Bad News Consultations Research Articles

A bridge between cultures: interpreters’ perspectives of consultations with migrant oncology patients

Migration is increasing worldwide. In previous research into people with cancer from culturally and linguistically diverse backgrounds, interpreter accuracy, professionalism and continuity have emerged as key concerns for patients. Little is known about interpreters' perceptions of their role and the challenges they face. This study aimed to obtain their perspective. Thirty interpreters (Greek n = 7, Chinese n = 11, and Arabic n = 12) participated in four focus groups which were audio-taped, transcribed and analysed for themes using N-Vivo software. Skills as an interpreter were broadly perceived as conveying information accurately, being confidential and impartial. Three broad dilemmas faced by interpreters emerged: accuracy versus understanding; translating only versus cultural advocacy and sensitivity; and professionalism versus providing support. Some saw themselves as merely an accurate conduit of information, while others saw their role in broader terms, encompassing patient advocacy, cultural brokerage and provision of emotional support. Perceived challenges in their role included lack of continuity, managing their own emotions especially after bad news consultations, and managing diverse patient and family expectations. Training and support needs included medical terminology, communication and counselling skills and debriefing. Interpreters suggested that oncologists check on interpreter/patient's language or dialect compatibility; use lay language and short sentences; and speak in the first person. Resolving potential conflicts between information provision and advocacy is an important area of cross-cultural communication research. Further training and support is required to enhance interpreters' competence in managing delicate situations from a professional, cultural and psychological perspective; and to assist doctors to collaborate with interpreters to ensure culturally competent communication. Ultimately, this will improve interpreters' well-being and patient care.

Is it possible to improve residents breaking bad news skills? A randomised study assessing the efficacy of a communication skills training program

Background:This study aims to assess the efficacy of a 40-h training programme designed to teach residents the communication skills needed to break the bad news.Methods:Residents were randomly assigned to the training programme or to a waiting list. A simulated patient breaking bad news (BBN) consultation was audiotaped at baseline and after training in the training group and 8 months after baseline in the waiting-list group. Transcripts were analysed by tagging the used communication skills with a content analysis software (LaComm) and by tagging the phases of bad news delivery: pre-delivery, delivery and post-delivery. Training effects were tested with generalised estimating equation (GEE) and multivariate analysis of variance (MANOVA).Results:The trained residents (n=50) used effective communication skills more often than the untrained residents (n=48): more open questions (relative rate (RR)=5.79; P<0.001), open directive questions (RR=1.71; P=0.003) and empathy (RR=4.50; P=0.017) and less information transmission (RR=0.72; P=0.001). The pre-delivery phase was longer for the trained (1 min 53 s at baseline and 3 min 55 s after training) compared with the untrained residents (2 min 7 s at baseline and 1 min 46 s at second assessment time; P<0.001).Conclusion:This study shows the efficacy of training programme designed to improve residents' BBN skills. The way residents break bad news may thus be improved.

Hospital consultants breaking bad news with simulated patients: An analysis of communication using the Roter Interaction Analysis System

Objective To explore how experienced clinicians from wide ranging specialities deliver bad news, and to investigate the relationship between physician characteristics and patient centredness. Methods Consultations involving 46 hospital consultants from 22 different specialties were coded using the Roter Interaction Analysis System. Results Consultants mainly focussed upon providing biomedical information and did not discuss lifestyle and psychosocial issues frequently. Doctor gender, age, place of qualification, and speciality were not significantly related to patient centredness. Conclusion Hospital consultants from wide ranging specialities tend to adopt a disease-centred approach when delivering bad news. Consultant characteristics had little impact upon patient centredness. Further large-scale studies are needed to examine the effect of doctor characteristics on behaviour during breaking bad news consultations. Practice implications It is possible to observe breaking bad news encounters by video-recording interactions between clinicians and simulated patients. Future training programmes should focus on increasing patient-centred behaviours which include actively involving patients in the consultation, initiating psychosocial discussion, and providing patients with opportunities to ask questions.

