An Essential Skill for all Physicians and Other Health Care Professionals - Research Paper Example

Introduction Delivering bad news is a major issue for health care professionals. Primary care physicians have a trusting relationship with their patients and hence are in a position to deliver bad news such as terminal illness or newly diagnosed cancer. However, the manner in which such information is delivered merits attention and physicians need appropriate training in this field. Without training, the physician may have discomfort while communicating the bad news and may not be in a position to discuss all aspects of care and management. Training allows primary care physicians to use a systematic approach so that they can discuss prognosis appropriately, explore therapeutic options, offer realistic hope, make appropriate referrals, relieve patient suffering including pain and coordinate disease transitions. This article analyses communication of bad news to a patient with colon cancer by a physician who has poor communication skills. The article also reviews literature and provides information as to how bad news can be communicated effectively. Critical Incident 55 years old James was seen in the out-patient department by Dr. Alexander, a primary care physician, for complaints of recurrent abdominal pain since a week prior to coming to the hospital. Along with abdominal pain, James also suffered from altered bowel habits, weight loss, cachexia and intermittent fever since 2 to 3 weeks time. After examining James, the doctor advised a few investigations and asked him to come back the next day for checking on the reports. The investigations requested for were complete blood count and stools routine examination. Complete blood count was normal. However, stools examination revealed occult blood with no pus cells. Hence when James came back on the next day, the doctor advised him to get a colonoscopy with biopsy done. After the procedure, James was advised further investigations which included computed tomography of the chest, abdomen and pelvis and was advised to come after a couple of days. Dr. Alexander received the reports of the biopsy and computed tomography through fax. The reports revealed adenocarcinoma of the colon with metastases in the liver and the lung. The reports were also reviewed by the clinical nurse assisting the doctor. When James met Dr. Alexander to find out what happened to the reports, he was informed nervously by the doctor that he had cancer of the bowel and that he needs to see an oncologist. Shocked at the news, James asked the doctor how could this happen to him all of a sudden and whether there was any immediate treatment for it. The unprepared doctor blurted out that nothing could be done because he already had metastasis in the liver. After that Dr. Alexander wrote out a referral letter to the oncologist about the condition of the patient and the fact that he had adenocarcinoma of the colon with metastasis in the liver. The doctor forgot to inform the patient and the oncologist about metastasis in the lungs too. The nurse in the doctor’s room who was aware of these reports did not interrupt the doctor even though she knew that complete and proper information was not imparted to the patient and the referral doctor. The 55 year old James who came all alone to the hospital was shocked at the news. He lost hope and was in despair. He sat in the waiting room for a long time until he coped up and moved o to meet the oncologist. It is clear from the case of James that the primary physician did not handle communication of bad news well. He also did not give correct information about the diagnosis and exhibited carelessness and malpractice on his part. The clinical nurse too did not do her job of correcting the doctor. One of the core clinical skills in oncology is good communication. Improper communication makes the patient confused about the diagnosis, unsure about the need for further treatment and uncertainty of the therapeutic intention of care and management (Fallowfield and Jenkins, 1999). Insensitive approach of communicating bad news increases the distress of the patient and his or her relatives. It also impacts the ability of the patient to adjust and adapt (Fallowfield and Jenkins, 2004). How should bad news be communicated in cancer cases? Communicating Bad News to the Patient Communication between physicians and patients has multiple dimensions like content of dialogue, affective component and behaviors other than verbal. Communicating bad news appropriately demands proper knowledge of the disease and its prognosis and good communication skills (Back and Arnold, 2006). Improper manner of delivery of bad news not only leads to uneasiness but also poor psychological adjustment for the patients and their close relatives (Mager and Andrykowski, 2002). Receiving bad news is a situation of crisis for the patient. The patient expresses severest form of anxiety, uncertainty, confusion, fear of losing control over his or her life and helplessness. Following certain recommendations as far as communicating bad news is concerned helps physicians deliver the news effectively. Prioritization is the first step in the process of preparation to deliver bad news (Metzger et al, 2008). The physician must identify certain key points which the patient must retain. He must also analyze what to expect from the patient after the encounter and what decisions must