Patients' Attitude toward Breaking Bad News; a Brief Report.

INTRODUCTION: Delivering bad news is a stressful moment for both physicians and patients. The purpose of this investigation was to explore the patients' preferences and attitudes toward being informed about the bad news.
METHODS: This cross-sectional study was done on patients admitted to Imam Khomeini Hospital, Sari, Iran, from September 2014 to February 2015. Patient attitude regarding breaking bad news was evaluated using a reliable and valid questionnaire.
RESULTS: 130 patients were evaluated (61.5% male, mean age = 46.21 ± 12.1 years). 118 (90.76%) participants believed that the patient himself/herself should be informed about the disease's condition. 120 (92.30%) preferred to hear the news from a skillful physician and 105 (80.76%) believed that emergency department is not a proper place for breaking bad news.
CONCLUSION: Based on the results of the present study, most participants believed that the most experienced and skillful physician should inform them completely regarding their medical condition. At the same time they declared that, it is best to hear bad news in a calm and suitable place and time rather than emergency department or hospital corridors during teaching rounds.

Introduction:

The most famous and common definition of the bad news has been presented as “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 be responsible for patients’ request in this regard. How the bad news is given to the patients affects their interpretation of the disease (1). Most physicians do not have previous experience in talking to patients about death or end-stage diseases and are required almost daily to give unwelcome news without being properly prepared for such instances (2). Delivering bad news is a stressful moment for both physicians and patients (3, 4). People with different cultural backgrounds may show different attitudes toward disclosing bad news. In North America and Europe, most physicians express the diagnosis obviously, but in South and East Europe and China, some patients are excluded from receiving information about their disease (5, 6). The purpose of this investigation was to explore the patients’ preferences and attitudes toward being informed about the bad news.

Methods:

This cross-sectional study was done on patients admitted to Imam Khomeini Hospital, Sari, Iran, from September 2014 to February 2015. Before beginning the project, questionnaire and the aim of study were explained to the participants and informed consent was obtained from them. The study protocol was confirmed by Ethical Committee of Mazandaran University of Medical Sciences and researchers adhered to Helsinki Declaration during the study period. The studied population consisted of all patients above the age of 18 who were admitted with definite diagnosis of a malignant or chronic disease. Exclusion criteria were refusing participation, disability to talk and communicate, and presence of cognitive disorders. The sample size was estimated to be 102 persons considering d = 0.1, z = 1.96, and p = 0.5 (7). A valid (Cronbach’s alpha coefficient was 0.88) and reliable questionnaire consisting of demographic data and 30 questions was used for data gathering (table1).

Table 1

Patients’ attitude toward breaking bad news

Questions	Answers n (%)
	Agree	No idea	Disagree
The patient should be completely aware of his/her medical condition.	118 (90.76)	6 (4.61)	6 (4.61)
People accompanying the patient should be informed about the medical condition.	73 (56.15)	23 (17.69)	34 (26.15)
Family physician is the most suitable person for breaking the bad news.	14 (10.76)	59 (45.38)	57 (43.84)
It is better if family members disclose the bad news (brother, sister, …)	59 (45.38)	26 (20)	45 (34.61)
It is better if patient’s relatives or friends disclose the bad news.	20 (15.38)	25 (19.23)	85 (65.38)
It is better if nurses or other medical staff disclose the bad news.	3 (2.30)	13 (10)	114 (87.76)
Specialist physician is the appropriate person to break the bad news.	115 (88.46)	9 (6.92)	6 (4.61)
Medical students are the appropriate people to break the bad news.	1 (0.76)	16 (12.30)	113 (86.92)
Giving the bad news during medical teaching round is suitable.	1 (0.76)	18 (13.84)	111 (85.38)
Hospital corridor is a suitable place for giving bad news.	3 (2.30)	19 (14.61)	108 (83.07)
A private retired room is suitable for giving bad news.	68 (52.30)	51 (29.23)	11 (8.46)
It is better to disclose bad news right after confirmation of diagnosis.	33 (25.38)	55 (42.30)	42 (32.30)
Emergency room is a suitable place for giving bad news.	8 (6.15)	17 (13.07)	105 (80.76)
An aged physician is a more appropriate person to break the bad news.	102 (78.46)	16 (12.30)	12 (9.23)
I like to be informed about the cause of my disease.	85 (65.38)	34 (26.15)	11 (8.46)
I like to be totally informed about my ongoing medical condition and its prognosis.	76 (58.46)	47 (36.15)	7 (5.38)
It is good to have some information about a medical condition before hearing bad news.	81 (62.30)	38 (29.23)	11 (8.46)
It is better for the doctor to know how much the patient knows about that medical condition.	87 (66.92)	38 (29.23)	5 (3.84)
Receiving bad news about a common disease is much easier than hearing about a rare disease.	108 (82.30)	20 (15.38)	3 (2.30)
Physician’s skill in treatment affects compliance of receiving bad news.	120 (92.30)	9 (6.92)	1 (0.76)
Medical condition awareness positively influences continuing a medical treatment.	102 (78.46)	27 (20.76)	1 (0.76)
It is better to educate doctors about how to disclose bad news.	66 (50.76)	63 (48.46)	1 (0.76)
Availability of psychology consultant is necessary at the time or after disclosure of bad news.	80 (61.53)	45 (34.61)	5 (3.84)
I would like to talk with a religious consultant after hearing a bad news.	66 (50.76)	50 (38.46)	14 (10.76)
Doctors should consider the psychological status of patients while breaking bad news.	100 (76.92)	21 (16.15)	9 (6.92)
Doctors should consider patients’ religious beliefs while breaking bad news.	90 (69.23)	26 (20)	14 (10.76)
Breaking of bad news by doctors makes patients pessimistic about their treatments.	31 (23.84)	80 (61.53)	19 (14.61)
It is the patient’s right to know everything about his/her medical condition.	98 (75.38)	30 (23.07)	2 (1.53)
Cancer patients should be informed about their disease.	70 (53.84)	17 (13.07)	43 (33.07)
Cancer patients should be completely informed about their ongoing medical condition and their life expectancy.	84 (64.61)	16 (12.30)	30 (23.07)

