Communication Pitfalls with Cancer Patients: “Hit-and-Run” Deliveries of Bad News
Surgeons deliver bad news frequently in the course of their careers.1 Much has been written about the difficulties inherent in delivering bad news, particularly in the context of cancer patients.[2] and [3] Back and colleagues4 argue that, although physicians often learn interviewing skills, their training does not include a focus on second-order communication skills, such as conveying empathy and understanding, which are critical to successful communication in cancer care and other domains in which communication of bad news is common. Complicating this lack of training in second-order communication is that doctors can experience high levels of emotions when caring for cancer patients. Discussing bad or difficult news is potentially stressful for both physicians and patients.5 From research, we know that there is a relationship between the communicator’s emotions and the way communicative interactions unfold.[6] and [7] The comfort level of a physician can lead to less productive patterns of communication, which are challenging for both the physician and the patient. Many surgeons are, through intuition, study, or practice, highly skilled at delivering bad news and at negotiating patients’ reactions to bad news empathically. Some find that their lack of training or discomfort with emotionally charged, negative information at times leads to unpleasant communication interactions.
There have been many attempts to craft communication training for health professionals, specifically among medical oncologists, because of the nature of their practice and the frequency with which they must deliver bad news.8 As for communication training among surgeons, Davidson3 asserts that communication skills should be integrated throughout surgical training curricula as a core aspect of the training. There continue to be instances where, despite training of all kinds, mishaps occur.9 The following case illustrates such an incident:
A 71-year-old woman with a long smoking history was admitted with a 3-week history of increasing shortness of breath. She was found to have a mass in the left lung, mediastinal adenopathy, and a left pleural effusion. Her effusion was drained, her reactive airways disease was improved with nebulizers and oxygen, and a biopsy was performed through bronchoscopy on the third hospital day. On the fifth hospital day, the physician was called with the results of her biopsy, poorly differentiated adenocarcinoma consistent with a lung primary. Five minutes later, nervous and anxious, the physician knocked on the patient’s door, entered, and stood at the foot of her bed. “Mrs S, we have gotten the results of your biopsy back. The pathologists are telling us that you have lung cancer,” the physician said.
She replied, “Are you sure that is what it is?”
“Yes,” he said. “I am afraid this is a very serious situation. We will have the oncologist see you. You should probably prepare to get some of your affairs in order, as the survival rates from this kind of cancer are very low. I’m sorry to be the one to tell you” [pager goes off]. “I need to run to an emergency … I’m sorry … I’ll be back around to talk more about it later.”
This article explores some of the circumstances that can lead to this kind of problematic interaction. We offer a way to consider how an understanding of patients’ unspoken “rules” about the delivery of bad new can illuminate more productive ways of communicating bad news.
Physician factors and difficult communication
Learning devastating truths about patients, truths patients themselves might not even be able to comprehend fully, is an enormous weight for physicians to carry.6 In addition, the “hectic pace of clinical practice may force a physician to deliver bad news with little forewarning or when other responsibilities are competing for the physician’s attention.”6 For some, the weight of telling necessary truths can be too much to bear, and the lack of time can compound those feelings. The combination of these conditions can necessitate a way of releasing the emotional pressure. One possibility, as illustrated in the case presented here, is the “dumping” of bad news, or being insensitively blunt.10 There is evidence that this kind of “hit-and-run” delivery of bad news is not uncommon.9 Yet, such occurrences can be devastating for patients and their families.
The hit-and-run method of delivering bad news illustrated in the case here might seem preferable to an inexperienced physician because it permits a kind of “quick disposal” of weighty and emotionally charged information, information that—properly—belongs to the patient. To the physician, this approach can appear an efficient choice. It is likely that any advantage in time gained by using hit-and-run deliveries becomes short-lived for the physician, given the ultimate pain and emotional chaos it can cause patients and their families. Although there appears to be no empiric information about how frequent such hit-and-run deliveries of bad news occur, or self-reported data about physicians’ reasons for using them, we turn to research that considers this type of communicative message choices within the context of disclosing information that can be perceived as potentially stress-producing.[11] and [12] It is likely that hit-and-run deliveries result from pent-up pressure to tell, physicians’ own emotional discomfort, perceived lack of time, and insufficient training in empathic communication skills.
Physicians who commit hit-and-run deliveries are probably not intentionally insensitive. Instead, this phenomenon has more to do with the difficulty of carrying an informational burden and not being armed with communicative skills to make productive choices about the disclosure of bad news.[12] and [13] In fact, the need to relieve informational burdens is not unique to physicians, people in many circumstances experience this phenomenon.14 For the physician, the guardianship role and the prospect of disclosing bad news to a patient in his or her care can trigger feelings of uncertainty about the way the diagnosis or prognosis might be received.15 Research has highlighted the trepidation people feel about making disclosures that have the potential to burden others.16 Often, in circumstances where people need to tell bad news, they might opt for topic avoidance rather than suffer the consequences of making a disclosure.17
Because physicians do not have the option of topic avoidance indefinitely, when they project that the emotional burden is too great for information they must disclose, they might feel the need to “dump” the truth on the receiver. Opting for the use of hit-and-run delivery of bad news can also be seen as a way to preclude additional discussion immediately after the disclosure and to temporarily limit involvement with the patient or the patient’s family. Lefebvre and Levert15 argue that, in general, “physicians and professionals who have to tell people about a serious illness or one that will affect the life of patients and family alike often feel a sense of powerlessness and failure.” For physicians, when a patient’s medical information becomes too difficult to handle, one way to relieve the burden of having to tell something that will unequivocally result in a negative reaction is to get rid of it as soon as possible.[11] and [12] The intense nature of the information generates its own kind of pressure.