be taken at the end of the meeting. In case of James, points to be prioritized are cancer of the bowel with multiple metastasis. After prioritizing, the physician must prepare to deliver the news. The discussion must be rehearsed and a location which is private and with an uninterruptive environment should be selected for the meeting. Once the physician meets the patient, he must attempt to assess the understanding of the patient by asking simple questions like “What is it you know about your condition?" “What do you think will happen to you?" “Why do you think I have arranged this meeting?" (Metzger et al, 2008). In the process, the physician must try to determine the preferences of the patient and also assess the amount of information he wants to know (Metzger et al, 2008). This can be done by asking questions like “What is it you know about your condition?” “What do you think you are suffering from?” “Why do you think we got so many tests done?” “Why do you think I called on you?” Some patients may be interested in knowing only major facts and some others may want to know even minute details. This can be assessed by asking questions like “Many of my patients want to know only the main picture of the problem and some others want to know every aspect of the condition. Which one do you prefer?” After gaining hold on the above aspects, the physician must deliver the information for which the meeting was held (Metzger et al, 2008). The bad news must be communicated in a language that is easy to understand. Also, medical jargon must not be used and small amounts of information must be delivered at a time allowing scope for comprehension by the patient. Lack of proper communication from health professionals is the most common complaint among oncology patients (Smith, 2000). Sometimes, barrier to poor communication comes from patients themselves. Patients may have unrealistic fears of asking questions. Patients don't want to hear about death and hence don't want to know more details (Smith, 2000). The physician must give time for the patient to express his emotions, must provide proper emotional support and must respond with empathy. It is worth assessing the patient's emotional state directly by asking certain questions like “How are you doing?" “Is this difficult for you to take?” “You look frustrated and angry- is it true?” “Please tell me when you want to continue.” At this stage details about additional support like support services must be given. The physician must bring hand-outs or pamphlets about the support organizations, support services, psychologists, chaplains and social workers and give to the patient. Compassionate approach is very important. This type of approach can self-reflect the interpersonal skills of the physician that helps both the doctor and the patient. Application of interpersonal skills reduces the emotional trauma associated with the reception of the news. It also helps the patient mobilize his or her own ability to cope (Baile and Beale, 2001). It is important for the physician to tailor the discussion based on the preferences and other aspects of the patient. The age of the patient, literacy status, sex, social status, cultural norms, religious faiths, race, ethnicity, previous health care experience, financial status, health care policy, employment- all must be taken into account while discussing about the disease. After providing emotional support, the physician must discuss plans of care and management. This includes helping the patient understand the course of the disease, the modes of treatment and their success rates and support services. The physician must assess and gauge the preferences of the patient and an individualized discussion must be held (Metzger et al, 2008). The emotional state of the patient and the readiness of the patient to engage in further discussion must be ascertained. It is clear form the critical incident that Dr. Alexander did not practice and rehearse the communication. He did not have enough knowledge about the condition of the patient. He did not dedicate much time to James and did not empathize with his situation. Worst of all he did not offer any type of console or help. The doctor expressed an insensitive attitude towards the patient. Communication in cancer patients is the most indispensable factor that keeps the patients spirits intact. (Science Daily, Sep. 24, 2007). Patients need to understand their problem properly so that they can make decisions about life- altering medical decisions. According to the National Cancer Institute, "Communication is necessary during all phases of the cancer continuum from prevention through survival and end-of-life care" (qtd. in Science Daily, Sep. 24, 2007). Epstein, who is the Director of the Rochester Center to Improve Communication in Health Care, quotes "ultimately, we need to structure our health care system so that it fosters excellent communication and improves access to information, particularly among those patients who are most disadvantaged" (Science Daily, Sep. 24, 2007). Taking care of physician's emotions Delivering bad news is an aversive act which is inherent in anyone (Baile and Beale, 2001). Same is the case with physicians too. The physician may feel sad for the patient. He may find himself in a helpless situation. He may also have fear of being blamed for the news. The physician, like any other human may not want to expose the patient to unpleasant