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Most patients, if they have cancer, want to be told about it, and they
want to know what the likely treatments are, the side effects of
treatment and their prognosis.1 A clear understanding of
prognosis can be particularly important in conditions such as breast
cancer, because patients need prognostic information to make
informed decisions about systemic treatment. So, how can this
information best be communicated?
Based on a literature review and recommendations of a consensus panel
of doctors (with input from patients with cancer), Girgis and
Sanson-Fisher2 published some useful
guidelines on conveying information to patients about serious
disease or death. Their guidelines included ensuring privacy and
allowing adequate time, assessing patients' understanding, giving
information about diagnosis and prognosis simply and honestly,
avoiding euphemisms, encouraging patients to express feelings,
being empathic, giving a broad but realistic time-frame concerning
prognosis, and arranging a review. The crucial question is how well
these recommendations are followed in clinical practice, as
discussing prognosis should be part of the process of breaking bad
news.
Audiotape recordings of consultations have shown that doctors break
the bad news of a cancer diagnosis to patients in a predictable and
routine way regardless of patients' individual information
needs.3 Although the doctors gave
reassurance that something could be done, few attempted to elicit
patients' thoughts and feelings about the symptoms and their cause.
They gave the information in a consistent order -- diagnosis, the
relevant evidence, the need for further investigations, the
treatments being considered and the probable outcome -- with no heed
to which issues patients wished to address first. Obvious verbal and
non-verbal cues of distress were not acknowledged and patients'
immediate concerns were not explored.
This consultation structure led patients to believe they were not
entitled to talk about their feelings or their major concerns.
Consequently, their preoccupation with these feelings and concerns
meant that they did not assimilate the information and advice given.
On being interviewed at the end of the consultation, patients
reported that they were left with important, but undisclosed,
concerns and also felt that the information given had been inadequate
for their needs.
The important article by Lobb and colleagues4 published in this issue of
the Journal looks at one aspect of breaking bad news
to cancer patients -- explaining prognosis to women with breast
cancer. It was clear from the women's answers to a questionnaire and a
clinical vignette that many had problems understanding prognostic
information in the form it is usually presented. The women also varied
considerably in what prognostic information they would like to
receive and how they preferred it to be presented. The study's
findings showed that not all women will desire or understand standard
methods of giving prognostic information.
It has been suggested that giving patients the opportunity to talk
with nurses after consultations in which they have been told they have
cancer, or have been given complex information about cancer
prognosis, would result in their disclosing concerns and
misunderstandings and these could then be fed back to the treating
clinicians.5 However, this solution
ignores important evidence that nurses are just as reluctant as
doctors to acknowledge patients' distress and elicit their
underlying concerns.6 Like doctors, nurses in
these situations have been found to adopt behaviours designed to
prevent further disclosure.7 These "blocking
behaviours" include telling patients that any distress is normal,
switching the subject to neutral topics, giving information and
advice before patients' concerns have been identified, focusing
only on physical aspects of the condition, and using leading, closed
and multiple questions.7
Doctors and nurses avoid exploring patients' feelings and concerns
because they fear that it will provoke too much emotion, which could be
harmful to patients.8 They feel that their
training has not equipped them with the necessary skills to explore
these issues and respond appropriately.9,10 Feeling that they are not
being supported emotionally and practically by colleagues and
supervisors has also been linked to a greater use of these "blocking
behaviours".6,11
The lack of adequate training of doctors and nurses in communicating
information to patients with cancer can have important negative
psychological consequences for the patients. The development of
clinical anxiety and depression is more likely when patients have
unresolved concerns and perceive that they have been given
inadequate information.12,13 So, how can these
communication deficiencies be remedied?
The data collected by Lobb et al4 could be used as a basis for
ongoing research to identify how best to structure and describe
prognostic information so that concepts such as "median survival"
and "relative risk" are made understandable. It would then be
possible to develop training programs in communication skills that
teach doctors how to elicit patients' preferences for information
about prognosis.
The use of intradisciplinary10 and multidisciplinary
workshops14 has been advocated. While
objective evidence of the value of intradisciplinary workshops is
awaited, multidisciplinary workshops have proved successful in
helping doctors and nurses acquire key communication
skills.14
Despite workshops being effective in changing key communication
behaviours, it is not certain how much of what is learnt is applied to
clinical practice. Two randomised trials are being conducted in the
United Kingdom in an effort to determine this. The Cancer Research
Campaign (CRC) Psychosocial Oncology Group is studying whether
training doctors in small groups enables them to be more effective in
communicating with patients and better able to cope with breaking bad
news and dealing with patient concerns. The CRC Psychological
Medicine Group is assessing whether senior doctors benefit from six
sessions of individual feedback on their "bad news" consultations
and whether this results in better patient recall and less patient
distress in future consultations (as measured by a patient interview
and the Hospital Anxiety and Depression Scale), as well as a
reduction in the level of burnout in the doctors themselves.
Without systematic training, the breaking of bad news and
discussions of cancer prognosis are likely to fall short of existing
guidelines and patients' needs and expectations. Consultations of
this type can be difficult and painful. Yet, for too long, we have
expected doctors and nurses to undertake these difficult tasks
without the necessary training and support.
G Peter Maguire
Consultant Psychiatrist; and Director Cancer Research Campaign
Psychological Medicine Group, Manchester, UK
- Meredith C, Symonds P, Webster L, et al. Informational needs of
cancer patients in West Scotland: cross sectional survey of
patients' views. BMJ 1996; 313: 724-726.
-
Girgis A, Sanson-Fisher RW. Breaking bad news: consensus
guidelines for medical practitioners. J Clin Oncol 1995; 13:
2449-2456.
-
Maguire P. Breaking bad news. Cambridge: Cambridge Handbook of
Psychology, Health and Medicine, 1998: 273-275.
-
Lobb EA, Butow PN, Kenny DT, Tattersall MHN. Communicating
prognosis in early breast cancer: do women understand the language
used? Med J Aust 1999; 171: 290-294.
-
Watson M, Denton S, Baum M, Greer S. Counselling breast cancer
patients: a specialist nurse service. Counselling Psychol Q
1988; 1(i): 23-31.
-
Wilkinson SM. Factors which influence how nurses communicate with
cancer patients. J Adv Nurs 1991; 16: 677-688.
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Maguire P. Barriers to psychological care of the dying. BMJ
1985; 291: 1711-1713.
-
Maguire P, Faulkner A, Booth K, et al. Helping cancer patients
disclose their concerns. Eur J Cancer 1996; 32A: 78-81.
-
Maguire P, Faulkner A. How to improve the counselling skills of
doctors and nurses in cancer care. BMJ 1988; 297: 847-849.
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Fallowfield L, Lipkin M, Hall A. Teaching senior oncologists
communication skills: Results from phase 1 of a comprehensive
longitudinal programme in the United Kingdom. J Clin Oncol
1998; 16: 1961-1968.
-
Booth K, Maguire P, Butterworth T, Hillier VT. Perceived
professional support and the use of blocking behaviours by hospice
nurses. J Adv Nurs 1996; 24: 622-527.
-
Parle M, Jones B, Maguire P. Maladaptive coping and affective
disorders in cancer patients. Psychol Med 1996; 26: 735-744.
-
Fallowfield LJ, Hall A, Maguire GP, Baum M. Psychological
outcomes of different treatment policies in women with early breast
cancer outside a clinical trial. BMJ 1990; 301: 575-580.
-
Maguire P, Booth K, Elliott C, Jones B. Helping health
professionals involved in cancer care acquire key skills -- the
impact of workshops. Eur J Cancer 1996; 32A: 1486-1489.
©MJA 1999
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