No doubt physicians who have fallen prey to such a strategy would like to do a better job, but breaking bad news and communicating with distressed patients are some of the most important yet challenging tasks required of doctors.18 Clearly, patients want to be informed, yet, they also do not want to be traumatized by the way the information is conveyed.19 To understand the intersection between the patient’s perspective and physician’s actions, we frame the dynamics of hit-and-run deliveries, using the evidenced-based theory of communication privacy management (CPM).12
Understanding the dynamics of the hit-and-run delivery of bad news: interface of patient and physician
Hit-and-run deliveries of bad news can leave patients, particularly cancer patients, cognitively unable to grasp the content of the disclosures about their conditions.20 Patients often know that something is wrong with them, but they are frequently unprepared for the impact of a new cancer diagnosis. Hit-and-run deliveries of bad news have the potential to blindside patients. Such life-altering news is emotionally laden, not only for the patient, but also for the patient’s family—the uncounted additional victims.21 CPM theory is useful in explaining the rules, usually unspoken, surrounding disclosures of private information, and the multilevel injury that occurs when hit-and-run deliveries of bad news occur. CPM theory, in fact, predicts the kind of devastation patients and families can experience when emotionally laden medical information is unloaded unexpectedly.
According to CPM theory, patients see physicians as “stakeholders” of the medical information they disclose during the course of their illness or that is elucidated by medical testing.12 Consequently, they assume that the physician will treat their important medical information, and them, with respect because they believe the physician shares the responsibility of caring for the information. Hit-and-run deliveries violate the implicit rules that patients have about how physicians should uphold their role as important stakeholders of critical medical information. Because physicians are seen as having a stake in the information, unloading the burden of bad news without taking their rightful responsibility for management of the medical information violates an implicit contract patients believe they have with their physician. Patients are left to endure the emotional burden by themselves because they see the physician not holding up his or her end of the bargain. The physician has not upheld the role of stakeholder where medical information is concerned.
Stakeholder dynamics surrounding medical information also highlights the unique obligations of the doctor−patient relationship.12 Physicians are in the distinctive position of caring for information that is theirs only by virtue of their position. Physicians acquire information that does not properly belong to them, yet both they and their patients co-own the information. Complicating this notion is the fact that, by definition, physicians always know about a devastating diagnosis and prognosis, including the far-reaching implications of the information, before the patient. Finally, physicians have a fiduciary responsibility toward patients who bear the consequences of the information. This additional set of obligations is unidirectional.
The dilemma created by possessing important health information that concerns someone else is not entirely idiosyncratic to medical professionals. Most of us are, at one time or another, made co-owners or shareholders of other people’s private information.12 For example, if we happened to discover a husband who is cheating on his wife, we would debate whether to tell his wife. The difference in medical contexts is that physicians are obligated to deliver the bad news, but the friend might opt to keep the knowledge secret. This confluence of obligations—knowing and having a stake in information about medical conditions of patients before they are aware of it and, simultaneously, having obligations toward patients that are implicit in the doctor−patient relationship—makes physicians stakeholders in ways that are substantively different from the husband−wife example given. Physicians have a duty to disclose the information no matter how they feel or to what extent the revealed information can impact the patient.22 In an ethical sense, they must also consider the emotional health of the recipient as part of their broader concern for the patient’s good. This last obligation can, in part, be the source of some of the stress that the obligations to communicate bad news engenders in physicians.
Patients have a strong sense of this implicit relational contract.18 Consequently, the hit-and-run delivery of bad news can leave them feeling duped, not only because they expect a physician to help them understand their medical condition, but also because they implicitly consider that the physician is a stakeholder in the information, and hold physicians responsible for caring for it appropriately. Patients, no doubt, see the situation as something that both they and their physician are “in” together.18 So the hit-and-run delivery of bad news entails two errors on the part of the physician: the first is the violation of the rules of a stakeholder of information as defined by the patient (most of which can be considered universal), and the second is a violation of responsibilities inherent in the doctor−patient relationship, which includes respect for personhood and information (such as prognosis) that can alter the profoundest parts of a patient’s sense of self.