reality. Such and other feelings on the part of the physician may create emotional detachment from the patient and hopelessness which in turn may be transmitted to the patient. However, the physician must suppress his own thoughts and emotions. This can be done by asking himself several questions like "Am I disturbed by the fact that I need to deliver bad news for this patient?" "Is this going to be more difficult than usual?" "How is the patient going to respond?" How am I going to respond" Acknowledging such and other thoughts on the part of the doctor helps the doctor consider several strategies to cope with his situation much before he meets the patient. Holding back truth either because it is difficult to communicate or because we dont want to arouse hopelessness, diminishes the chances of making appropriate informed decision. This is futile and as Smith (2000) quotes "this causes us to treat too many patients for too long, for too little benefit, and without them knowing about it." The physician may recruit support by asking another member of the medical team to join the meeting or may request the patient to bring a member of the family or a close friend or a colleague to the meeting (Baile and Beale, 2001). The physician may even acknowledge to the patient how difficult it is for him to communicate this bad news (Baile and Beale, 2001). Such and other strategies can neutralize the strong emotions of the physician. Discussion of the prognosis After breaking the bad news, the next important step is discussing the prognosis. This is best scheduled after proper staging of the cancer (Metzger et al, 2008). Staging of colon cancer can be done using Dukes classification (El- Deiry, Emedicine) as follows: Dukes stage A- Carcinoma in situ limited to mucosa or submucosa (T1, N0, M0) Dukes stage B- Cancer that extends into the muscularis (B1), into or through the serosa (B2) Dukes stage C- Cancer that extends to regional lymph nodes (T1-4, N1, M0) Dukes stage D- Modified classification; cancer that has metastasized to distant sites (T1-4, N1-3, M1) All physicians involved with the care of the patients must prepare well and coordinate before discussing the prognosis to avoid confusion. While discussing prognosis, patient must be educated about the natural course of the disease, the treatment options available, the adverse effects of the treatments and what outcomes may be expected. The patient must be mentally prepared about the quality of life. The physician must discuss 5-year and 10-year survival rates of the disease with and without treatment. The overall 5-year survival rate from colon cancer is approximately 60%. In Dukes Stage A, the 5- year survival rate exceeds 90%, for Stage B, the rate is 70%, for Stage C it is 60% and for metastatic cancer, this rate is only 5% (El- Deiry, Emedicine). Patient’s fears must be addressed with empathic listening (Metzger et al, 2008). Details of the prognosis of the disease must be given only after assessing how much the patient wants to know. It is important and effective to communicate clinical evidence than just giving an account of facts. While majority of the patients want to know every bit of detail about the disease, the course and the prognosis, some may want to know only important information and take life the way it comes. The most important aspect of talking about prognosis is not to give false hope. The best approach is "hoping for the best and planning for the worst” (Back et al, 2003). One of the methods of safe discussion is by discussing both best and worst scenarios. The patient must be informed about full spectrum of treatment options and also sequential treatment options. The first-line standard therapy of metastatic colorectal cancer is a combination of 5- Fluorouracil, leucovorin and irinotecan (El- Deiry, Emedicine). Other therapies include Saltz regimen (irinotecan and 5- Fluorouracil/leucovorin). Liver metastasis can be dealt with partial hepatectomy, cryoablation or intrahepatic chemotherapy with intraarterial floxuridine (Barber et al, 2004, p.425). Goals of care must also be discussed and the goals can be different as the disease progresses. Hence, stage-specific goals only must be discussed. This can relieve psychological distress and prevent under- and over-treatment (Metzger et al, 2008). Role of the physician at different stages of the disease As the disease progresses and the patient enters into different stages of the disease, the role of the primary care physician changes. At this juncture, it becomes important to note that primary care physicians are the backbone of the integrated services and they have the closest relationship with the patient. Thus they are in a position to deliver unbiased medical perspective, provide continuity of care, negotiate and mediate important decisions, monitor complications and support through emotional crisis (Metzger et al, 2008). Open communication is the best approach to adapt while negotiating this role to the satisfaction of one and all. Open communication involves asking simple and leading questions. The purpose of communication skills is to establish trust and rapport. In the early stages of breaking the bad news, the physician must discuss about the diagnosis, course of the disease, various therapeutic options, patient values, family values, aims and goals of the treatment and the preferences of the patient. In the middle stage, he must discuss about the effectiveness