Preferences and attitudes of the Saudi population toward receiving medical bad news: A primary study from Riyadh city.

BACKGROUND: Breaking bad news is one of the most stressful and difficult things a physician has to do. Good communication skills are required in order to ensure that bad news is delivered in a humane but effective way.
OBJECTIVES: This study was designed to explore the preferences and attitude of the Saudi population toward receiving bad news. Second, it was to identify the associations between preferences, attitudes, and sociodemographic characteristics.
MATERIALS AND METHODS: This was a cross-sectional study conducted during the month of April 2009 in Riyadh. Data were collected from 1013 adult Saudis. Stratified random sampling technique was used through a self-administered questionnaire.
RESULTS: In this study, 474 (46.8%) were males and 539 (53.2%) were females. Almost two-third of the participants preferred to be the first to receive the bad news. A majority of the participants 695 (68.6%) preferred to be told the bad news at a private place, whereas, 441 (43.5%) preferred to be told by the head of the medical team. Moreover, almost half of the participants would like the one who breaks the bad news to remain with them to give them some more information about the disease. Significant associations were observed between participants' perception and attitude with age, marital status, gender, and education (P < 0.001), respectively.
CONCLUSION: Factors such as marital status, age, and gender, and education play significant roles in how bad news is received. Understanding what is important in the process of breaking bad news may help in determining how best to perform this challenging task.

INTRODUCTION

Bad news may be defined as “any information which adversely and seriously affects an individual's view of his or her future.[1] No one likes breaking bad news, although doctors and other healthcare professionals inevitably have to perform this task.[2] The increase in chronic illnesses and issues related to quality of life, heighten the importance of understanding how the delivery of bad news affects patients, their family/guardians and doctors/other professionals.[3] Studies have consistently shown that the way a health care professional delivers bad news leaves an indelible mark on doctor-patient relationship.[4]

Many studies have reported cultural variations. Physicians in the United Kingdom and Italy, generally withhold information from the patient at the family's request.[5] Western values that promote the principle of patient independence may not be universally applicable. In Japan, China, Greece, and Ethiopia, physicians believe that informing patients about their terminal illness will only hasten their death.[6]

The debate about the levels of truth given to patients about their diagnosis has increased significantly in the last few years. The evidence indicates that patients increasingly want additional information regarding their diagnosis, their chances of a cure, the side effects of therapy and a realistic estimate of how long they will live.[789]

Patients want their doctors to be honest, compassionate, caring, hopeful, and informative. They want to be informed personally, in a private setting, at their pace with time for discussion and if they wish in the presence of a supportive person.[10] In a Systematic Literature Review published in 2009, four main structural components of patients' preferences for communication of bad news were highlighted: “Setting”, “manner of communicating bad news”, “what and how much information to be provided”, and “emotional support”.[11]

Patients' preferences and attitudes toward the receipt of bad news play a major role in guiding health care providers to select the appropriate method(s) of revealing bad news.[12] According to Dias et al., the presence of relatives can inhibit the disclosure of difficult issues that patients may wish to discuss.[13]

Cultural norms sometimes supersede professionalism. Cultures where family bonds are strong, and where families are predominantly patriarchic, such as the Saudi culture, tend to place the decision-making with the elders of the family. Preferences and attitudes have not yet been studied in Saudi Arabia. Therefore, this study is the first of its kind to explore the preferences and attitude of the Saudi population toward receiving bad news.

MATERIALS AND METHODS

This was a cross-sectional study conducted during the month of April 2009 in Riyadh, the capital of Saudi Arabia. The sample size of 1125 was calculated by using the level of precision formula and was reconfirmed by Power Analysis and Sample Size Software (2008). The data was collected using stratified random sampling technique, and only Saudi adults were included in the study. The targeted population was stratified according to age groups. Those between 20 and 30 years were selected from universities and other public areas; those above 30 years were selected by surveying work and public areas such as ministries, companies, hospitals, airports, and malls. The response rate was approximately 90% of the available sample size of 1013 participants. Permission was obtained from the concerned administrative departments and ministries before the administration of the questionnaires. Informed consent and ethical approval were also taken from participants and King Saud University respectively. A self-administered questionnaire in Arabic was used. The questionnaire consisted of 17 items, the first section of which concerned demographic characteristics.