How stressful is doctor–patient communication? Physiological and psychological stress of medical students in simulated history taking and bad-news consultations

Introduction Medical communication can be a stressful experience for both doctors and patients. In particular, inexperienced doctors facing the demanding task of a bad news consultation may experience high levels of distress. The aim of this exploratory study is to test students' differential cardiovascular reactivity to history taking and bad news consultations with a simulated patient, and to test the relation between the students' self-reported stressfulness of the consultation and their cardiovascular response. Methods Fourth and fifth year medical students ( n = 20) conducted a history taking (HT) and a bad news (BN) consultation in a randomized order with a standardized patient. Heart rate (HR), mean arterial pressure (MAP), cardiac output (CO) and systemic vascular resistance (SVR) were assessed by way of the Finapres-technique in four conditions: rest, reading aloud, and during both consultations. Self-reported stress was assessed before and after each interview using the State and Trait Anxiety Inventory (STAI), and a visual analogue scale (VAS). Results Both HT and BN provoked more cardiovascular stress than reading. Bad-news provoked the highest HR and CO responses compared to all other conditions, and had a greater impact when it was the student's first consultation. The STAI and VAS data showed some correlations with the cardiovascular stress measures and a comparable but less significant pattern in stress response. Discussion The effect of order of the HT and BN consultations on the students' stress levels suggests an additional impact of novelty and habituation. Unfamiliarity with the patient may enhance the stressfulness of the task of breaking bad news.

Doctorsʼ Stress Responses and Poor Communication Performance in Simulated Bad-News Consultations

No studies have previously evaluated factors associated with high stress levels and poor communication performance in breaking bad news (BBN) consultations. This study determined factors that were most strongly related to doctors' stress responses and poor communication performance during a simulated BBN task. In 2007, the authors recruited 24 doctors comprising 12 novices (i.e., interns/residents with 1-3 years' experience) and 12 experts (i.e., registrars, medical/radiation oncologists, or cancer surgeons, with more than 4 years' experience). Doctors participated in simulated BBN consultations and a number of control tasks. Five-minute-epoch heart rate (HR), HR variability, and communication performance were assessed in all participants. Subjects also completed a short questionnaire asking about their prior experience BBN, perceived stress, psychological distress (i.e., anxiety, depression), fatigue, and burnout. High stress responses were related to inexperience with BBN, fatigue, and giving bad versus good news. Poor communication performance in the consultation was related to high burnout and fatigue scores. These results suggest that BBN was a stressful experience for doctors even in a simulated encounter, especially for those who were inexperienced and/or fatigued. Poor communication performance was related to burnout and fatigue, but not inexperience with BBN. These results likely indicate that burnout and fatigue contributed to stress and poor work performance in some doctors during the simulated BBN task.

The impact of assessing simulated bad news consultations on medical students’ stress response and communication performance

Seventy second-year medical students volunteered to participate in a study with the aim of evaluating the impact of the assessment of simulated bad news consultations on their physiological and psychological stress and communication performance. Measurements were taken of salivary cortisol, systolic and diastolic blood pressure, heart rate, state anxiety and global stress using a Visual Analogue Scale. The subjects were asked to take three salivary cortisol samples on the assessment day as well as on a quiet control day, and to take all other measures 5 min before and 10 min after conducting the bad news consultation. Consultations were videotaped and analyzed using the information-giving subscale of the Amsterdam Attitude and Communication Scale (AACS), the Roter Interaction Analysis System (RIAS), and the additional non-verbal measures, smiling, nodding and patient-directed gaze. MANOVA repeated measurements were used to test the difference between the cortisol measurements taken on the assessment and the control day. Linear regression analysis was used to determine the association between physiological and psychological stress measures and the students' communication performance. The analyses were restricted to the sample of 57 students who had complete data records. In anticipation of the communication assessment, cortisol levels remained elevated, indicating a heightened anticipatory stress response. After the assessment, the students' systolic blood pressure, heart rate, globally assessed stress level and state anxiety diminished. Pre-consultation stress did not appear to be related to the quality of the students' communication performance. Non-verbal communication could be predicted by pre-consultation physiological stress levels in the sense that patient-directed gaze occurred more often the higher the students' systolic blood pressure and heart rate. Post-consultation heart rate remained higher the more often the students had looked at the patient and the more information they had provided. However, the heart rate appeared to diminish the more often the students had reassured the patient. These findings suggest that in evaluating students' communication performance there is a need to take their stress levels into account.

