How to break bad news: physicians' and nurses' attitudes.

OBJECTIVE: Bad news disclosure is one of the most complex tasks of physicians. Recent evidences indicate that patients' and physicians' attitude toward breaking bad news has been changed since few years ago. The evidence of breaking bad news is different across cultures. The aim of this study is to evaluate the attitude of medical staff toward breaking bad news to provide a clinical guideline in Iran.
METHODS: A descriptive study was conducted during 2008-2009 on a sample of 100 medical staff (50 physicians and 50 nurses) at Cancer Institute of Imam Khomeini hospital. The subjects' demographic characteristics and their attitudes toward the manner of revealing the diagnosis were registered in a questionnaire.
RESULTS: The majority of the physicians (86%, n=43) and nurses (74%, n=37), mostly the older and more experienced, tended to reveal the diagnosis to patients. Only a few physicians (8%, n=4) had been trained how to disclose bad news, which discloused diagnosis more than non trained ones. Physicians and nurses preferred to inform the patients about the diagnosis when either the patients were alone or in the presence of their spouse respectively. Only a few physicians (14%) and nurses (24%) agreed to explain life expectancy to patients.
CONCLUSION: Compared to past, physicians and nurses are more willing to share cancer diagnosis with patients. However, lack of adequate communication skills in caregivers, and their concerns about managing patients' emotional reactions reduce their tendency to disclose bad news to the patients. Therefore, training physicians and nurses to expose bad news to the patients seems to be necessary.

Emphasizing on technical skills rather than communication skills in medical education has led to physicians’ incompetency to communicate with patients such as to expose them with diagnosis. Subsequent result is doctors’ avoidance of such situations and stressing on treatment solely and ignore patients’ emotional problems (1).

Verbal and non verbal communication skills plays a critical role in improving physician-patient relationship (2). It can lead to better caring for patients and helps them to comply with their illness and to accept treatment. Physicians' failure in communication skills leads to patients’ resentment and also inspires the feeling of incompetency in physicians to control the patients' pain and symptoms (3, 4).

One of the most famous and common definition of bad news has been presented by Robert Buckman: “any news that adversely and seriously affects an individual's view of his or her future ”.

A physician is expected to be able to disclose bad news, and evaluate patients’ demand for it. The way of presenting bad news affects the patients’ understanding of the disease (5), their psychological adjustment to the disease (6–8), satisfaction of medical care (9, 10) and level of hope (11). Disclosing bad news to patients may also encourage them to participate in complex decision makings (12).

Giving bad news to patients is one of the difficult tasks of physicians and nurses (13–16). Today it's highly agreed that being informed of ones disease is the patients’ legal and ethical right (17, 18) and concealing the information about the disease may lead to distrust towards physicians (19).

As the past treatments in some fields of medicine including oncology were not promising, most physicians believed that revealing the diagnosis is harmful for patients. Today, by advanced treatments, giving hope to patients has become easier, and skills of revealing bad news is felt to be more necessary for physicians (20). The moral duty to give knowledge of disease has mixed with concerns about making patients frustrated, and it has established a difficult situation for physicians to make a decision whether to disclose bad news to patients (18).

In 1961, the majority of physicians were reluctant to expose the diagnosis to patients (21). First demonstrations of inclination to disclose bad news appeared in the late 1970's (22). It seems that through time and more advances in treatments and increasing life expectancy, physicians’ attitudes toward diagnosis disclosure has been changed. Among the related studies done in Iran, a study in 1993 revealed that most physicians believed patients should be aware of the truth (23). A review of the studies shows that 50-90% of patients demand for full disclosure of diagnosis. Since still a minority of patients does not want to be aware of bad news, physicians should evaluate their patients’ demands on this issue (1).

Evidence shows that there are different attitudes toward bad news disclosure based on different cultures. In North America and Europe, most physicians express the diagnosis clearly, but in South and East Europe and China due to dominated patriarchal view some patients are excluded to receive information about their disease (24, 25).

The present study intends to assess medical staff's attitudes towards disclosure of bad news and its ways which may lead to a clinical guidance of giving bad news to patients in Iran.

Materials and Method

Subjects

Subjects comprised of 100 medical staff (50 physicians and 50 nurses) working at the Cancer Institute of Imam Khomeini Hospital who provided care for cancer patients. The inclusion criterion was the history of professional work in the field of cancer care.

Instrument

The questionnaire core body was designed based on literature review. Final questionnaire draft was prepared during 8 sessions of 1-2 hours, focusing on patients and doctors interviews, and the factors affecting how to disclose the diagnosis and bad news. To examine the content validity of every sentence and phrase of the questionnaire, the draft was given to five oncology and psychiatry professors. After modification based on the professors comments, the final questionnaire was prepared.

