How doctors record breaking bad news in ovarian cancer

Quality of breaking bad news to patients diagnosed with neoplasia of the uterine cervix

OBJECTIVE

Little is known about the quality of receiving bad news (BN) for women diagnosed with cervical neoplasia. We evaluated adherence to the SPIKES protocol in three cohorts of women with different stages of the disease and treatment modalities.

PATIENTS AND METHODS

We included women with cervical cancer who underwent radical vaginal trachelectomy (RVT group, n = 110), radical hysterectomy or chemo-radiation (HE/RCT group, n = 101), and women with CIN 3 treated by loop excision (CIN group, n = 108). We asked the participants about how they received the bad news delivery in reality and how they would envision an ideal communication process based on the main items of the SPIKES protocol. The participants filled out a questionnaire with 38 items of the Marburg Breaking Bad News (MABBAN) Scale representing the six SPIKES subscales.

RESULTS

Only 72% of all patients reported being satisfied with their BBN experience. The following factors were considered important by 90% of the patients: an undisturbed atmosphere, taking enough time, coherent explanation of the disease, and the possibility to ask questions. However, the reality of their experiences fell significantly short of their expectations. Asking about the patient's knowledge of the disease, addressing their concerns, allowing them to show emotions, providing clarity about the change in quality of life, informing them about alternative therapies, and involving them in further planning were also significantly lacking in the actual BBN encounters compared to the patients' preferences. The experience of RVT patients was more negative compared to the HE/RCT patients (p = 0.036). The CIN patients had an overall satisfactory impression (p < 0.0001).

CONCLUSION

The process of breaking bad news in German women diagnosed with cervical neoplasia requires substantial improvement. The SPIKES protocol can be used as a guideline for enhancement but should be supplemented by incorporating a second consultation as the norm rather than the exception. Continuous monitoring and improvement of the quality of BBN is recommended for all oncologic institutions, utilizing the MABBAN questionnaire as a valuable tool.

Prognostic disclosure in cancer care: a systematic literature review

Background:

Collusion in cancer care is the diplomatic concealment of information between a triad of the health care professional (HCP), patient, and caregiver. Free and expressive communication is determined by multiple factors, which establishes a healthy balance between ‘patient-centric’ and ‘family-centric’ decision making. The lack of a universal approach to prognostic disclosure techniques emphasizes the need for a systematic review of contemporary practice.

Methods:

A systematic review of the literature was conducted till June 2020 using themes based on cancer, communication, prognostic disclosure, and collusion by using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results:

Fifty-three studies involving 10,569 subjects were studied for their utility on prognostic disclosure using different communication methods and interfaces. Twenty-three studies used a face-to-face interview with subjects while in-person telephonic interviews were conducted in two studies, 16 studies implicated semi-structured questionnaires, and 6 studies mentioned the development of a new technique/tool for disclosure. The duration of a session for prognosis-disclosure ranged from 22 min to 1 h. The involvement of palliative care specialists and mental health professionals was limited during the disclosure of the prognosis.

Conclusion:

The findings of the review indicate that patients in cancer care are aware of their diagnosis and to a certain extent of prognosis despite nondisclosure by their family members and treating teams. This review emphasizes the assessment of ‘disclosure wishes’ among patients and caregivers in separate interviews rather than simply relying on one specific method of interviewing. The nonconfrontational approach and training among HCPs are of utmost importance to build therapeutic resilience among the treating team involved in cancer care. Since many factors such as family wishes, cultural dissonance, medical model, and patient perception could become barriers to prognostic disclosure, there is a need to develop a universal approach to prognostic disclosure and handling associated collusion.

Prevalence of collusion in cancer communications: A meta-analysis

INTRODUCTION

Collusion is the non-disclosure of information about diagnosis or prognosis, frequently encountered in cancer care and palliative services. Unraveling collusion is a skill and differences among communication techniques by Health Care Workers have maintained the process of non-disclosure to patients and caregivers. Identifying the prevalence of collusion in cancer care is required to improve the existing strategies across the world.

METHODS

A systematic review of the literature from 1991 to 2020 in the English language was conducted with the protocol registration on PROSPERO ID (CRD 42021249216.) to identify the pooled prevalence of collusion.

