Much attention is given to how bad news affects patients with cancer. Yet, little is known about the experience of physicians and what is required by them to deliver this news. “As a medical oncologist who has practiced for 15 years, I wanted to know whether my colleagues had similar feelings about the emotional burden of breaking bad news to our patients in our daily practice,” Guilhem Bousquet, MD, PhD, Université Paris Diderot, and Hôpital Avicenne, Bobigny, France, told Value-Based Cancer Care.
To address this issue, Dr Bousquet and colleagues conducted a retrospective study on this topic, and found that they are not alone in their reaction, noting that “the delivery of bad news by oncologists to their patient is a key moment in the physician-patient relationship” (Bousquet G, et al. J Clin Oncol. 2015;33:2437-2443).
The emotional experience of breaking bad news is complex, and 50% of senior oncologists had at least 1 symptom of burnout (ie, emotional exhaustion). The inevitability of this emotional complexity should be taught at medical schools and especially to oncology residents, “so they do not fear this specialty, and they learn how to talk about this,” Dr Bousquet said.
Dr Bousquet and colleagues used a qualitative approach to capture the experience of the oncologists in context and to take into account relevant interactions, by using thematic analysis to conduct their metasynthesis. They included 40 published articles, representing the views of more than 600 oncologists from 12 countries.
The investigators used the definition of “breaking bad news” from Robert Buckman’s 1992 How to Break Bad News: A Guide for Health Care Professionals, which states, “any information which adversely and seriously affects an individual’s view of his or her future.”
Personalized Communication with Patients
“A key finding from this study is the need for oncologists to adapt their approach to each patient and situation,” said Dr Bousquet. This requires a balancing act and reflects the subjectivity of the relationship between the medical oncologist and the patient.
Among the factors that influence this encounter is the physician’s evaluation of the patient’s attitude, wishes, needs, and knowledge before the news is given. The need for the oncologist to accurately perceive the feelings of the patient was reported in more than 50% of the studies in the metasynthesis.
Direct questions from patients are important clues for physicians to gauge the readiness of patients for bad news, how much information to give at a time, and whether treatment decisions should be delayed for another conversation.
The need to maintain hope is balanced against sharing the bad news in an ongoing process that includes preparing the patient; adapting the style of communication; and addressing the emotions of the patient, family, and oncologist.
Role of the Family
Family relationships are one of the external factors that affect the encounter, and the oncologist must consider the role of the family within the context of its particular culture.
Cultural communication barriers were also an influence on oncologists, and they cited the lack of intercultural training as a hindrance.
Challenges and Barriers
System and institutional barriers, such as the lack of time or private rooms for difficult conversations, continuous interruptions by phones, no internal communication between healthcare providers, and their own lack of training for breaking bad news, were reported by the oncologists.
Overall, the oncologists reported that during these encounters:
- They vary the degree of directness for each patient
- They focus on emotions rather than fact.
- Use general statements that may seem impersona.
- Emphasize treatment information over prognostic information
- Pair bad news with better news.
Many oncologists reported that talking directly with their patient and showing an interest were important steps in communication. As for terminology, oncologists reported using generalities; avoiding the use of the words death, cancer, and malignancy; and using general time frames when talking about survival.
Structured Support and Training for Oncologists
“We must take into account the emotional capacity of the oncologist for enduring this repeated emotional experience,” which occurs almost daily, said Dr Bousquet. The majority of oncologists do not have specific training in psychiatry or psychology to help them with their patients or with their own emotions.
In this study, oncologists reported physiologic reactions, such as increased autonomic arousal, along with a range of emotional reactions, including anger, anxiety, exhaustion, guilt, and failure.
Dr Bousquet and colleagues recommend that oncologists talk about this with family and friends, and that oncologists encourage their colleagues to do this as well.
They further recommend a regularly scheduled and structured discussion group for oncologists within the hospital or practice to provide needed support. This could also include a discussion of cases to review the oncologists’ interactions with patients to improve their skills and to reduce burnout.
Consideration could also be given to professional emotional support with a dedicated psychologist.
Programs to teach communication skills are needed, including multicultural communication, especially in regions with large multiethnic and multicultural populations. Training young residents to prepare for this difficult but rewarding specialty is also warranted.
The investigators stress the need to move away from the stereotypical ways in which oncologists are trained to newer methods that better equip them for the challenges of balancing the therapeutic and emotional care of their patients with their own emotional demands.
“Breaking bad news is a balancing act that requires oncologists to adapt continually to different factors: their individual relationships with the patient, the patient’s family, the institutional and systemic environment, and the cultural milieu,” Dr Bousquet and colleagues wrote.