Method

This study was a cross-sectional study being conducted during 2008_2009. After obtaining informed consent, subjects underwent a questionnaire survey which was completed in self report order. The recorded data were extracted from the questionnaire. The questionnaire was made by arranging a patient focus group and a physician expert panel.

The data were analyzed by the SPSS 16 software, and central statistics indicators were used to describe the gathered data. Pearson and Spearman correlation coefficients, independent sample t test and Chi-square were used to investigate the relationship between the variables.

Ethical issues

The study has been conducted after providing sufficient explanation to the participants and obtaining their informed consent. All data are kept confidential and no person will have access to information except for scholars. This project was approved by the Research Ethical Committee of Tehran University of Medical Sciences.

Results

50 physicians and 50 nurses participated in this study. Among the physicians, 54% were male (n=27) and 46% were female (n=23). Among the nurses, 32% were male (n=16) and 68% were female (n=34).

Sixty four percent (n=32) of the physicians were residents, 18% (n=9) specialists and 18% (n=9) were subspecialists; 90% (n=45) of the nurses had bachelor's degree and 10% (n=5) had master's degree.

Forty two percent (n=21) of the physicians were radiotherapists, 40% (n=20) surgeons, and 18% (n=9) oncologists and a total of 30% (n=15) were faculty members.

Physicians had an average age of 36.08±8.05 years while the average age of the nurses was 38.5±5.17 years.

The physicians experienced 6.4±5.65 years as an average in the field of oncology while the same number for the nurses was 10.72±4.94 years.

The physicians disclosed bad news to 7.86±4.22 of the cases and the same number for nurses was 4.06±3.59 cases on average in each month.

The majority of physicians (92%, n=46) and nurses (94%, n=47) declared that they had not been trained to disclose bad news during their educational period or professional career.

Forty percent of the physicians (n=20) assessed their ability of bad news disclosure good and very good, and 22% (n=11) weak and very weak. Among the nurses, 42% (n=21) assessed their ability of bad news disclosure average and 36% (n=18) weak and very weak.

The majority of the physicians (82%, n=41) and nurses (62%, n=31) needed to be highly trained for giving bad news to patients. Only 6% of the physicians (n=3) and 2% of the nurses (n=1) assessed the necessity of being trained as low and very low.

More than half of the physicians (56%, n=28), usually exposed the diagnosis to patients as the general policy, only 20% (n=10) always exposed the diagnosis, and 2% (n=1) never stated the diagnosis, while most of the nurses (62%, n=31) rarely revealed the diagnosis, and only 2% (n=1) always informed the patient about the diagnosis.

Most of the physicians (86%, n=43) and nurses (74%, n=37) were willing to inform the patients. Eighty four percent (n=42) of the physicians and 74% (n=37) of the nurses chose the physicians in charge as the appropriate person for exposing the diagnosis.

Fifty eight percent (n=29) of the physicians believed that the diagnosis should be revealed to the patient as the first person, while nurses considered family members to be informed first.

Fourty four (n=22) of the physicians preferred the patients to be alone during diagnosis disclosure; 60% (n=30) of the nurses preferred to disclose bed news in the presence of the patients’ spouse.

Both physicians and nurses considered hospital and physicians’ office as the most appropriate places for disclosing diagnosis compared to clinic or patients’ home. Most physicians and nurses mentioned that the proper time to reveal the diagnosis is before starting the treatment, and they believed that the same gender of medical staff as the patient did not have any importance in disclosing bad news.

The most important factor affecting the decision whether to disclose the bad news was the disease prognosis in the physicians’ point of view, and patients’ relatives request in nurses’ point of view. Patient gender was the less important factor in both groups’ points of view. Other factors affecting bad news disclosure were: patients’ request, their medical information, socio-cultural background, mood, age, and religious beliefs.

Both physicians and nurses mentioned concerns about patients’ anxiety and emotional reaction as the most important factor leading to refusal for bad news disclosure, and patients’ previous information about the diagnosis as the less important factor. Other factors for not wanting to disclose bad news included: patients’ relatives request, the inability to answer the patients’ questions and fear of patients’ negative view.

31 phrases in two separate sections were used to assess the medical staff's attitudes toward the content of bad news and verbal or nonverbal communication with patients. The participants were asked to score the phrases based on their agreement (1=completely opposed, 5= totally agreed). The results are listed in Tables 1 and 2.