RESULTS

By using random effect model, the pooled prevalence estimate among patients for the diagnostic and prognostic collusion was 24.15, (95% CI [17.09; 32.96], Tou2 = 1.0801, I²  = 97.9%, Cochran's Q = 1058.22, df = 21, p-value < 0.001) and 37.92, (95% CI [22.46; 56.30], Tou2 = 1.9641, I²  = 98.6%, Cochran's Q = 944.26, df = 13, p-value < 0.001) respectively. There was no difference across subgroups with different types of setting for the interview, WHO regions and trend over the years.

CONCLUSIONS

Substantial prevalence of collusion goes unnoticed in cancer care. A meaningful understanding of such a large prevalence requires inquiry into the existing communication paradigm in cancer care across the world. The findings also question the need of formulating uniform interview techniques and structured assessment tools or questionnaires in cancer care to improve the disclosure rates.

Preferences for disclosure of information about serious illness among older Korean American immigrants in New York City

BACKGROUND

The majority of persons of Western European background want to know their diagnosis and prognosis of serious illness, but minimal information is preferred by some ethnic groups, including Asians. Little is known about disclosure preferences of Korean Americans, the fourth largest East Asian immigrant group in the United States.

OBJECTIVE

The objective was to describe disclosure preferences about serious illness of Korean Americans in New York City and characteristics associated with disclosure preferences.

METHODS

A cross-sectional study of a volunteer sample of 26 Korean Americans, 65 years and older, was conducted. Interviews were conducted in Korean. Measures included comfort in talking about death and dying, disclosure preferences, disclosure to relatives, self-rated physical and mental health, and sociodemographic characteristics.

RESULTS

Most agreed doctors should tell patients (n = 23) and relatives (n = 25) if they have cancer, and should tell patients (n = 22) and relatives if they are likely to die from this disease. Less than half (n = 9) agreed doctors should not discuss death and dying with patients, yet 15 agreed it is best to avoid talking about serious illness and dying before they occur. Participants who agreed a doctor should tell patients their cancer diagnosis were younger and had lived in the United States longer than those who disagreed. Self-rated physical health and mental health were associated with disclosure preferences.

CONCLUSIONS

Health professionals are advised to determine the disclosure preferences about serious illness of older Korean Americans and avoid stereotypical assumptions that do not apply to many in this population.

Understanding of prognosis among parents of children with cancer: parental optimism and the parent-physician interaction

PURPOSE

Patients often overestimate their chances of surviving cancer. Factors that contribute to accurate understanding of prognosis are not known. We assessed understanding of likelihood of cure and functional outcome among parents of children with cancer and sought to identify factors that place parents at risk for overly optimistic beliefs about prognosis.

PATIENTS AND METHODS

We conducted a cross-sectional survey of 194 parents of children with cancer (response rate, 70%) who were treated at the Dana-Farber Cancer Institute and Children's Hospital in Boston, MA, and the children's physicians. Parent and physician expectations for likelihood of cure and functional outcome were compared. In 152 accurate or optimistic parents, we determined factors associated with accurate understanding of likelihood of cure compared with optimism.

RESULTS

The majority of parents (61%) were more optimistic than physicians about the likelihood of cure. Parents' beliefs about other outcomes of cancer treatment were similar (quality-of-life impairment, P = .70) or more pessimistic (physical impairment, P = .01; intellectual impairment, P = .01) than physicians' beliefs. Parents and physicians were more likely to agree about chances of cure when physicians had confidence in knowledge of prognosis (odds ratio [OR] = 2.55, P = .004) and allowed parents to take their preferred decision-making role (OR = 1.89, P = .019).

CONCLUSION

Parents of children with cancer are overly optimistic about chances of cure but not about other outcomes of cancer therapy. Parents tend to be overly optimistic about cure when physicians have little confidence and when the decision-making process does not meet parents' preferences. These findings suggest that physicians are partly responsible for parents' unrealistic expectations about cure.

Communication about prognosis between parents and physicians of children with cancer: parent preferences and the impact of prognostic information

PURPOSE

Concerns about the harms of prognostic information, including distress and loss of hope, cause some physicians to avoid frank disclosure. We aimed to determine parent preferences for prognostic information about their children with cancer and the results of receiving such information.

