainly in poor countries.
Cultural differences also affect how bad news is delivered. In western countries, patient autonomy is important. It is the doctor's duty to inform patients of, and it is the patient's right to know, all the details about their illness.
But in some cases, families want to protect the patient from knowing, and this can create ethical dilemmas for physicians when it comes time for palliative care, discussing end-of-life issue, and admitting that the treatment has failed.
"In all studies, physicians reported difficulties when they had to break bad news to people from other cultures, and they attributed these difficulties to a lack of intercultural training. These difficulties were increased by the need to use an interpreter," the authors write.
"This is research that tried to make some sense of the complexity of the situation and to try to figure out what the different perspectives are, and coalesce them into one study. I don't know that there is anything in particular that is practical in terms of a take-home message, other than highlighting how complex all of these interactions are," Dr Gilewski commented.
"These topics are often not discussed because they are very hard to evaluate. You can see from the content of this article that the relationships are personalized, they are individual, and we have those interactions every day. I don't think this complexity and difficulty are perceived by the public," she said.
"Physicians don't have enough time to deliver bad news the way they want to, there is so much pressure from other external forces, there are many patients to see in a short time period, there are so many different pressures. On top of that, you have to read the situation that is right in front of you with the patient and the family members, and that depends on what kind of relationship you already have with them," Dr Gilewski said.
"As one of my colleagues said to me once, you try to have an interaction with one patient one way and then you try to do that with the next person and it doesn't work. So you have to constantly be adjusting, and figure out what it is that that person and that family need from you. Can you give what they need in the context of the whole situation? That is what is so challenging," she said.
"It's extremely challenging when you have to give bad news to somebody that you have cared for for many years. You have gotten to know them, you know their family, and it becomes even more difficult on many different levels, so there's a lot to this," Dr Gilewski said.
Getting together with fellow physicians to discuss such experiences could be helpful, she said.
"Schwartz Rounds, a forum for healthcare providers of all types, including nurses, social workers, and physicians, meet to discuss individual patients and their interactions with these patients. Schwartz Rounds are in multiple hospitals across the country and perhaps internationally as well. We have them here at Memorial. It allows us to talk about how we felt caring for the patient, and how the patient has impacted our life," Dr Gilewski said. "It's not just bad news."
Changes in the Practice of Oncology Needed
"Much more evidence is needed to characterize the best strategies to deliver bad news before any guidelines can be prepared," Dr Bruera said.
"The implementation of oncologist-patient and family communication in clinical settings will also require changes in the structure and process of oncology practice. Settings where patients and families can spend enough time sitting comfortably and communicating with the oncologist will need to replace small examining rooms and crowded waiting rooms. This paper proposes some important directions for such research," he said.
This study was supported by the Fondation de France, "Soignerm soulager, accompagner" 2014. Dr Bousquet, Dr Bruera, and Dr Gilewski have disclosed no relevant financial relationships.
J Clin Oncol. Published online June 29, 2015. Abstract
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Cite this: Breaking Bad News Difficult for Oncologists - Medscape - Jul 15, 2015.