Receiving bad news: patients with haematological cancer reflect upon their experience

The literature on breaking bad news (BBN) tends to focus on professional consensus rather than empirical patient evidence--the 'giver' rather than the 'receiver'. Using semi-structured interviews, this study explores the experiences of patients with haematological cancer as they reflect on the process and content of receiving bad news. Fifteen patients with a diagnosis of leukaemia or lymphoma were recruited through a haematology service during a routine clinical visit, with the decision to participate being made later. Interviews were audiotaped, transcribed and analysed using thematic content analysis. Patients place importance on not being rushed during the bad news consultation and the doctor's manner. Receiving bad news was the first step on a journey, not an isolated incident. Doctors were regarded as the best judge of their information needs, with leaflets and written summaries as supplements. Patients had strong preferences about continuity and language use. Displays of empathy were important, but must be genuine. Patients wanted to know about likely emotional reactions and future support. Where patients brought a companion, they found this valuable. Patients concur with much of the content of the guidelines, but place more emphasis on their illness journey, the doctor's ability to adapt to their emotional needs, language used, information leaflets, having a companion and genuinely personalizing the approach. Reflection on these patient-derived factors may help health professionals better serve patients with serious illness.

Increasing social and psychological information conveyed to General Practitioners after bad news consultations by use of separate letters from the Lung Cancer Nurse Specialist

Multidisciplinary teams (MDT) now review all cases of lung cancer. These teams include a Lung Cancer Nurse Specialist (LCNS). These Nurses help support the patient and should facilitate communication and liaise with other services. The LCNS is present when the diagnosis is given to the patient but also usually spends time afterwards with the patient and their family. We postulated that a separate letter from the LCNS to the General Practitioner (GP) after the consultations would convey extra information to the GP. In 58 new lung cancer patients reviewed in the clinic, the LCNS and Physician independently wrote separate letters after the consultation in which the diagnosis of lung cancer was given. The GPs were asked by questionnaire about the usefulness of the letter from the LCNS. This letter was considered by the GP to provide extra information in: (i) 69% concerning the patients reaction to the diagnosis; (ii) 85% concerning who attended the clinic with the patient; (iii) 85% about what referrals were made to community services; (iv) 86% about who the patient was living with; (v) 81% about who the patients carers were; (vi) 81% information on the patients condition; (vii) 70% concerning the information given to patients about benefits. Ninety-seven percent of the GPs found the LCNS letter useful or very useful and 92% of the GPs thought that the information in the letter would be useful or very useful when they next saw the patient. Separate and independent letters from the LCNS after “bad news” consultation in lung cancer provides added useful information for GPs. Ninety-one percent of the GPs wanted the letters from the LCNS to continue.

Increasing social and psychological information conveyed to General Practitioners after bad news consultations by use of separate letters from the Lung Cancer Nurse Specialist

<h2>Abstract</h2> Multidisciplinary teams (MDT) now review all cases of lung cancer. These teams include a Lung Cancer Nurse Specialist (LCNS). These Nurses help support the patient and should facilitate communication and liaise with other services. The LCNS is present when the diagnosis is given to the patient but also usually spends time afterwards with the patient and their family. We postulated that a separate letter from the LCNS to the General Practitioner (GP) after the consultations would convey extra information to the GP. In 58 new lung cancer patients reviewed in the clinic, the LCNS and Physician independently wrote separate letters after the consultation in which the diagnosis of lung cancer was given. The GPs were asked by questionnaire about the usefulness of the letter from the LCNS. This letter was considered by the GP to provide extra information in: (i) 69% concerning the patients reaction to the diagnosis; (ii) 85% concerning who attended the clinic with the patient; (iii) 85% about what referrals were made to community services; (iv) 86% about who the patient was living with; (v) 81% about who the patients carers were; (vi) 81% information on the patients condition; (vii) 70% concerning the information given to patients about benefits. Ninety-seven percent of the GPs found the LCNS letter useful or very useful and 92% of the GPs thought that the information in the letter would be useful or very useful when they next saw the patient. Separate and independent letters from the LCNS after "bad news" consultation in lung cancer provides added useful information for GPs. Ninety-one percent of the GPs wanted the letters from the LCNS to continue.

Effect of breaking bad news on patients' perceptions of doctors

The breaking of bad news is a routine but difficult task for many health professionals. There are numerous anecdotes of insensitive practice but the subject has attracted little systematic research. We therefore interviewed 106 patients with advanced cancer (from an original sample of 195) to assess their perceptions of the doctors involved in their care. Aspects of the 'breaking bad news' event were recorded during discussion of the illness history and were subsequently rated. Participants were also asked to nominate doctors under the headings 'most helpful' and 'less helpful', and completed standardized psychological screening questionnaires. In 94 of the 106 cases the bad news had been given by a doctor, usually a surgeon. Of the 13 doctors categorized as 'most helpful' when breaking bad news, 8 were general practitioners; of the 7 categorized as 'less helpful' all were surgeons. 69% of patients were neutral or positive about the bad-news consultation, but 20% were negative and 6% very negative. Doctors in surgical specialties were significantly more likely to be rated poorly than non-surgical specialists or general practitioners. Surgeons were the group of doctors most likely to break bad news, but non-surgical doctors were rated more positively in performance of the task. This finding has implications for training.

