Sharing serious news is a key communication task that occurs frequently throughout the trajectory of caring for a cancer patient. When sharing serious news, it is important to consider many factors, including those related to patient diversity, such as cultural and family background; language barriers; socioeconomic factors; and health literacy. Importantly, the way in which serious news is discussed significantly affects many outcomes and aspects of patient care. Sharing serious news is not an innate skill but can be effectively taught and learned.
A common definition of bad news is “any news that seriously and adversely affects the patient’s view of his or her future.”[1] Whether news is “bad” cannot be determined a priori, but is dependent on an individual’s subjective evaluation.[2] This is a key point because it distinguishes bad news from other types of more emotionally neutral information about cancer given to patients, such as information about chemotherapy. At the same time, practitioners should be cautioned that what they might think is good news to one patient (“I’m glad this tumor can be removed”) might be perceived as much more troubling to another (“This is terrible…I just can’t handle another surgery”). Thus, it is important to elicit the patient’s expectations and understanding of the medical situation as part of the “bad news” discussion.
We prefer to use the term “sharing serious news” rather than “breaking bad news” because it more accurately reflects both the interactive nature of the communication and the fact that it may be a process rather than a discrete, one-time event. Sharing serious news is a complex communication task and involves a verbal component (giving the news), as well as recognizing and responding to the patient’s emotions, involving the patient in decision making, and finding ways to frame “hope” and provide support.[3] Ideally, sharing serious news is a dynamic interaction between the clinician and the patient in which not only is information transmitted to the patient, but the patient, in reacting to this information, provides cues to the clinician regarding his or her attitudes, goals, needs, and concerns. This process requires that the clinician continually adapt to a variety of patient, system, cultural, and other factors.[4,5] Importantly, sharing serious news is the gateway to many aspects of patient care, such as discussing a treatment plan, engaging in shared decision making, obtaining informed consent, and involving the family in the patient’s care.
What is important to patients when being told serious news?
Studies across a variety of cancer populations have shown that cancer patients desire information about the status of their disease.[6,7] This is true even in countries where, traditionally, bad news (especially a dire prognosis) has been withheld from patients. For example, in a UK study, Jenkins et al[6] found that 98% of patients wanted to be informed of their diagnosis and 87% wanted all possible information, both good and bad. It is important to note, however, that not all patients are interested in obtaining complete information. Thus, an important first step may be to ask patients about their information preferences.
In several studies, patients have been asked how they would like to be given bad news. For example, Parker et al asked 351 patients with a variety of different cancers at different stages about their communication preferences when given bad news of an initial cancer diagnosis or disease recurrence.[8] The highest-rated elements included the following physician behaviors:
• Being up to date on the latest research on the patient’s cancer.
• Informing the patient about the best treatment options and taking time to answer all patient questions.
• Being honest about the severity of the condition.
• Using simple and clear language, giving the news directly, and giving full attention to the patient.
Differences in patient preferences were based on sex, age, and level of education, underlining the importance of tailoring the conduct of the discussion to the individual patient. In this study, cancer type did not predict patients’ preferences.
Why is it challenging for clinicians to share serious news? What are the barriers?
Due to the increase in cancer survival, not only must information regarding the state of the disease and its response to a multitude of treatments over time be communicated effectively to the patient, but adverse information related to side effects and complications of the illness and the treatment must be discussed as well. Sharing serious news is typically not perceived as a skill that can be learned, but is seen rather as an innate ability.[9,10] Oncologists are rarely trained in techniques for sharing serious news.[11,12] Additionally, physicians often experience negative emotions, such as anxiety and fear of being blamed, when they must tell their patients that treatment has not worked.[13,14] Consequently, there is a danger that they may react to patient emotion by offering false hope or premature reassurance, or that they may omit important information from the disclosure.[15]
Patient diversity, including differences in cultural and family background, language, socioeconomic status, and health literacy, can also make sharing serious news more difficult.[16-18] In a meta-synthesis of more than 40 qualitative studies of breaking bad news, researchers identified several factors that affected these discussions. Among the important factors were the characteristics of the family and cultural considerations.[5]
As described previously, cultural background greatly influences many aspects of the communication process. Although some cross-cultural descriptive studies have been conducted, especially on views about disclosure of the diagnosis,[19,20] relatively little is known about the specific influence of culture on the interaction between patients and their healthcare practitioners. The ways in which cultural variables might affect the information that patients want, their preferred and assumed participatory style, and other aspects of the interaction warrant future study.