Table 1

Medical staff's attitudes toward doctor patient communication style

		Mean	SD
Letting the patients express their emotional feelings (anger, sadness, and etc). during the diagnosis disclosure	Physicians	0.84	3.94
	Nurses	0.73	4.16
Supporting the patients with silent respect, during the diagnosis disclosure	Physicians	0.87	3.66
	Nurses	0.63	4.14
Physicians should not express any certain emotional response during the diagnosis disclosure	Physicians	1.34	2.68
	Nurses	1.01	3.60
Physicians should not express any certain emotional response during the diagnosis disclosure.	Physicians	1.21	2.48
	Nurses	1.27	3.28
Physicians’ clarity affects patients’ trust to them	Physicians	0.59	4.36
	Nurses	0.83	4.20
Disease and the treatment methods (chemotherapy, radiation therapy and surgery) should be explained to patients.	Physicians	0.80	3.86
	Nurses	0.99	3.90
Treatment complications should be explained to patients	Physicians	0.91	3.88
	Nurses	1.02	3.88
Treatment administration route (injection or oral) should be explained to patients	Physicians	1.09	3.50
	Nurses	1.05	3.84
Patients’ chance of recovery should be explained to them.	Physicians	1.27	2.76
	Nurses	1.14	3.76
Patients’ life expectancy should be explained to them	Physicians	1.03	2.32
	Nurses	1.24	3.28
Patient has got a right to know his situation	Physicians	0.58	4.34
	Nurses	0.53	4.40
Diagnosis disclosure makes patients better accept the treatment and cooperate with their physicians.	Physicians	0.08	4.08
	Nurses	0.79	3.94
Patient would understand the diagnosis, finally	Physicians	0.91	3.82
	Nurses	1.10	3.60
Decision about treatment options must be made solely by the physicians	Physicians	1.18	2.32
	Nurses	1.12	3.50
Patient would be disturbed by understanding the diagnosis	Physicians	0.73	4.46
	Nurses	0.92	4.04
Decision about treatment options must be made according to patients’ desire	Physicians	1.19	1.92
	Nurses	1.24	2.52
Patient would be disturbed by understanding the diagnosis.	Physicians	1.16	2.72
	Nurses	1.23	3.34
Diagnosis awareness would not help the patient	Physicians	0.96	1.92
	Nurses	1.03	2.22
Diagnosis awareness would help the patients to finish their incomplete life tasks	Physicians	0.94	3.40
	Nurses	0.99	3.72

1=Totally agreed, 2=agree, 3=no difference, 4=opposed, 5=completely opposed

Table 2

Medical staffs’ attitudes toward communicating statements

Statements		Mean	SD
I'm accompanying you.	Physicians	0.77	3.74
	Nurses	0.80	3.74
I admire your courage	Physicians	0.75	0.84
	Nurses	3.72	3.8
I understand your feeling	Physicians	1.09	0.78
	Nurses	3.76	4.10
Encouraging Statements	Physicians	0.67	4.14
	Nurses	0.58	4.08
There have been patients like you, who have been improved.	Physicians	0.76	0.90
	Nurses	4.32	4.10
Things will go well.	Physicians	1.11	3.88
	Nurses	0.83	3.86
This is a struggle, you should go through the disease	Physicians	0.77	0.76
	Nurses	4.24	4.30
Disappointing Statements	Physicians	0.67	0.54
	Nurses	2.00	2.24
I wish I had a better news for you	Physicians	1.02	1.12
	Nurses	2.12	2.58
You You couldn't be helped more	Physicians	0.84	0.72
	Nurses	1.68	2.04
No worse situation is possible	Physicians	0.99	0.87
	Nurses	1.90	2.08
All of us will die one day	Physicians	1.19	1.24
	Nurses	2.38	2.44
I'm sorry I've got a bad news for you	Physicians	0.94	1.01
	Nurses	1.86	2.10
You will face some discomfort	Physicians	1.05	1.16
	Nurses	2.10	2.16

1=Totally agreed, 2=agree, 3=no difference, 4=opposed, 5=completely opposed

According to Table 2 of the medical staff's view, the encouraging phrase of “this is a struggle, you should go through the disease.” was scored the highest, and the disappointing phrase of “ no more could be done” was scored the lowest. Totally, encouraging phrases were scored the highest, and disappointing phrases were scored the lowest.

The relationship between physicians’ age and their professional experience in oncology field with their usual policy in disclosing bad news revealed that the more experienced and older physicians often or always disclosed bad news (p<0.002 and p<0.001, respectively). Male physicians were more willing to disclose the diagnosis than females (p<0.689) and they acted so more commonly as a general policy (p<0.75).

Physicians and nurses who were trained for bad news disclosure were more willing to inform the patients about the diagnosis (p<0.339).

More experienced and older physicians as well as faculty members assessed their skill of exposing the diagnosis better (p<0.001, p<0.003 and p<0.021 respectively) and disclosed diagnosis more frequently ( p<0.012 and p<0.01); they also had less demands for trained in this field (p<0.828, p<0.54 and p<0.0001 respectively).