Effect of breaking bad news on patients' perceptions of doctors.

The breaking of bad news is a routine but difficult task for many health professionals. There are numerous anecdotes of insensitive practice but the subject has attracted little systematic research. We therefore interviewed 106 patients with advanced cancer (from an original sample of 195) to assess their perceptions of the doctors involved in their care. Aspects of the 'breaking bad news' event were recorded during discussion of the illness history and were subsequently rated. Participants were also asked to nominate doctors under the headings 'most helpful' and 'less helpful', and completed standardized psychological screening questionnaires. In 94 of the 106 cases the bad news had been given by a doctor, usually a surgeon. Of the 13 doctors categorized as 'most helpful' when breaking bad news, 8 were general practitioners; of the 7 categorized as 'less helpful' all were surgeons. 69% of patients were neutral or positive about the bad-news consultation, but 20% were negative and 6% very negative. Doctors in surgical specialties were significantly more likely to be rated poorly than non-surgical specialists or general practitioners. Surgeons were the group of doctors most likely to break bad news, but non-surgical doctors were rated more positively in performance of the task. This finding has implications for training.

Cue-responding in a Simulated Bad News Situation: Exploring a Stress Hypothesis

The stress-coping paradigm of Folkman and Lazarus (1984) was applied to investigate if the communicative reactions of the physician in a bad news transaction are related to the stressfulness of the situation. A standardized video bad news consultation was presented to 88 medical students. To examine their communicative reactions we selected 10 patient cues with different levels of expressed emotion to which the participants responded from the physician's point of view. A strongly positive relationship between expressed emotion and perceived difficulty of the cues and a gender effect occurred, confirming that handling emotions is stressful for physicians. The reluctance of physicians to address the emotionally laden issues of the consultation can be understood as a lack of a frame of reference. The problem-solving strategies, which they apply in the instrumental domain of the consultation, are ineffective when dealing with psychosocial suffering.

How should doctors communicate the diagnosis of cancer to patients?

The majority of doctors in North America, Australia and much of Europe now inform patients about a cancer diagnosis. However, many doctors report that they have difficulty disclosing a cancer diagnosis. Poor doctor-patient communication skills may lead to psychological distress including increased anxiety and depression and poorer psychological adjustment to cancer. Presenting ‘bad’ news in an unhurried, honest, balanced and empathic fashion has been shown to produce greater satisfaction with communication of the news. Consensus guidelines have been developed to assist doctors to disclose a cancer diagnosis. Important aspects include exploring the patient's expectations, warning him/her that the news is bad, giving the news at the patient's own pace, allowing time for the patient to react and eliciting the patient's concerns. Doctor-patient communication can be improved by including training courses in communication skills for medical students and clinicians and providing audiotapes of bad news consultations to enhance patient recall of information and increase patient satisfaction with communication. Additional research is needed to investigate effects of strategies to implement guidelines for delivering a cancer diagnosis.

Can oncologists detect distress in their out-patients and how satisfied are they with their performance during bad news consultations?

Recognition of psychological distress in patients with cancer, some of which can be ameliorated with appropriate intervention, is a crucial aspect of patient care. Previous studies, with the exception of one, indicate that oncologists often fail to detect general distress and do not identify those patients with significant psychological disorder. As approximately 25-30% of patients experience anxiety and/or depression severe enough to merit psychological intervention, this is a serious problem. This study assessed the ability of five oncologists to recognise distress in newly referred out-patients who were receiving bad news. Self-report measures of the oncologists' satisfaction with their performance during the bad news interviews were also collected. Each patient had two clinical interviews in which information concerning diagnosis and treatment were given. Prior to each interview patients reported their own levels of distress by completing two self-report questionnaires. These were correlated with the ratings of distress and satisfaction made by each clinician on a visual analogue scale after each interview. Only one oncologist's ratings consistently correlated with patients' self-reported scores. The clinicians tended to under-rate the distress in their patients and were mostly satisfied with their performances during each interview. The ability to detect distress varied between each clinician and confirmed the conclusions of past studies that oncologists would benefit from up-grading their psychological assessment skills.