of the various treatment options offered. In the late stage of breaking bad news, the physician must assess the understanding of the family and the patient as far as the prognosis and disease is concerned. In the early stage of communicating prognosis, the physician must discuss the expected prognosis. In the middle stage, the physician must help the patient to understand the fact that changes in prognosis can happen as the disease progresses and based on these changes, expectations will be refocused and values and preferences will be revisited. In the late stage of communication of progress, advantages and disadvantages of the experimental treatment must be discussed objectively. Palliative care options also must be discussed here for those who may need it (Metzger et al, 2008). During the initial stages of discussing transitions of the disease, the physician must focus mainly on the medical treatment. Palliative needs must only be assessed. The goal of the treatment at this stage is to extend life along with improvement in the quality of life. In the next stage, the physician must focus both on medical treatment and also palliative needs. In the late stage, focus must be mainly on palliative care to give patient relief from various bothering symptoms like pain, tiredness, nausea and shortness of breath. The goal at this stage must be to improve the quality of life and treat metastases which are causing symptoms (Metzger et al, 2008). The physician’s role in coordinating care varies at different stages. After the patient has been referred to a sub specialist, the patient must be asked to schedule follow-up visits with the primary care physician. The sub specialist must also be asked to update information about the patient in a timely manner. In the next stage, the patient must be monitored for symptoms and various physical and psychological adverse effects of the medications. The physician must discuss about the option of hospice. When the patient is deteriorating, the patient must be encouraged advance care planning like living will, power of attorney and advance directives. In the later stages, benefits and also adverse effects of the major treatments must be discussed. Importance of palliative care must also be stressed upon (Metzger et al, 2008). Proper and effective dissemination of information helps navigation of successful transition to palliative care. While providing support, the patient must given time and space to express emotion and ask questions. The physician must address any concerns raised and answer all the questions patiently with concern and empathy. The patient and his or her family must be referred to support groups and counseling services as may be required. In the middle stage of providing support, the physician must answer questions, address concerns, provide emotional support and show empathy. In the late stages, along with the above aspects, the job of the physician is to ascertain the fact that the patient shall not be abandoned at any cost. The primary care physicians need to remain proactive and inform the patient that even if he is referred to an oncologist for further care and management, continued caring would be provided by him itself. This will make the patient feel better. In the process, the physician can communicate to the referring doctor to provide periodic updates. The physician can also help the oncologist by offering input (Metzger et al, 2008). As the disease progresses, the need for palliative care increases, and physicians play a role in bridging the gap between curative care and palliative care. The physician can provide options for skilled palliative care at home. Home-based hospice programs can bring about patient satisfaction, shorten hospital stay, reduce medical costs and prevent emergency room (Metzger et al, 2008). Physicians must be careful in using certain phrases of expression and avoid phrases which demoralize the patient (Metzger et al, 2008). Taking care of words and phrases in End-of-Life discussions with patients In delicate situations like discussing end-of-life details, physician must monitor the words and phrases he uses to prevent confusion and misinterpretation by the patient (Metzger et al, 2008). For example using “there’s not much we can do for you” will mean abandonment and the patient will think “My doctor does not want to see me anymore”. This can be avoided by using alternative phrase like “There are many options to ease your discomfort and make you feel better.” Another example would be the physician using phrase like “I think we should withdraw care”. This phrase will be misinterpreted by the patient as “My doctor is not interested in caring for me now”. This can be avoided by using phrase like “Is this the time we think of different type of treatment to control your symptoms. Don’t worry; I will be there with you for whatever decision you make”. Considering individual preferences and cultural diversity In cases of despair, family, friends and colleagues give their individualized suggestions which may influence the patient. Also, based on the culture, religion and family background, the patient may develop his own individualized preferences. Conflict arises when patient and his or her family demand treatment which the physician feels is medically futile. The best way to handle such situations is by respectfully listening to the opinions of the patient and the family and then by arriving at