PATIENTS AND METHODS

We surveyed 194 parents of children with cancer (overall response rate, 70%), treated at the Dana-Farber Cancer Institute and Children's Hospital (Boston, MA) and the children's physicians. Our main outcome measure was parent rating of prognostic information as extremely or very upsetting.

RESULTS

The majority of parents desired as much information about prognosis as possible (87%) and wanted it expressed numerically (85%). Although 36% of parents found information about prognosis to be extremely or very upsetting, those parents were more likely to want additional information about prognosis than those who were less upset (P = .01). Parents who found information upsetting were no less likely to say that knowing prognosis was important (P = .39), that knowing prognosis helped in decision making (P = .40), or that hope for a cure kept them going (P = .72).

CONCLUSION

Although many parents find prognostic information about their children with cancer upsetting, parents who are upset by prognostic information are no less likely to want it. The upsetting nature of prognostic information does not diminish parents' desire for such information, its importance to decision making, or parents' sense of hope.

Advance Directives for Truth Disclosure

INTRODUCTION

Although most patients wish to be fully informed about bad news such as a diagnosis of cancer, a significant minority prefer no or minimal information. We examined the value of asking patients about their disclosure preferences at the outset of hospitalization.

METHODS

Consecutive patients admitted to a respiratory and a geriatric unit were asked whether and how they would wish to be told of cancer or Alzheimer disease.

RESULTS

Of the 207 patients interviewed, 174 (84%) wanted to be told about cancer or dementia; the proportion who would wish to be told did not differ between older patients (89 of 108 patients; 82%) and younger patients (85 of 99 patients; 86%; p = 0.34). Thirty patients (15%) sought reassurance during or after the interview, and 13 patients (6%) reported that they had been bothered by the questions. Of the 207 patients, cancer or dementia was diagnosed in 23 patients (11%). Preferences for disclosure or nondisclosure were honored for 20 patients (87%).

CONCLUSIONS

Seeking preferences regarding truth disclosure at the outset of hospitalization is helpful and feasible in everyday practice, and the results can be used by clinicians to improve communication with patients and families in accordance with patients' own wishes.

Relationships among perceived diagnostic disclosure, health locus of control, and levels of hope in Taiwanese cancer patients

OBJECTIVES

To explore relationships among perceived diagnostic disclosure, health locus of control, and levels of hope in Taiwanese cancer patients.

RESEARCH DESIGN

A cross-sectional, descriptive correlational design was used in this study. One hundred and twenty-four (N=124) patients were recruited. The Background Information Form, the Multidimensional Health Locus of Control (MHLC) Scales, the Herth Hope Index (HHI), and patients' medical records were used. Data were analyzed using descriptive statistics, t-test, ANOVA, Chi-square, Pearson's correlation, and multiple regression.

RESULTS

The major findings of this study are as follows: (1) overall, cancer patients had medium levels of hope; (2) patients who were aware of their own diagnosis reported significantly higher levels of hope than those who were not informed of their own diagnosis; (3) patients who were aware of their diagnosis tended to have higher levels of the internal locus of control than those who were not informed; (4) the internal health locus of control was significantly positively related to levels of hope; (5) the chance health locus of control was significantly negatively related to levels of hope.

CONCLUSIONS

The results of this study provide important implications for Taiwanese clinicians concerning the practice of diagnostic disclosure of cancer to patients.

Communicating sad, bad, and difficult news in medicine

In every medical specialty bad, sad, and difficult information must be given to patients and their families. An insensitive approach increases the distress of recipients of bad news, may exert a lasting impact on their ability to adapt and adjust, and can lead to anger and an increased risk of litigation. Many doctors also find these interactions stressful, and in the absence of much effective training they may adopt inappropriate ways of delivering bad news and coping with the emotional fall-out. Recognition of these difficulties has led to many initiatives, ranging from increased communication skills training to the development of guidelines and protocols. We review some of the research on the impact that giving sad, bad, and difficult news has on doctors and patients, and assess whether interventions are helping. We focus mainly on difficulties encountered involving parents in an obstetric or paediatric setting, people in acute trauma situations such as accident and emergency departments, and patients with cancer.