There are many ways in which effective communication skills can help clinicians when sharing serious news with patients and their families. Effective communication can provide structure for the consultation, enhance the relationship between patients and their families, and may make consultations more efficient.
How the Way Clinicians Communicate Can Impact Patients and Other Key Outcomes
There is a growing body of empirical research examining the associations between aspects of communication and patient outcomes. Effective communication helps establish a working relationship between the practitioner and the patient and plays an important role in the diagnosis and treatment of medical illnesses, including cancer.[21] According to a recent review of physician-patient communication, the three main goals of effective communication are:
• To create a good interpersonal relationship.
• To facilitate exchange of information.
• To include patients in decision making.[22]
Consistently across the literature, practitioner-patient communication has been identified as one of the most essential facets of patient care.[23] Research has shown that aspects of the practitioner-patient interaction impact patient outcomes, including satisfaction, distress, knowledge, and adherence.[24-27] For example, studies have found that empathic communication is associated with improved satisfaction and decreased distress among patients.[25-30] These findings emphasize the benefits of effective communication between practitioners and their patients and that training practitioners in communication skills may improve their communication with their patients.
However, in discussing benefits of effective practitioner-patient communication, it is also important to highlight what constitutes ineffective communication. In a qualitative study of negative feedback from patients about physicians, 38 causes of complaints were analyzed and coded.[31] Results indicated that ineffective communication involved these verbal/nonverbal physician behaviors:
• Inadequate information provided to the patient.
• Poor quality of information (ie, no rationale given, inadequate explanations).
• Lack of empathy and lack of respect.
• Poor nonverbal behaviors (ie, lack of eye contact, negative facial expressions, problems with volume/tone of voice).
• Poor verbal behaviors (ie, not listening, patients not given a chance to ask questions, inappropriate choice of words).
The deleterious patient outcomes when serious news is shared in an ineffective manner include increased distress and suffering, failure to thrive, nonadherence, and dissatisfaction with medical care.[25,32,33] Since poor communication has also been found to be associated with medical malpractice suits, this is another important reason to strive to communicate serious news as effectively as possible.[34,35]
Specific Guidelines and Recommendations for Sharing Serious News
Studies have shown that the majority of physicians do not have a consistent plan or strategy when they share serious news with their patients. For example, Baile et al[11] found that among a sample of physicians attending an annual meeting of the American Society of Clinical Oncology, 22% reported that they did not have a consistent approach to the task of breaking bad news to patients, and 51.9% reported that they had several techniques or tactics but did not have an overall plan. Determining what patients believe to be important in the interaction may help refine the current guidelines and yield specific evidence-based recommendations that can help with this challenging task.[3]
Guidelines provide a useful roadmap for key steps or issues to focus on when sharing serious news. However, as with any other complex skill, sharing serious news is best learned through practice. One protocol or method for disclosing serious news is represented by SPIKES,[3] a six-step approach that comprises:
• Setting up the interview (choosing the right location, establishing rapport).
• Understanding the patient’s Perception of the medical situation.
• Asking the patient permission to explain, or getting an Invitation.
• Addressing Emotions that might occur during bad news disclosure.
• Strategizing a treatment plan and Summarizing the plan for the patient and family.