The second section reflected participant's preferences during and after receiving the bad news. The questionnaire was validated and re-modified via a pilot study on 50 individuals from the society and was reviewed by five experts. Data were collected by researchers and trained research assistants. Uncompleted questionnaires were omitted. Data were entered and analyzed using Statistical Package for Social Sciences (SPSS Inc. 19.0, Chicago, IL, USA). Mean ± standard deviation is reported for quantitative variables. Frequencies and percentages are given for qualitative variables. Pearson Chi-square and Fisher exact test were applied to observe associations between qualitative variables. P < 0.05 was considered as statistically significant.

RESULTS

A total of 1013 Saudis 474 (46.8%) of whom were men and 539 (53.2%) women participated in the study. Less than half of the participants 480 (47.4%) were between the ages of 20 and 29 years. Only, 203 (20.0%) participants either had their own businesses or worked in private institutions as demonstrated in Table 1.

Table 1

Sociodemographic characteristics of the participants

Six hundred and eighty (67.1%) participants preferred to be the first to know the bad news followed by 141 (13.9%) who wanted their parents to be told first of the bad news. Three hundred participants (29.6%) preferred that their parents should be second in receiving the bad news, followed by one of their siblings 217 (21.4%), spouse 216 (21.3%), and nobody 203 (20.0%). Almost one-third of the participants 358 (35.3%) would rather not be accompanied by anyone when they are to receive the bad news. Where 441 (43.5%) preferred to be given the bad news by the head of the medical team [Table 2].

Table 2

Preferences of participants on receiving the bad news

Almost 50% of the participants preferred to be given the bad news by telephone, and by mail. Most of the participants 695 (68.6%) preferred to be given the bad news at a private place, whereas 288 (28.4%) said that place was not important. More than half of the participants 551 (54.4%) declared that the best way to be given bad news was for it to be “started with Allah's grace and remembrance”. Next was 371 (36.6%) who wanted the physician to “start with an introduction that contained some information about the disease.” Again almost half of the participants said they would like the one who breaks the news to stay with them to give them some more information about the disease. Almost, 50% of the participants would like the person who breaks the bad news to have good management skills and be a medical expert with good knowledge [Table 3].

Table 3

Attitude of participants while receiving the bad news

Female participants significantly preferred their parents to be the second (P < 0.001) to be told the bad news. They also preferred one of their parents to be with them (P < 0.001) when being given the bad news. Moreover, females were in favor of receiving the bad news from one of their family members (P = 0.045) and preferred to be left alone immediately (P < 0.001) after receiving the bad news. On the other hand, male participants significantly preferred one of their siblings to be the second (P < 0.001) to be told the bad news and also preferred to have one of the siblings with them (P < 0.001) when being given the news. Males also significantly preferred to get the bad news from a psychologist or social worker (P = 0.045) and that the physician who breaks the news should stay with them and give them some information about the disease (P < 0.001) [Table 4].

Table 4

Association between sociodemographic characteristics and preferences and attitude of participants when receiving the bad news

Participants who were unmarried and those who had general education significantly preferred their parents to be told first (P < 0.001), be the second to be told (P < 0.001) and also have one of the parents with them (P < 0.001) when being given the bad news. On the other hand, participants who were married and those with university degrees significantly preferred their spouses to be told first (P < 0.001), be the second to be told (P < 0.001) and also be accompanied by the spouse (P < 0.001) when they are to receive bad news. Both married and participants with university degrees also significantly preferred to receive the bad news from the head of medical team (P < 0.001) and would like the physician who breaks the news to remain with them to give them some information about the disease (P < 0.001). Moreover, participants with university degrees preferred to get the bad news by telephone (P = 0.015) and at a private place (P < 0.001) [Table 4].

Participants aged <30 years significantly preferred their parents to be given the news first (P < 0.001), be the second to be told (P < 0.001) and also preferred one of the parents to be with them (P < 0.001) when the bad news was broken to them Moreover, they preferred to be left alone immediately after the bad news is given (P < 0.001). On the other hand, participants aged >30 years significantly preferred their spouses to be told first (P < 0.001), second to be told (P < 0.001) and also preferred to be accompanied by the spouse (P < 0.001) to receive the bad news. They also preferred to be given the bad news by the head of medical team (P < 0.001) and would like the physician who breaks the news to stay with them and give them some more information about the disease (P < 0.001) [Table 5].

