Breaking Bad News Is a Key but Frequently Neglected Oncology Nursing Skill

Brief training can improve the effective communication of bad news to patients with cancer, according to a recently published randomized controlled trial and a separate evidence-based review.[1,2]

As clinical oncology has moved from physician-centered to patient-centered models of care, patient autonomy-informing patients and incorporating their wishes, values, and goals into treatment decision making-has become more widely embraced, noted the authors of the randomized controlled trial.[1] But breaking bad news to patients remains one of the most emotionally difficult communication challenges that cancer clinicians face-a task that some clinicians therefore avoid or delay, sometimes in an effort to “spare” patients from experiencing stress.[1-4]

Effectively disclosing new information to patients that is likely to “drastically and negatively” alter their view of life is a complex, multistep process that involves preamble discussions aimed at gauging patient understanding and readiness; unambiguous communication of the bad news that clearly details prognostic implications and treatment options; and then confirming patient understanding.

A number of consensus statements, recommendations, and protocols have been published over recent decades to guide how oncology nurses and others break bad news to their patients.[1,2,5] Using such frameworks, oncology nurses and other members of the cancer care team can more effectively communicate unwelcome but important information to patients.[2] Unfortunately, however, because training tends to be “labor intensive and time consuming,” breaking bad news is not a formal component of clinician education at many nursing programs.[1]

To determine if brief communication skills training modules can improve performance, the study authors of the randomized controlled trial randomly assigned 66 medical students and residents to complete the module or to serve as control-group participants, ahead of a Objective Structured Clinical Examination (OSCE) assessment.[1] The authors developed five 1-hour videos and readings–based training modules using interviews with patients.

The authors of the trial found that most OSCE scores of students were significantly higher for the intervention group as compared with the control group.[1] Improvements were statistically significant for three measures: breaking bad news scores (effect size r = −0.47; P = .007), attention to patient responses after breaking bad news scores (r = −0.74; P < .001), and communication related to patient emotions (r = −0.30; P = .034).[1]

“While improvement was demonstrated in most skill areas, some differences were found between students and residents,” the authors noted. “For example, after training, residents improved active listening skills, were more likely to address patient emotions, and to close the interview effectively by identifying patient perspectives, explaining impressions, establishing mutual responsibility, and checking for understanding, agreement, and feasibility.”[1]

Students, in contrast, were more likely to wait or pause after initially delivering that they have bad news to convey, even after they had completed the training module.[1]

Effective approaches to communicating bad medical news can vary between cultures, cautioned the authors of the evidence-based review.[2] Other barriers can include oncology nurses’ unawareness that they “lack adequate knowledge and expertise when breaking, or recommunicating, bad news to patients and families,” and the physical space in which such news is delivered.[2] “From a patient perspective, most clinical settings are not conducive to breaking bad news effectively,” they noted. “Choosing an appropriate, quiet, and private area that is free of interruptions conveys respect and maintains a patient’s dignity during a difficult time.”

The review authors advise oncology nurses to prepare for these conversations “by fully understanding the extent of the patient’s cancer diagnosis and choosing a quiet, private setting.” They also advise to set goals for the discussion prior to the meeting to ensure that information is relayed appropriately.[2] They also encourage adopting an evidence-based communication model (like SPIKES[5]) to guide delivery of bad news associated with a cancer diagnosis, disease progression, and treatment decisions.

References:

1. Gorniewicz J, Floyd M, Krishnan K, et al. Breaking bad news to patients with cancer: a randomized control trial of a brief communications skills training module incorporating the stories and preferences of actual patients. Patient Educ Couns. 2017;100:655-66.
2. Bumb M, Keefe J, Miller L, Overcash J. Breaking bad news: an evidence-based review of communication models for oncology nurses. Clin J Oncol Nurs. 2017;21:573-80.
3. Quinton S, Srivastava AK, Kahrilas IJ, et al. “Breaking the bad news”: a survey of practice patterns in disclosing a pancreatic cancer diagnosis among US endosonographers. Gastrointest Endosc. 2014;79(suppl):abstr 1049.
4. Salander P. Patients with cancer react differently: training in breaking bad news can therefore not be reduced to learning pre-defined behaviors. Patient Educ Couns. 2017;100:1955-6.
5. Baile WF, Buckman R, Lenzi R, et al. SPIKES - a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5:302-11.