certain mutually acceptable goals (Metzger et al, 2008). Dynamic understanding of the balance between honesty and hope enhances the efficiency of communication and helps the patient live with serious illness (Thorne et al, 2007). Certain considerations in the meeting with the patient may lead to certain potential consequences. Physician frankness in the form of either direct or indirect communication may be regarded as rudeness, cruelness or uncaring attitude on the part of the physician. This happens when the patient is not ready to receive the news. In some situations, hearing the news from some member of the family may be preferred. Some patients may land up in anxiety and hopelessness when they hear about poor prognosis. A good group of people prefer to remain hopeful until the end. Another consideration is whether the patient prefers autonomy or would like to involve family members. When family members are present, they also must be assessed properly. Otherwise, disagreements may occur between the physician and the family members or the patient and family members too. Some patients may feel isolated if the family is not involved. While discussing decision making, the physician may ask some questions to help the patient arrive at a plan. “In what way would you like to make decisions about the management plan?” “Do you want to decide after I give all options to you?” “Or you want me to give my opinion on which is the best treatment for you?” “Do you want to know about both the pros and cons and then decide for yourself” “Do you want to ask anybody else’s opinion?” “Do you want your family to help in deciding plans for you?” Such questions will make the patient think and give proper responses. Directive counseling may lead to unwelcome decisions and can cause lack of collaboration between the patient and the physician. In indirect counseling, the patient may lose confidence in the physician. Hence one must ascertain what type of counseling the patient is interested in and act accordingly. Questions which help in advanced care planning are “Presently, what are your goals in life?” “When a stage arrives when you can stay alive only or artificial life support, how would you feel prolonging your life?” “Incase you are unable to make decisions, who would you prefer should make them for you?” Religious and spiritual preferences must also be addressed. If this is not done, the physician may be deemed as disrespectful and the patient may reject medical advice. Trust in nurse-patient relationship Nurses play an important role in the health promotion of an individual due to their direct contact and proximity with the patients. The 3 basic roles of a nurse are that of a practitioner, leader and researcher. As a practitioner, the nurse attends to all the medical needs of the patient and as a leader she takes decisions which relate to, influence and facilitate the actions of others with an aim to achieve a particular goal. As a researcher, the nurse aims to implement studies to determine the actual effects of nursing care and to work towards further improvement in nursing care (Nettina, 2006). The role of nursing is authenticated in helping people move towards independence in all activities of daily living. They take up the role of a family member. Their actions have an impact on the individual and affect their levels of dependence/independence and these include biological, psychological, socio-cultural, environmental and politico-economic variables (Roper et al, 2002). The relationship between a nurse and a patient is of therapeutic nature and based on the provision of care, guidance and assistance of the patient (Neal, 2007). It is shaped mainly by four concepts namely, trust, power, intimacy and respect (Neal, 2007). Trust is a critical concept in the nurse-patient relationship because, the patient is in a vulnerable position and the patient places trust in the nurse as soon as he or she enters the health care setting. As such, illness makes an individual vulnerable and this is exaggerated in the presence of unfamiliar surrounding, relationships and situations. In the example presented, Jane was in a vulnerable situation and she put trust in Susan. Trust in this relationship is largely based on the assumption of the fact that the nurses are skilled and knowledgeable and will excise these aspects in dealing with the patient. During the initial stages of relationship with the patient, the nurse needs to instill confidence into the patient about confidentiality and must ensure that the information about the patient will be divulged on a need to know basis only. Nurses must maintain confidentiality about the nature of the patient's disease and other aspects. If the patient wishes not to divulge any information to the relatives, family and friends, the nurse must cooperate in doing so. Susan did not mention to Jane’s husband about heart attack as requested by Jane (Neal, 2007). Trust in a nurse-patient relationship improves care and reduces stress. In most of the cases, consent will be taken for divulging information. In cases where the patient is not in a position to give consent, the multidisciplinary team takes a consensus decision about divulging information (NMC 2002). Nurses must make all efforts against improper disclosure of information. The major source of potential disclosure is verbal overhearing. Role of clinical nurses in preventing malpractice The profession of nursing is