Suggestions for change
Clearly, there are more adaptive ways to communicate a diagnosis or a prognosis to patients. Several authors have offered reflective systems that can be used to improve the communication and reception of bad news.[23], [24], [25] and [26] Common factors among these approaches are that patients should receive some advance warning that the bad news is forthcoming, the circumstances under which the delivery is made should be as caring and uninterrupted as possible, and a reasonable amount of time should be allotted for questions, answers, reflection, and grieving. Maynard10 has shown that sending a warning signal that bad news is forthcoming—that he calls “forecasting”—is received better by patients than stalling or being blunt.
Prognostic information probably falls into a category of information in which no casual exchanges of information are permissible. Just as one would not make an offhand, casual, or brief remark concerning the sexual lives of one’s patients, discussing important diagnostic or prognostic information without carefully considering the rules, implicit or explicit, which govern how patients want such information to be communicated (and have the right to define) is also to be avoided.
Reducing the tendency to commit hit-and-run deliveries of bad news is an admirable goal. We offer several guidelines drawn from communication privacy management theory that can help some physicians interact with patients in more productive ways.12
Allowing time and space for communication of bad news
Although self-evident, there should be no brief conversations with cancer patients about any important aspect of their condition. Patients should be permitted to dictate the length of the conversation; ie, the conversation ends when the patient has nothing more to add. Sometimes waiting to see if there are any additional cues communicated by the patient gives the patient a chance to collect his or her thoughts, as illustrated in the review by Zimmermann and colleagues.27 Eggly and colleagues28 have demonstrated that some of our most basic assumptions about communication of bad news can, in fact, be incomplete. For example, we might not always be able to predict what patients perceive to be bad news, and because we cannot always predict what constitutes bad news, we might not always be able to prepare ourselves and patients for talking about it. Their suggestion, based on their research, is to institute a kind of “universal precaution” with cancer patients, applying strategies for discussing bad news to all interactions in which information is discussed because any information has the potential to be perceived as bad news.
Awareness of one’s own emotional state
As we have pointed out, delivering bad news is stressful.18 Being aware of the stress level a physician feels when it becomes necessary to communicate bad news allows the physician time to prepare for the important conversation and to recognize a kind of “danger zone.” Learning to be cognizant of this internal response can allow one to take the time to consider the whole process of communicating bad news before it takes place and resist the urge to “get it off one’s chest” too quickly. Back, Baile, Lenzi and their colleagues[23], [24] and [29] have shown that reflecting on one’s own feelings is an essential element in overcoming the tendency to react in nonadaptive ways to patients’ strong emotional reactions in the face of bad news. Adaptive communication strategies can make physicians less likely to use such strategies as giving false hope, providing premature reassurance, or offering ineffective therapies. Clearly, preventing the temptation to use a hit-and-run strategy needs to be included in the training of young surgeons. When the clinician becomes aware of his or her own attitudes and, in particular, any uneasy feelings about the disclosure of bad news, it is likely to become easier to avoid these kinds of communication pitfalls. With practice and training, particularly for students and residents, this kind of self-preparation can be a part of every patient encounter involving the delivery of bad news.
Stakeholder rights and responsibilities
When physicians approach patients, they should do so with the knowledge that patients see them as both a partner and a stakeholder in managing their important medical information. Patients clearly believe that the information physicians know about them still belongs to them, but that same access makes physicians integral stakeholders of the information and not detached bystanders. A useful perspective is to keep the magnitude and the seriousness of the information delivered to the patient in appropriate perspective. Although in the day-to-day work environment it might be difficult, it seems essential to remind ourselves that the information we give to patients about their diagnosis and prognosis carries a much larger burden for them than it does for us.30 Finally, recognizing that silence is an important tool during these transition times is often helpful for patients. Giving “space” by tolerating silence meta-communicates willingness to offer the patients time to “digest” the information, so they can consider what it means to them. Silence in this situation also suggests that the physician is giving the time to the patient and cares about him or her as an individual.
In conclusion, we have identified, framed, and named a phenomenon that occurs in medical practice: the hit-and-run delivery of bad news. Our discussion here has attempted to highlight several issues. First, as the bearers of bad news, physicians must battle the natural tendency to relieve informational burdens by disclosing them quickly and moving on. Training in communication skills can be one means of combating this tendency and can provide clinicians with a set of skills to draw on so that other more productive choices will be made.29 Second, we suggest that there are issues of information management that are relational between physicians and patients. From research, we know that patients have certain expectations about how they think their private medical information will be treated by their physician.18 Hit-and-run deliveries of bad news necessarily violate those expectations of responsibilities as a stakeholder on the part of a physician. Third, bad news, particularly concerning cancer, is emotional. Physicians need training to become familiar with ways to manage their own complex emotions so that they can more effectively engage in these challenging interactions with patients.
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Correspondence address: Paul R Helft, MD, Department of Medicine, Division of Hematology/Oncology, Charles Warren Fairbanks Center for Medical Ethics, Indiana University Center for Bioethics, Indiana University Cancer Center, Indiana University School of Medicine, 535 Barnhill Drive, RT 473, Indianapolis, IN 46202.
Journal of the American College of Surgeons Volume 205, Issue 6, December 2007, Pages 807-811
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