SPIKES is a useful approach because it is short, easily understandable, and focuses on specific skills that can be practiced. Moreover, it can be applied to most situations that involve the sharing of serious news, including discussions of diagnosis, recurrence, transition to palliative care, and even error disclosure. It also has reflective suggestions for the physician regarding how to deal with their own distress in being the “messenger of bad news.” It incorporates many of the common recommendations for sharing serious news.
Using culturally appropriate approaches to communicating news about cancer may lessen levels of distress for the patient and/or family members. Developing awareness of cross-cultural practices regarding cancer disclosure allows the clinician to become more sensitive to the expectations of cancer patients of diverse backgrounds. When discussing diagnoses and treatment options with patients from different cultures, it is important to consider how to balance a commitment to frank discussion and a respect for the cultural values of the patient.[36]
One model for sharing serious news is described in the program Oncotalk, in which oncology fellows are given a didactic lesson in how to give bad news and then afforded practice with standardized patient interviews.[37] Compared with the standardized patient interviews before the workshops, post-workshop interviews showed that participants displayed significantly more skills in breaking bad news.[37]
The Communication Skills Training and Research Program (Comskil) at Memorial Sloan Kettering Cancer Center was created to train providers in communication skills to support the patient throughout the cancer disease trajectory.[38] The Comskil program includes a module on sharing serious news; the module has an overarching goal, which is achieved through a set of broad strategies.[39] These strategies are in turn achieved through communication skills and process tasks.[39]
KEY POINTS
- Sharing serious news is a complex communication task that occurs many times during the course of caring for a cancer patient.
- Although challenging, sharing serious news in a compassionate and clear way can enhance the clinician-patient relationship, as well as other important patient and clinician outcomes.
- Communication skills are not innate, and experience alone does not improve these skills; however, there are many strategies and recommendations that can be employed to enhance these skills.
The goal of this module is to convey threatening information in a way that promotes understanding, recall, support for the patient’s emotional response, and a sense of ongoing support. In order to accomplish this goal, six strategies are recommended (Table). Strategy 1 focuses on setting the agenda so that the clinician and the patient share goals for the meeting. Skills that allow the clinician to do this include declaring the agenda, inviting the patient to submit agenda items, and negotiating the agenda (if appropriate). Strategy 2 involves tailoring the consultation to the patient’s needs. By checking patient understanding and exploring patient preferences for information, the clinician elicits how much (or how little) the patient knows about his or her disease and learns how to best provide relevant information. Strategy 3 focuses on providing information in such a way that it will be understood and recalled. Using the information gathered from the patient in Strategy 2, the clinician can modify the consultation to provide the most relevant information while previewing information, inviting patient questions, checking understanding, and summarizing. For Strategy 4, empathically responding to the patient’s emotion or experience allows the clinician to check how the patient is doing emotionally and respond appropriately. The skills required for this strategy include acknowledging, validating, normalizing, and encouraging expression of feelings, as well as praising patient efforts. Strategy 5 involves checking readiness to discuss management options, including palliative needs. This involves the skill of taking stock, which allows the clinician to review the prior discussion and then seek the patient’s permission to move on. Then, the clinician recaps the main details that were just conveyed to the patient, and provides a review statement about what was just said in order to summarize the information. The last strategy (Strategy 6)-closing the conversation-focuses on checking patient understanding, inviting patient questions, summarizing information, and reviewing next steps. These six strategies, along with their respective skills and process tasks, are summarized in the Table.
Although there are some subtle differences between the various approaches recommended for sharing serious news, there are also many common elements. For example, each of these strategies recommends giving the news in an appropriate setting (quiet place, with uninterrupted time), assessing the patient’s understanding of his or her illness, providing information that the patient wants, allowing the patient to express emotions and responding appropriately, summarizing the information provided, and developing a plan for the next step(s). Additional research is needed to further empirically support the impact of these techniques.
