Circumstances Related to the Reporting of Bad News in the Medical Profession

Introduction

Communicating bad news in medicine is a challenge for all healthcare professionals and they are often poorly prepared for such moments. This process includes not only skills that medical professionals have acquired in their training and experience with patients, but also personal viewpoints, e.g., the professionals’ perceptions of life and death in general, specific life experience and identification with the patient and his/her situation, and transfer of emotions related to situations in their own life, associations with relatives and close friends.

The patients with their problems and emotions present an important party in the process of communicating bad news. At the same time the healthcare professionals with their experience, emotions and personal background are also an intrinsic part of this process. Some healthcare professionals will bring up the bad news to many patients, and they must maintain their own mental balance and emotional state in order to be available to help the patients.

Perceiving some news as bad usually relates to consideractions about the changes that could occur after bringing up the news. How bad the news is for the patient depends to a great extend on the patients' expectations, the nature of the illness, and whether or not the patient suspects the diagnosis (Buckman, 1984).

There are many factors which interfere with the health professionals’ attempts to disclose the bad news in a clear and calm way, e.g. the professionals’ own anxieties and fears especially hinder the start of the conversation or who is taking the responsibility for managing disease and the treatment (Buckman, 1984). This probably is related to insufficient followup statement about the true patient’s health status as well as attempts to avoid certain words.

Among the most common potential areas of improvement of the perception of the bad news are the knowledge of the patient expectations, the speed and timing of presenting the news to the patient, the incremental presentation of the information, sharing of troublesome information warning, allowing the patients to express their emotions and worries (Ellis & Tattersall, 1999), following the patient’s pace, avoidance of medical jargon and euphemism and answering of the patient’s questions (VandeKieft, 2001). The medical professionals should give enough time for the conversation, they must insure high quality of the information and facilitate the patient’s understanding, provide emotional support and allowing expression of emotions (Fujimori et al., 2005).

When receiving the bad news, the patients usually expect both empathy and complete information (Munoz Sastre at al., 2011) and this process is an important part of the adaptation of the patient, Phipps, Cuthill, 2002). Patients often state they want their doctors to provide them with realistic information, to include them in the discussion of the prognosis, and to give them clear answers to their questions. Raising the hope of the patient depends on the possibilities to have modern methods of treatment, more clever and well informed doctor, and a promise to keep the pain under control. Most patients worry that doctors feel nervous about reporting the bad news, or give the prognosis to the family first and use euphemisms. As a result, the patients feel less hopeful about the outcome of the treatment (Hagerty et al. 2005). Also, the medical professionals must be careful, because the patients’ preferences for inclusion in the process could be unstable and the situational factors may alter the needs for information (Butow et al., 1997).

A review of several studies in the field indicates that the patients’ preferences to communicating bad news includes four components: setting, manner of communication, emotional support, type and completeness of information. The review also finds that patients‘ preferences are associated with their age, gender and educational level. Younger patients, female patients and highly educated patients want to have detailed information and they are expecting more emotional support (Fujimori & Uchitomi, 2009).

Many medical professionals believe that delivering bad news is related to skills that are of great importance, the ability to respond to the patients’ verbal and non-verbal signals (Bennett, Alison, 1996), and to manage their own reactions to death and dying (Fields, Johnson, 2012). The medical professionals need to be trained and taught in communicating the bad news in addition to training in diagnostics and therapy in medicine in general. Thus, training courses in communication skills are recommended to enhance the perception of information and the patients’ satisfaction (Monden, et al. 2016, Rabow & McPhee, 1999). In addition, the competency in the bad news communication skills should be included in the core curriculum for the health care training and education (Minichiello et al., 2007). Important personality characteristics include reflection skills and the ability to show empathy and to care.

Participants and Methods

The study included 232 health specialists /144 doctors and 88 nurses/ with different professional experience from healthcare facilities in Bulgaria – demografic data table 1. The participants were asked to fill in a survey with questions related to bad news disclosure. It aimed to find: (i) the most common difficulty in communicating the bad news to cancer patients, (ii) the most difficult aspects of that information, and (iii) the specific words the medical professionals prefer to avoid when communicating the bad news.

Table 1 Demographic data

The results present the number of answers provided by each participant and the distribution of those answers as a percentage. Every health care professional had the opportunity to give more than one answer to the questions included in tables 3, 4 and 5 and the percentages have been calculated based on the total number of participants.

Results

The first question of our survey attempts to find the most common answers that the healthcare professionals give to cancer patients in response to the direct question "Do I have cancer?". This question is of a great importance to the communication with the patient, because after hearing it the doctor clearly understands that the patient wants to know the truth about his/her diagnosis. Also, the Bulgarian Health Law states that every patient is entitled to clear and accessible information about his/her health and the methods of treatment and every patient must have an access to the medical records related to his or her diagnosis and treatment (Bulgarian Health Law, 2018). Therefore, the question checks what types of responses the healthcare professionals give to the cancer patients when they are sure that the patients want to know their diagnosis and the situation requires an honest answer.