Oncologists disclosed bad news more often than surgeons and radiotherapists. This difference was statistically significant (p<0.001).

Physicians who considered patients’ conditions (age, mood, demands, medical information, relatives’ request, disease prognosis, sociocultural background) as determinant factors, expressed bad news more often. However this relationship was not statistically significant. On the other hand, physicians or nurses who were afraid of their inability to answer the patients’ questions (p<0.063) and patients’ inappropriate reaction to medical staff (p<0.152) expressed the diagnosis of cancer less commonly.

Compared to nurses, physicians agreed less to have physical contacts with patients (taking patients’ hands, pat and etc.) when exposing bad news (2.68 and 3.60 the mean scores respectively, p<0.001).

Nurses also agreed more to let patients express their emotional feelings (p<0.35), and support them through a respectful silence (p<0.01).

The results showed that fewer physicians tended to describe treatment options for the patients than nurses (3.86 and 3.90 the mean scores respectively, p<0.826). However, they preferred more to consult the patients about medical decisions (4.46 and 4.04 average scores respectively, p<0.01).

Compared to physicians, nurses had more tendency to inform the patients about their life expectancy (3.28 and 2.32 mean scores respectively, p< 0.001), and they agreed more about using accompanist and encouraging phrases and avoiding disappointing phrases during disclosing bad news. However, the difference was not statistically significant.

Discussion

The majority of the physicians (86%,n=43) and nurses (74%, n=37), mostly the older and more experienced ones, agreed to disclose the diagnosis to patients. This is consistent with the results of recent studies conducted in 2002 (26) and in the late 1970 (22), but it is different from previous studies conducted in 1961 (21) and 1993 (23). It seems that physicians’ attitudes towards diagnosis disclosure have been changed by the emergence of more advanced treatments leading to increase in life expectancy of patients.

Among the three subgroups of surgeons, oncologists and radiotherapists, surgeons intended more to disclose bad news as most surgeons inform patients about the diagnosis to encourage them to accept surgical treatments, while radiotherapists often encounter patients after they have undergone surgical and chemotherapic treatments (21).

Only 8% of the physicians declared that they had been trained to disclose bad news to patients, and this is similar to findings of Buckman study (20) in which less than 5% of physicians were trained in this field. Trained physicians were more willing to express the diagnosis; and this indicates that training physicians for bad news disclosure will improve their communication skills and help them to expose the truth about diagnosis and prognosis of cancer (21).

Fear of the patients’ emotional reaction was the most important factor predicting physicians’ refusal to express diagnosis. This refusal could be due to physicians’ inability to handle patients’ emotional reactions and it underscores the need of training in this field.

44% of the physicians preferred to expose the diagnosis when the patient was alone. 38% of the physicians and 60% of the nurses preferred to expose the diagnosis in a presence of patient's spouse. In Rassin study, physicians and nurses had stressed on presence of family members during diagnosis disclosure (27).

According to conventional methods, no information about patients’ life expectancy should be given to them, and this was similar to the results of this study. In the present study, only 14% of the physicians and 24% of the nurses agreed to discuss patients’ life expectancy (2.32 and 3.28 mean scores respectively). In the Lee and Buck study(26), physicians stated that only in 37% of the cases, they informed the patients about their accurate life expectancy on their request. In Safran study(5) all of the 49 physicians were reluctant to give patients an accurate survival estimation. Also in Rassin study (27), both physicians and nurses scored lower points for exposing the information on the patients’ life longevity (mean 1.32).

In Rassin study (27), compared to physicians, nurses emphasized more on non-verbal support during bad news disclosure, such as letting the patients express their emotional feelings, respectful silence, and physical contact with the patient ( taking hands, pat,etc.).

In Rassin study (27) physicians and nurses preferred to use accompanist sentences during diagnosis disclosure ( 2.43 and 2.87 mean scores, respectively), but in our study encouraging phrases were scored higher than accompanist phrases ( mean score 4.14 in physicians and 4.08 in nurses).

Both groups were opposed to use disappointing phrases which is compatible with Rassin reviews (27).

Conclusion

Compared to past, physicians and nurses are more willing to share cancer diagnosis with their patients. However, lack of adequate communication skills and concerns about patients’ emotional reaction and its consequent management, reduces the tendency to disclose bad news. Therefore, training physicians and nurses to communicate with patients and to find appropriate ways to disclose bad news to patients seem to be necessary.

Limitations and suggestions

This study has some limitations including small sample size in each group, sample collection from only one medical center in Iran, and participation of physicians in some few specialties. Therefore, it is difficult to generalize these results to all medical staff. Another limitation of the present study is the error in self-reporting method that may occur due to participants’ differences in understanding questionnaire's phrases.