Tough Talks With Cancer Patients: Dealing With Challenges

Shelly Reese

Disclosures

April 06, 2016

In This Article

Little Preparation for Those Tough Conversations

Over the course of a career, an oncologist may impart bad news an average of 20,000 times, according to one estimate.[1] Such conversations are, of course, difficult and emotional for the patient, and they're also difficult for the physician. Yet most practicing oncologists have never received any formal training to help them prepare for such conversations.

"Oncologists find themselves in tough conversations with seriously ill patients all the time," says Dr James Tulsky, chair of the Department of Psychosocial Oncology and Palliative Care at the Dana-Farber Cancer Institute and chief of the Division of Palliative Medicine at Brigham and Women's Hospital in Boston. "They're not only dealing with patients facing life-threatening illnesses, but there is constant monitoring, recurring scans, and a lot of decision points, so I think oncologists face these conversations more regularly and in a more intense way than many other clinicians."

Given the nature of these conversations, sharing the facts with patients isn't enough, he says. Doctors have to recognize patients' emotional needs and respond to those needs if they want their message to sink in.

Any discussion of cancer is likely to be emotionally fraught for patients, and this profoundly affects their ability to process what their doctor is saying, according to Kathryn Pollak, a professor at Duke University School of Medicine. "When a person's emotional channel is full of fear and anxiety, their cognitive channel is turned off, and they can't hear about their care. They hear the word 'cancer,' and that is it. They have no idea what the doctor says afterward."

The problem, experts say, is that many physicians aren't trained to handle these conversations. "Many doctors recognize when their patients are expressing emotion, but they don't know what to do," says Dr Tulsky, who emphasizes that empathic communication is a skill—and like all skills, it can be cultivated though awareness, coaching, and practice. "This is not what you learn in the sandbox in kindergarten."

Common Communication Problems

For doctors and patients, clear communication is hindered by a broad array of linguistic, logistical, physical, and emotional barriers. Collectively, these can result in serious communication breakdowns, particularly when the subject is as emotionally charged as cancer.

A 2012 study conducted by researchers at the Dana-Farber Cancer Institute and published in the New England Journal of Medicine underscores the extent to which communication can fail.[2] In surveying and reviewing medical records for 1274 patients with metastatic lung or colorectal cancer, researchers found that 69% of patients with lung cancer and 81% of patients with colon cancer did not understand that the chemotherapy they were receiving was unlikely to cure their disease.

To help physicians and their patients avoid such misunderstandings, we asked experts in the field of physician communication to describe some of the most common problems physicians face and to propose solutions to help them better handle difficult conversations.

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