What's the best way to break bad news to a patient? It depends on the patient, the patient's family, the news, the prognosis, where the conversation is taking place—and when—and numerous other factors, said Guilhem Bousquet, MD, PhD, a researcher in the Medical Oncology Unit at Hôpital Avicenne in Bobigny, France. “The oncologist needs to constantly adapt to each patient and each situation.”
Though various medical communities have developed recommendations to improve the communication skills of health care professionals in delivering bad news—oncologists and oncology care providers included—there is still a dearth of data on the experience of doing so, Bousquet and his colleagues explain in a metasynthesis report recently published in the Journal of Clinical Oncology (2015;33:2437-2443).
The research systematically reviewed 40 qualitative studies that focused on the experiences and points of view of oncologists about breaking bad news to patients to determine common themes, as well as where research was lacking.
In an email interview, Bousquet told OT more about the work:
1. What was the impetus for this review—and why a metasynthesis?
“Most research in this area has focused on the patient's point of view—which is important—but as a medical oncologist, I wanted to address the question of the oncologist's perspective about breaking bad news.
“We did a metasynthesis—a systematic review of qualitative studies, which is more suitable for investigating health care issues in context because it takes into account interactions, behavior, and perceptions within groups and teams.
The metasynthesis methodology makes it possible to synthesize numerous small qualitative studies that are contextually specific and interesting, but have little generalizability. It identifies the themes from each of the individual studies, compares these themes across all of the selected studies, and constructs broad categories formed by the themes that are sufficiently supported, frequent, and pertinent.
“Our metasynthesis provides the first overview of oncologists' experiences regarding breaking bad news, and it enabled us to build generalizable theories that provide a deeper and more textured understanding than could be obtained from quantitative research alone.”
2. What did you learn?
“Oncologists need to constantly adapt to each patient and each situation when it comes to delivering bad news. And we learned that the repeated emotional experience of breaking bad news is invasive, complex, and inevitable. And when it comes to breaking bad news, the emotional capacity of the oncologist in his or her daily practice needs to be taken into account.
“More educational programs are needed. Oncologists should be offered specific training in listening. And education should include training on the ‘external factors’ that shape the patient-oncologist encounter—particularly the family and cultural factors.
“And oncologists should be taught coping strategies they can use to deal with their own feelings and emotions. Regardless of the programs and/or efforts to improve their communications skills, providers need to be taught that the emotional experience they live will remain extremely complex, invasive, and hard to manage over time.”
3. And in what areas did you find that more research is still needed?
“There is a lack of research in the cultural factors that can strongly affect the experience of both giving and receiving bad news. Each culture structures the representations that individuals have about death and disease differently. Physicians and patients interact in a particular cultural context that shapes their respective ways of dealing with the question of death—and potentially with the best way to receive and/or give bad news.
“So what do we do when the physician and the patient come from different cultures? Do we talk about death directly? Is death associated with religious practices that structure the transition between life and death? What is the place of the family?
“The physician must take the patient's perspective into account. Very little is known about the burden of breaking of bad news for oncologists in a context of multi-ethnic diversity.”
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