such that it demands delivery of care in a confident manner. Erring is common in clinical practice and it is the duty of every health professional to prevent erring. Serious errors are expected to occur, the rate being 150 for every 1,000 patient-days and half of these are deemed preventable (Critical Care Safety Study, 2005; qtd. in ECRI Institute, 2007). Common errors include errors in conducting procedures, errors in carrying out medication orders, errors in communicating or reporting clinical findings, failure to follow protocols and failure to take precautions. Errors occur not only due to carelessness on the part of staff and lack of knowledge, they also occur due to the complexity of the medical devices and technology. For example, intubation and mechanical ventilation is life- saving in a patient with respiratory failure. But tube dislodgement or tube block can occur and cause oxygen insufficiency. Equipments with clinical alarms, intravenous drug delivery systems, monitors and special care beds and mattresses can go wrong and contribute to errors if they are not used properly in good conditions and by properly trained staff. Proper training, adequate knowledge, presence of mind and good communication skills can help a nurse from erring and also prevent others from erring. Also, certain hospital protocols can help diminish erring. Having a culture that promotes and supports safety activities in a medical practice setting is a key element in providing error- free and accident- free treatment for the patients. This can be enhanced by working collaboratively and communicating effectively. As Chauhan and Long (2000) quote “effective communication is the foundation upon which nursing should stand." Also, creating a healthy work environment with productive interaction, making vital decisions and performing medical interventions safely contribute to the safety of the patient. Since stress fatigue and distractions increase the likelihood of errors, mistakes and adverse events, adequate staffing and composed environment must be created in intensive care units. Conclusion Communicating bad news to a patient and his relatives requires some amount of training. It is an essential skill for all physicians and other health care professionals. The physician who has to impart this information needs to practice, rehearse and plan the encounter with the patient. While passing on the information, the physician must express empathy, care and offer emotional support. Neither false hope nor hopelessness must be projected. Communication must be based on the expectations of the individual. Lot of time must be given for the patient to clarify his doubts and reconcile with the situation. The role of physician should be based on the stage of the disease of the patient. Also, the most important aspect is to give correct information. Nurses also play an important role in effective communication of bad news. They should exhibit confidence in communication. They also play a major role in prevention of malpractice and carelessness on the part of doctor. References Back, A.L., Arnold, R.M., and Quill, T,E. (2003). Hope for the best, and prepare for the worst. Ann Intern Med., 138(5), 439-443. Back, A.L., and Arnold, R.M. (2006). Discussing prognosis: "How much do you want to know?" Talking to patients who are prepared for explicit information. J Clin Oncol., 24(25), 4209-4213. Barber, F.D., Mavligit, G. & Kurzrock, R. (2004). Hepatic arterial infusion chemotherapy for metastatic colorectal cancer: a concise overview. Cancer Treat Rev., 30(5), 425-36. Block, S.D. (2006). Psychological issues in end-of-life care. J Palliat Med., 9(3), 751-772. Chauhan, G., and Long, A. (2000). Communication is the essence of nursing care 1: breaking bad news. British Journal of Nursing, 9(14), 931- 938. Davidhizar, R. (1993). Professional confidence in baccalaureate nursing stidents. Nursing education in practice, 3(3), 163. ECRI Institute. (2007). Critical Care Safety: Essentials for ICU Patient Care and Technology. Retrieved on 8th January 2009 from https://www.ecri.org/Documents/CriticalCare_TOC.pdf. El- Deiry, WF. "Colon Cancer, Adenocarcinoma." Emedicine from WebMD. Oct 11 2006. 1 Dec 2008 . Fallowfield, L., and Jenkins, V. (2004). Communicating sad, bad and difficult news in medicine. The Lancet, 363 (9405), 312- 319. Fallowfield, L. and Jenkins, V. (1999). Effective communication skills are key to good cancer care. European Journal of Cancer, 35, 1, 1592 – 1597. Mager, W.M., and Andrykowski, M.A. (2002). Communication in the cancer 'bad news' consultation: patient perceptions and psychological adjustment. Psychooncology, 11(1), 35-46. Metzger, Q. et al. (2008). End-of-Life Care: Guidelines for Patient-Centered communication. American Family Physician. http://www.aafp.org/afp/20080115/167.html Neal, K. (2007). Nurse-Patient relationships. http://www.nursing-practice.co.uk/docs/newCh5.pdf Nettina, S.M. (2006). Manual of Nursing Practice. (8th ed.). New York: Lippincott Williams & Wilkins. Nursing & Midwifery Council 2002. The Code: Standards of conduct, performance and ethics for nurses and midwives London: NMC. Roper, N., Logan, W. & Tierney, A. (1996). The Elements of Nursing Model for nursing based on a Model for Living. (4th ed.). Edinburgh: Churchill Livingstone. Thorne, S. et al (2007). Prognosticating futures and the human experience of hope. Palliative & Supportive Care (2007), 5, (3), 227-239. Read More