Table 2 Survey question: How do you usually answer a patient who has cancer when he/she asks you, “Do I have cancer?”

The next survey question is related to the separate parts of the information needed to be disclosed after the definitive answer about the diagnosis. The assumptions include the prognosis and life expectancy, the meaning of the word cancer itself, the existence of metastasis that is associated with the prognosis and the possibility of complete cure, the need for heavy and/or painful treatment, in this case chemotherapy. These topics often generate communication difficulties and health professionals would like to avoid them. /Every health professional had the opportunity to give more than one answer and the percentages have been calculated based on the total number of participants/.

Table 3 Survey question: If your patient has cancer, what part of the information is most difficult to share?

The next survey question is related to the frequent complaints from patients that the healthcare professionals often use euphemisms and difficult words when communicating the bad news. The question is related to the most difficult words and the attempts of the healthcare professionals to avoid them and try to cope with their own emotions and the transfer of their personal experience to the current situation. /Every health professional had the opportunity to give more than one answer and the percentages have been calculated based on the total number of participants/.

Table 4 Survey question: If the patient has cancer, which words do you prefer to avoid?

The last survey question probes the factors that interfere with the communication of the bad news. The expectation here was related to the common problems with the patient’s relatives in Bulgaria who play an important role in such communication. Often, the relatives believe that the bad news disclosure will shorten the patients’ life, because he will not be able to overcome the illness if he knows his life expectancy. /Every health professional had the opportunity to give more than one answer and the percentages have been calculated based on the total number of participants/.

Table 5 Survey question: What is most interfering with communicating bad news?

Discussion

Only 66% of the health professionals tend to respond directly to the question of the cancer patients “Do I have cancer?” and definitely say „Yes“ when answering it . About ¼ of them give vague answers that they are not able to say the definite “Yes”. It is important to notice that answering the patient’s question it is not a matter of examining of the patient's wishes, his/her emotional state, and the willingness to hear the answer. Here, the health professionals are asked only about their answer to the the patient’s question "Do I have cancer?" However, only 66% of healthcare professionals in this group are able to give a definite answer to this clear question.

The most difficult part of the information is related the prognosis and life expectancy. Traditionally, it is difficult for Bulgarians to talk about death. Many of them also believe that talking about death makes a prophecy for a short life and the only way to overcome a serious illness is to think and talk positively. Probably, many healthcare professionals also experience identification with the patient and have difficulties in communicating the facts about the short life expectancy due to projections to their own experience and the idea that every human life is limited.

The most commonly avoided word is “cancer”, followed by “formation” and “tumor”. This is probably related to the healthcare professionals' attempts to avoid direct communication related to the diagnosis and the idea that the word "cancer" brings extreme anxiety and tension in the patient and his/her relatives.

The most difficult part of the communication is the fact related to the fatality of the disease, and the conversation about imminent terminal prognosis followed by the problem that is often generated by the relatives, the request to the healthcare professionals not to report the diagnosis to the patient. This obviously is related to the fatality of the potential outcome and the other difficulties that the healthcare professionals enlist to be associated with the short life expectancy. Other difficulties identified by the healthcare professionals are related to the low level of education of the patients and their poor cognitive abilities.

Conclusions

Many healthcare professionals in our study report problems in communicating directly the diagnosis and naming the illness with the proper words. The most important part of this process relates to the prognosis, life expectancy, and terminal outcome. The information concerning the diagnosis and its sharing in response to direct questions is an interesting aspect of this study especially in the context of the regulations and laws in the country. According to the law, the patient has the right to know and be completely informed about his/her medical problems. The situation is exactly the same, even if the relatives want the patient not to be informed about the diagnosis, the life expectancy and the upcoming therapy.

The survey makes clear that the healthcare professionals need adequate knowledge and skills to talk clearly and openly with the patients, complying with their emotions and desires, while keeping their own capabilities to reflect without accumulating additional negative feelings about themselves from any conversation related to the bad news.

References:

Tables

Table 5. Cross tabulation Lacunar Stroke – Plaques number at pre bulbar segment level

Table 2 Survey question: How do you usually answer a patient who has cancer when he/she asks you, “Do I have cancer?”

Table 6. Cross tabulation Lacunar Stroke – Plaques number at carotidal bulb level

Table 3 Survey question: If your patient has cancer, what part of the information is most difficult to share?

Table 7. Cross tabulation Lacunar Stroke – Plaques number at

Table 4 Survey question: If the patient has cancer, which words do you prefer to avoid?

Table 8. Cross tabulation Lacunar Stroke – Plaques number at

Table 5 Survey question: What is most interfering with communicating bad news?