Table 5

Association between age (grouped and overall) and preferences and attitude of participants while receiving the bad news

DISCUSSION

To learn that one has a life-threatening disease is a major event, and as has been noted before[12] many patients recall the occasion with clarity even years later. The majority of the studies that explore patient preferences of the communication of bad news used descriptive evidence or qualitative measures, and mainly came from Western countries[14] that used different measures to obtain information on patient preferences. In agreement with one study,[15] patients generally stated that they would like to be the first to be told bad news by the physicians, 67.1% of respondents in the current study felt the same.

Lack of time is often blamed for limiting good communication, and also the lack of privacy, interruptions, and distractions compound stress. The more subtle and yet potentially more difficult aspects of giving bad news include responding to patients' emotions, giving hope when the situation is bleak, and handling difficult family issues.[16] In another study, 96.1% of the patient group wanted to hear the bad news from the head of the team and emphasized they would like to know immediately after the diagnosis was made,[17] whereas in the current study (43.5%) participants preferred to be given the news by the head of medical team. Dias et al., 2003[13] documented that doctors should identify and address emotional responses. Patients may express shock, denial, sadness, frustration, fear or anger; each of these emotions deserves attention, yet physicians often fail to address them.

In a qualitative study of five oncologists, the physicians were frequently ineffective in identifying a patient's stress, while giving the bad news. In the same study, this sharply contrasted with physician self-assessment.[18]

Regarding the preferred way of receiving bad news, the current study showed that almost half of the participants would rather receive bad news by telephone, while 42.9% would prefer a face to face communication. These findings are closer to what was reported in the study of melanoma patients in which one-third of the patients preferred to receive their diagnosis over the telephone, and half of the patients expressed a preference for a face-to-face communication of the news.[4]

In accord with what has been reported by Dias, et al.[14] almost one-third of the participants in the current study preferred to be accompanied by one of their family members (parents, siblings, and spouse) when they are to receive bad news. They reported that the presence of relatives could inhibit the disclosure of difficult issues that patients may wish to discuss. In family-centered cultures, such as the Japanese culture, patients preferred their relatives to be with them more than patients in Western cultures did, and comparatively fewer patients in Asian cultures would discuss life expectancy.[14]

Marked cross-cultural differences were found in some patients' preferences. For example, there was a wide variation with respect to having relatives present when being given bad news,[1619] and the desire to get information on how long they had to live.[17] These differences were clearly observed in the current study where more than half of the participants (54.4%) declared that the best way to receive the bad news was to “start with Allah's grace and remembrance,” which is a religious concept in Muslim culture.

Previous studies[2021] showed that patients who are young, female, educated and those who were extremely distressed desired to receive as much detailed information as possible. Findings of the current study showed that female participants significantly preferred their parents to be the second to be told, and also would like one of their parents to accompany them to receive the bad news.

Contrary to this, male participants significantly preferred one of their siblings to be the second to know, and also one of the siblings to accompany them to receive the bad news. This may be because in the culture males are responsible for themselves whereas females remain under the guardianship of their parents even if they are adults. Males also significantly preferred to receive the bad news from a psychologist or social worker. In contrast to the females, they would also like the physician who breaks the bad news remain with them to give them some information about the disease.

In a study by Schofield, et al.[5] almost half (47%) of the patients would rather have “no one else” present and 44% wanted their spouses to be present when being given bad news. The results of current study in agreement with this show that (35.3%) participants preferred “no one to accompany them” when they were to receive bad news; however, only 16% participants preferred a spouse to be present.

The strength of the present work is that, to the best of our knowledge, this is the first study conducted in Saudi Arabia to explore patient preferences with regard to being given bad news. In addition, the study sample size was a large one comprising different categories of our community. The study results showed that patient preferences regarding the communication of bad news consisted of four main components: setting, manner of communicating bad news, what and how much information was provided and emotional support.

LIMITATIONS OF THE STUDY

Some limitations of the current study should also be noted. First, this study explored participants' perception and attitude, and therefore, may be different when the perception and attitudes of patients who are receiving treatment in hospitals or other settings are examined. Second, this study was conducted in Riyadh city only, the preferences and attitude may have differed if other cities had been included.

RECOMMENDATIONS

Three recommendations are suggested whereby the process of revealing bad news could be made more efficient: First, healthcare providers should be trained in the breaking of bad news, which hopefully should result in bringing about a change in patient outcomes. Second, in order to change the research effort in such areas as breaking news, a more strategic approach could be taken with the allocation of research funds, as the studies may require multidisciplinary teams with links to treatment centers. Third, qualitative studies need to be conducted to examine patients' perceptions more deeply and in a psychosocial manner.