Summary and Future Directions
Sharing serious news is stressful for the patient, the family, and the doctor. Learning to give bad news is a complex skill that involves major communication tasks such as establishing rapport, obtaining information from the patient, providing information in understandable language without jargon, dealing with patient emotions, and providing a treatment plan to guide the patient through cancer therapy.[40] Communicating in ways in which patients’ information needs are met and in which they feel emotionally supported increases their feelings of trust, hope, and sense of being respected as a person, and it promotes their willingness to be a partner with their doctor to achieve the best outcome possible. The argument may be made that there has been little research done to show the efficacy of these methods in regard to patient outcomes. While this may be true, communication skills in general have been shown to have a significant impact on outcomes. Nonetheless, this is an area in which research could and should be expanded.
One should also be aware that most recommendations for how to deliver bad news are based on “best practices” and derive from patient preferences for receiving information. Communication skills training has been shown to be effective in enhancing oncologists’ skills and competencies in sharing serious news. However, very few oncology training programs provide opportunities for fellows to learn skills related to sharing serious news with patients and their families.[12] One of the core competencies outlined by the Accreditation Council for Graduate Medical Education is interpersonal skills and communication. This has increased awareness of and emphasis on approaches to ensure that oncology residents and fellows receive adequate training in how to share serious news and carry out other important communication tasks. In addition, an increased emphasis on patient satisfaction and the patient experience in healthcare has highlighted the importance of practitioner-patient communication. Additional educational and research efforts should be directed at evaluating training efforts, as well as identifying other factors that influence how serious news is shared and received.
Financial Disclosure:The authors have no significant financial interest in or other relationship with the manufacturer of any product or provider of any service mentioned in this article.
Acknowledgment:This work was supported by the Cancer Center Support Grant (CCSG-Core Grant; P30 CA008748; Principal Investigator: Craig B. Thompson, MD).
References:
1. Buckman R. Breaking bad news: why is it still so difficult? Br Med J (Clin Res Ed). 1984;288:1597-9.
2. Fallowfield L, Jenkins V. Communicating sad, bad, and difficult news in medicine. Lancet. 2004;363:312-9.
3. Baile W, 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.
4. Maguire P. Improving communication with cancer patients. Eur J Cancer. 1999;35:1415-22.
5. Bousquet G, Orri M, Winterman S, et al. Breaking bad news in oncology: a metasynthesis. J Clin Oncol. 2015;33:2437-43.
6. Jenkins V, Fallowfield L, Saul J. Information needs of patients with cancer: results from a large study in UK cancer centres. Br J Cancer. 2001;84:48-51.
7. Degner LF, Kristjanson LJ, Bowman D, et al. Information needs and decisional preferences in women with breast cancer. JAMA. 1997;277:1485-92.
8. Parker PA, Baile WF, de Moor C, et al. Breaking bad news about cancer: patients’ preferences for communication. J Clin Oncol. 2001;19:2049-56.
9. Guest CB, Regehr G, Tiberius RG. The life long challenge of expertise. Med Educ. 2001;35:78-81.
10. Fallowfield L, Lipkin M, Hall A. Teaching senior oncologists communication skills: results from phase I of a comprehensive longitudinal program in the United Kingdom. J Clin Oncol. 1998;16:1961-8.
11. Baile WF, Lenzi R, Parker PA, et al. Oncologists’ attitudes toward and practices in giving bad news: an exploratory study. J Clin Oncol. 2002;20:2189-96.
12. Hoffman M, Ferri J, Sison C, et al. Teaching communication skills: an AACE survey of oncology training programs. J Cancer Educ. 2004;19:220-4.
13. Wallace JA. Emotional responses of oncologists when disclosing prognostic information to patients with terminal disease: results of qualitative data from a mailed survey to ASCO members. J Clin Oncol. 2006;24(suppl):abstr 8520.