Results:

138 patients participated in this study and 130 patients completed the questionnaire and returned it (61.5% male). The mean age of the included patients was 46.21 ± 12.1 years. 93 patients (71.5%) were married, 18 (13.84%) widowed, 12 (9.23%) single, and 7 (5.8%) divorced. Among the patients, 67 (51.53%) had cancer, 21 (16.15%) end-stage renal disease (ESRD), 18 (13.84%) hepatic cirrhosis, 17 (13. 07%) chronic obstructive pulmonary disease (COPD) and 7 (5.38%) had other chronic diseases. The attitudes of patients toward breaking bad news is shown in table 1.

Discussion:

In this study, 90.76% of patients believed they should be informed about their ongoing medical condition and receive the unwelcome news. Similarly, in other studies done in China and Australia, 83% and 77% of patients, respectively, believed they should be completely aware of their medical condition (8, 9). In our study, 56.15% of the patients were eager to be accompanied by someone while receiving bad news. Furthermore, 45.38% of our participants preferred receiving bad news from their families while only 15.38% wanted to hear it from their second degree relatives or friends. Studies in Japan showed that 78% of patients prefer to share the bad news with their families (1). In Australia, 57% of patients liked to have their families beside them while unwelcome news is disclosed (9). In contrast, some other studies showed that many patients prefer not to tell their families about having cancer (8). It was revealed that 81% of American patients like to be alone while receiving bad news (10). This study also showed that families have a helpful and supportive role at the time of unwelcome news disclosure and they can help patients accept the situation (7). Moreover, our patients generally deemed a highly experienced rendering specialist to be the best person to break the bad news to them and they did not accept other medical staff or medical students for this purpose. This result is similar to findings of researches done in Australia and Portugal, which showed that only 13% and 0% agreed to receiving bad news from nurses or hospital staff, respectively (5, 9). Similar to our findings, most studies showed that the treating physician is the best person to convey unwelcome messages (5, 11). A proper doctor-patient relationship in breaking bad news can enhance patient’s compliance in treatment and stress management (12, 13). Many studies showed that doctors did not have enough self-confidence and skill for breaking unwelcome news and were unable to handle patients’ reactions and emotions (14, 15). In this survey, 50.76% of patients believed that doctors needed education about bad news disclosure, which shows the necessity of skill achievement for doctors and medical students regarding this issue. Therefore, it is highly recommended to make a plan and educate doctors for becoming skillful in communicating with patients especially for giving bad news and handling their different reactions toward the news. This study demonstrated that 83.07% and 80.76% of patients did not want to receive bad news in hospital corridors and emergency room, respectively. Also, 52.30% of them emphasized that this should be done in a private retired room. In a study by Alrukban et al. 68% of people believed it was necessary to convey unwelcome messages in a private place (16). Other studies have also emphasized this issue (17, 18). The participants of our study stated that they needed psychological and religious consultations after receiving unwelcome messages and physicians should pay attention to their religious and emotional conditions in this situation. Few studies have been done regarding this point (19, 20). In our study, 75.38% of patients affirmed that they should be thoroughly informed about their disease and the majority of them desired to know the cause, progress and prognosis of their disease. Knowing life expectancy was crucial for cancer patients. Participants of all the studies done in Asia and western countries declared that it is their right to know all details of their diseases (5, 10, 16). Breaking bad news to patients demands more consideration for cultural and personal status of patients and it should be done by the treating specialist privately. Educational workshops are needed for medical staff concerning this topic. It is recommended to design a standard questionnaire considering numerous factors cultural status of the area and status of medical services to achieve more accurate results.

Conclusion:

Based on the results of the present study, most participants believed that the most experienced and skillful physician should inform them completely regarding their medical condition while considering patients’ psychological status. At the same time they declared that, it is best to hear bad news in a calm and suitable place and time rather than emergency department or hospital corridors during teaching rounds.

Conflict of interest:

None

Funding support:

None

Authors’ contributions:

All authors passed four criteria for authorship contribution based on recommendations of the International Committee of Medical Journal Editors.