14. Buckman R. Communications and emotions. BMJ. 2002;325:672.
15. Maguire GP. Breaking bad news: explaining cancer diagnosis and prognosis. Med J Aust. 1999;171:288-9.
16. Mystakidou K, Parpa E, Tsilila E, et al. Cancer information disclosure in different cultural contexts. Support Care Cancer. 2004;12:147-54.
17. Mitchell JL. Cross-cultural issues in the disclosure of cancer. Cancer Pract. 1998;6:153-60.
18. Surbone A. Cultural aspects of communication in cancer care. Recent Results Cancer Res. 2006;168:91-104.
19. Wuensch A, Tang L, Goelz T, et al. Breaking bad news in China--the dilemma of patients’ autonomy and traditional norms: a first communication skills training for Chinese oncologists and caretakers. Psychooncology. 2013;22:1192-5.
20. Bou Khalil R. Attitudes, beliefs and perceptions regarding truth disclosure of cancer-related information in the Middle East: a review. Palliat Support Care. 2013;11:69-78.
21. Bird J, Cohen-Cole SA. The three-function model of the medical interview: an educational device. Adv Psychosom Med. 1990;20:65-88.
22. Ha JF, Longnecker N. Doctor-patient communication: a review. Ochsner J. 2010;10:38-43.
23. Institute of Medicine. Levit LA, Balogh EP, Nass SJ, et al, editors. Delivering high-quality cancer care: charting a new course for a system in crisis. Washington, DC: The National Academies Press; 2013.
24. Mager WM, Andrykowski MA. Communciation in the cancer ‘bad news’ consultation: patient perception and psychological adjustment. Psychooncology. 2002;11:35-46.
25. Ong L, Visser M, Lammes F, de Haes J. Doctor-patient communication and cancer patients’ quality of life and satisfaction. Patient Educ Couns. 2000;41:145-56.
26. Roberts CS, Cox CE, Reintgen DS, et al. Influence of physician communication on newly diagnosed breast patients’ psychologic adjustment and decision-making. Cancer. 1994;74:336-41.
27. Butow PN, Dunn SM, Tattersall MH, Jones QJ. Computer-based interaction analysis of the cancer consultation. Br J Cancer. 1995;71:1115-21.
28. Zachariae R, Pedersen CG, Jensen AB, et al. Association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease. Br J Cancer. 2003;88:658-65.
29. Fallowfield L, Jenkins V, Farewell V, et al. Efficacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial. Lancet. 2002;359:650-6.
30. Takayama T, Yamazaki Y, Katsumata N. Relationship between outpatients’ perceptions of physicians’ communication styles and patients’ anxiety levels in a Japanese oncology setting. Soc Sci Med. 2001;53:1335-50.
31. Kee JWY, Khoo HS, Lim I, Koh MYH. Communication skills in patient-doctor interactions: learning from patient complaints. Health Professions Education. 2018;4:97-106.
32. Cherny NI, Coyle N, Foley KM. Suffering in the advanced cancer patient: a definition and taxonomy. J Palliat Care. 1994;10:57-70.
33. Haskard Zolnierek KB, DiMatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47:826-34.
34. Levinson W, Roter DL, Mullooly JP, et al. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277:553-9.
35. Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice: lessons from plaintiff depositions. Arch Intern Med. 1994;154:1365-70.
36. Hern HEJ, Koenig BA, Moore LJ, Marshall PA. The difference that culture can make in end-of-life decision making. Camb Q Healthc Ethics. 1998;7:27-40.
37. Back AL, Arnold RM, Baile WF, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med. 2007;167:453-60.
38. Kissane DW, Bylund CL, Banerjee SC, et al. Communication skills training for oncology professionals. J Clin Oncol. 2012;30:1242-7.
39. Brown RF, Bylund CL. Communication skills training: describing a new conceptual model. Acad Med. 2008;83:37-44.
40. Back AL, Arnold RM, Baile WF, et al. Approaching difficult communication tasks in oncology. CA Cancer J Clin. 2005;55:164-77.
